SA JOURNAL OF PHYSIOTHERAPY 2004 VOL 60 NO 1 7 CORRESPONDENCE TO: Nomathemba Patricia Taukobong Medical University of S.A Physiotherapy Department Box 239 Medunsa 0204 Tel: 27 12 521 4050/5828 Fax: 27 12 521 5684 E-mail: taukob@medunsa.ac.za The growing health care needs of communities within our country was reiterated by the president of the Republic of South Africa (RSA) Mr. Thabo Mbeki in his foreword in the White Paper on Integrated National Disability Strategy (1997), depicting the pressing need for caring of disabled people within our communities. It is therefore within this context that health professionals should be trained hence the present structure of the community-based clinical program within the physiotherapy department. The World Health Organisation’s (WHO), (1998) call for reorientation of medical education towards community based education has pushed most clinical training programs to shift the emphasis from a hospital based to a community-based approach. It is of note that the majority of South Africans are still experiencing the need for acces- sible health care services. The provision of community-based service has thus become a necessity. It is for this reason that the training of physiotherapy students has to recognize the needs of people in ABSTRACT: Backgound: The aim of community based clinical training is to produce graduates who are responsive to the health needs of their community. It is envisaged that upon completion of training graduates would go back and serve their respective communities following exposure to community needs. Program evaluation should therefore allow students to express the inadequacies and strengths of the program. Aim: To evaluate the community-based clinical program through student's expe- riences. Methodology: A qualitative research design was used. End of block students reports for both third (8) and fourth (15) year physiotherapy students (n = 23) were used to collect the data. Responses in the reports were grouped into the following categories for purpose of data analysis: feeling about the block, suggestion/s and supervision. Results: The students described the community based clinical program as an unique learning experience which equipped them with the understanding of life within communities. Sixty five percent (65%) expressed satisfaction with the supervision given. The main complaints were amounts of paper work involved and clinical workload. Conclusion: The student's experiences indicated that the community-based clinical program within the MEDUNSA physiotherapy department realizes the goal of community-based clinical training as determined by WHO, except for inclusion of some multi-professional approaches and adaptation of the supervision provided. KEY WORDS: COMMUNITY-BASED CLINICAL PROGRAM, MEDUNSA STUDENTS, EXPERIENCE. COMMUNITY BASED CLINICAL PROGRAM: THE MEDUNSA PHYSIOTHERAPY STUDENTS’ EXPERIENCE Q U A L I T A T I V E R E S E A R C H INTRODUCTION Essential understanding of the commu- nity based clinical program within the MEDUNSA physiotherapy department requires a knowledge of the context in which it was developed. (Mission state- ment of the Institution, MEDUNSA General Calendar 2003) For the training to be relevant it has to take place and operate within this mission. The shift in emphasis in health care delivery to a managed health care sys- tem, whereby the hospital stay becomes shorter usually translating into less time for rehabilitation (Rimmer J H 1999), becomes an important factor to consider. This compels students training to take cognizance of the fact that other clinical settings, such as community- based facilities, should be included. The situation dictated the structuring of cli- nical training of physiotherapy students at MEDUNSA, in such a way that it would allow follow-through rehabilita- tion to other settings. order to provide the required services. Despite the aforementioned back- ground upon which the community block at Medunsa had been developed, the strengths and weaknesses of this block are still unclear in spite of the fact that the training is widespread and now includes: • old age homes • disabled children creche's • local community clinics • special schools • individual home visits within local CBR programs as well as • rural placements. TAUKOBONG NP, BSc Physiotherapy (MEDUNSA), HED (UNISA), MphysT (Pretoria)1 1 Physiotherapy Department, MEDUNSA. 8 SA JOURNAL OF PHYSIOTHERAPY 2004 VOL 60 NO 1 Because program evaluation is an integral part of medical education, which can expose the weaknesses and strengths of the program (Murray E, Alderman P, et al 2001), students are required to submit end of block reports as feedback on the activities within the block, for that purpose. The aim of the study was therefore: To evaluate the community-based clinical program through student’s experiences. Relevance Student feedback is very helpful and informative towards development of programs and activities for medical education as it allows them to highlight the weaknesses and strengths of pro- grams and is this way assisting in the provision of quality training/education. This would result in production of quality professionals and the develop- ment of a comprehensive curriculum (Allen et al 1998; Pipas et al 2002). METHODS Design A qualitative method was utilized to obtain better understanding and so increase the depth of interpretation of issues from the viewpoint of the students. Sample All 3rd and 4th year MEDUNSA physiotherapy students of 2001 who had completed the program and submitted end of program reports, comprised the study population (n =30). Only 23 quali- fied to be participants as their reports were legible and contained information that could be used to analyze their feedback. Seven (7) were excluded as the information reflected no personal experience but report on patients. This exclusion did not affect the validity of the study as the analysis used was qualitative in nature and based on stu- dents’ expressions. For the purpose of this study students remained anonymous. Data collection End of block reports were used to pro- vide data and a data capturing form was used for recording students’ expressions in three categories. These were feelings about the block, comments on super- vision, the frequency of supervision and suggestions for change. Data analysis Expressions on the report were grouped under each category and further divided to depict both negative and positive experiences. Moreover, the frequency of the positive and negative expressions were converted to a percentage. RESULTS Category 1: Feelings The general feeling of students (100%) was that community-based clinical train- ing was a unique learning experience which equipped them with understanding of the rural life. Category 2: Suggestion Deductions made from the students’ suggestions (13%) reflected an apparent weakness in a multidisciplinary approach experienced within this program. Category 3: Supervision Most students (65%) expressed satis- faction with supervision received and (20%) were not happy. The main com- plaint cited was paperwork and work- load of clients/patients as well as being asked questions in front of patients. Lack of knowledge about what their colleagues were doing, was also men- tioned. The remaining (15%) did not express their personal experiences but reports on patient’s management. DISCUSSION The aim of this study was to evaluate the community-based clinical program from students’ experiences. Data collection encompassed feedback from students by analysing the end of block reports. Students’ feedback by reflective diaries is an effective tool for promoting reflec- tions and learning in students as well as self assessment and evaluation of a clinical experience as documented by Richardson and Maltby (1995). The common goal of Community- Based Education (CBE) is to increase the number and quality of Primary Health Care (PHC) professionals in medically underserved areas which are generally rural (Carney et al 2002; O’Sullivan et al 2000). The majority of South African citizens still live in a rural-type setting and are poor. The most appropriate training approach would be to provide an accessible and cheaper service translating into commu- nity-based service provision. It is the policy of the WHO to foster a type of education program for health personnel that will enable them to respond to the needs of the population they serve. This is seen as part of the effort to achieve the goal of health for all through Primary Health Care. These concepts thus dic- tates the structuring and approach used in community-based training programs. Expressions such as “For me working in the community has brought a lot of confidence in me, the importance of physiotherapy as well as an experience of working with different people”; “People out there really need us as physiotherapists and it is important for us to go out there and help the commu- nity according to their needs”, indicate that the goal of community-based clinical training is being realized. If the policy of the WHO as well addressing the needs of the population are recognized in the training of health professionals then this would mean appropriate training. It is from this perspective that the strength of the program can be measured (WHO 1998). The findings of the study there- fore confirms the strength of the community-based clinical program of physiotherapy students at MEDUNSA. The WHO expression on Community Based Educators (CBE) has been the fact that an education program can only be called community based, if for its entire duration, it consists of an appro- priate number of learning activities in a balanced variety of educational settings. The students have again confirmed that the program consisted of a variety of challenges in different clinical settings outside the hospital-base. This conclu- sion was arrived at, when considering the following comment: “It was such an interesting and challenging block in such a way that I came across different conditions with different needs and made sure that at the end of the day I achieved something”. This reflected educational value and enjoyment of various activities by the students within SA JOURNAL OF PHYSIOTHERAPY 2004 VOL 60 NO 1 9 the block, findings similar to those reported by Murray et al (2001). “I felt very much great about the block because I learnt a lot”, expressed the feeling of positive perception by one student within this clinical program. If the students enjoyed the block activities it means that their participa- tion would also have been productive and yielded a positive outcome within the served communities, a sentiment expressed by Nooman et al (1987). The reflection that utilization of PHC units by patients, increases appreciably in the presence of students was demonstrated in their study. The repeated emphasis made by researchers from reviewed literature is that basic education programs for health personnel should aim at producing generalized practitioners who are able to see each patient or client both as a whole person and as part of society. This calls for a holistic as well as psychosocial approach in the management of clients and that is why the service should be provided within the context of a com- munity which is being served (WHO 1998; Carney et al 2002; Pipas et al 2002). Student’s experiences in continued care along the path such as, follow- through care to home-based care, enable them to develop good problem solving skills. They also learn to understand the social aspect of the in-clients. Placement of students during their training within various clinical facilities enable them to be familiar with the health care system which they will be part of. Students’ expressions therefore supported the sen- timents expressed by other researchers (Davidson 2002; Delaney et al 2002) which were: “What I can say is that the block needs a lateral thinker who is creative as well” and “What I learnt is that without community physiotherapy our people will become helpless within their homes”. The fact that only 65% indicated satisfaction with supervision revealed weaknesses in this area. If students are to achieve a positive learning experience it is vital that they receive adequate supervision and mentoring (Channel 2002). The expressions from student revealed that there was no opportunity for them to see what others are doing within the same block as is the case with hospital based clinical training where rounds are conducted for students. This was a valid point and prompted that a re-look into supervision within the community-based clinical program, be made. Positive comments, however, included: “The supervisor was available all the time, but we were not spoon fed and had to work hard”. The negative report on supervision could be attributed to the fact that there was too much close supervision, as deduced from these com- ments, which Orchard (1994) supports by stating that the more closely the stu- dents are supervised the more likely it is that their level of anxiety will increase. Comments highlighting attention were: “Supervision was alright but I particularly needed more attention because I couldn’t easily understand the concept of treatment at community level”. The fact that students also com- plained about workload cannot be ignored but the reality of the situation is that the workload in the work within the community is not the same as in the hospital-based situation. Therefore to expose the students to a different work- load prepares them for challenges facing them within the community-based setting. The suggestions recognized from the reports were: “For improvement I suggest that the department should talk to the Occupational Therapists (OT) to work together, if possible, because we were encountering some of the problems which needed OT”. Such comments disclosed lack of a multi-professional approach, a very important aspect of medical education especially in commu- nity-based one. The WHO stipulates that during their education, students of dif- ferent health professions, should learn together all the skills necessary for solving priority health problems. The emphasis should be learning how to interact with each other (WHO 1998). These findings reflected a weakness in that regard. Developments Based on the Results of the Study Modification and adaptation in the methods of supervision were imple- mented and students’ rounds were also initiated. This has lead to a more comprehensive and student tailored supervision within the block. The researcher wants to believe that the MEDUNSA physiotherapy community- based clinical block has reduced the shortage of trained personnel by provid- ing the service where it is needed the most. There is also a growing demand by community-based health care centers for clinical assistance by means of placing students within these facilities. CONCLUSIONS Students’ experiences have revealed no need for structural changes to the block except for consideration of implementing a multi-professional approach together with improved supervision in the pro- gram. Most students indicated that they had been sensitized towards the needs of the communities for physiotherapy services. It can therefore be said that the general aim of community-based clinical training is being realized and training is thus appropriate as well as in line with the standards set by the WHO. LIMITATION The findings are only applicable to the MEDUNSA community-based clinical training program within the Physio- therapy department, which may be dif- ferent from other institutions’ programs hence the results cannot be generalized. It was not also possible to include all physiotherapy students as the clinical training program within the community only commences at third year level. Another limitation was the fact that no differentiation was made between the third and fourth year students' comments because of the few number of third years available when the study was conducted. RECOMMENDATIONS It would be interesting to determine and establish these student’s performance within the introduced compulsory com- munity service for physiotherapist within the RSA. It is recommended that a study in this regard be commenced. 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