Medical students perceptions of their learning during longitudinal primary care clinical placements in a sub-Saharan medical school

Molwantwa, Mmoloki Cornelius (2018-03)

Thesis (MMed)--Stellenbosch University, 2018.

Thesis

ENGLISH SUMMARY : Clinical placements are used as a bridge from classroom learning to real life settings (Stupans et al., 2013). Over the years, the Block Rotation Clerkship (BRC) model of clinical placements has been adopted by educational institutions and applied in different health settings such as hospitals, primary care or rural centres. However, emerging evidence in the literature supports the use of other models of placements over the BRC model to achieve clinical training outcomes (Wamsley et al., 2009; Hirsh et al., 2012). In view of this, Longitudinal Integrated Clerkships (LICs) have been shown as an acceptable alternative to the traditional block rotations (Strasser & Hirsh, 2011; Hauer et al., 2012; Hirsh et al., 2014). At the University of Botswana, an approach similar to LICs has been adopted for clinical placements. This approach involved changing clinical placements from a rotational structure to a longitudinal one in community primary care clinics. Consequently, the purpose of this study was to investigate the perceptions of second year medical students of their learning in the newly introduced longitudinal placements in primary care clinical settings. A cross sectional survey design which used the Manchester Clinical Placement Index (MCPI) tool to determine students’ perceptions of these newly introduced placements was adopted. The tool consisted of eight items that related to students’ experiences in clinical placements. Students then shared their views pertaining to the items in the tool. The tool generated quantitative and qualitative data which were analysed separately and thereafter points of alignment within the two sets of findings were identified for interpretation. This process was done using the MCPI domains as the organising framework for each item in the tool. Analysis of the quantitative data indicated that the majority of the students (more than 60%) perceived teaching of clinical tasks as optimal in the longitudinal placements at UB. Other items in the quantitative data which had majority of students perceiving them as appropriate included: leadership in terms of supervision at the placements, reception of students at placements, clinic staff supporting student learning at the placements and observations of students by staff when performing clinical tasks. In comparison to the above items, three items of organisation, facilities and feedback in the placements drew contrasting data from the students. The organisation of the placements was perceived as satisfactory by approximately half of the students (51%). There is clear evidence from the quantitative data that students were not satisfied with two items: clinic facilities as a learning environment and the feedback they received on how they performed clinical tasks. This was evidenced by less than half of the students strongly agreeing that both of these items were appropriate in the placements. Although the extrapolation was done with caution, the qualitative data from group leaders who completed the questionnaire advanced some of the reasons which could have explained the quantitative scores given by the students. According to the group leaders, the leadership was viewed as satisfactory because clinic staff who in most cases were nurses assumed responsibility over the students and allowed them to interact with patients. In terms of reception, they cited that the explanations of what was expected of the students made them feel welcome in their placement sites. In addition, the group leaders also indicated that clinic staff were supportive and possessed desirable human qualities that contributed to their learning at the placements. They also reported that the teaching they obtained on how to perform clinical tasks was delivered with clear instruction. The group leaders also added that there was sufficient observation from the different health professions in the clinics when they were performing tasks. In contrast, group leaders also advocated for an improvement in the feedback given to them while on placement. The structure, content and time were some of the factors that leaders felt presented challenges to staff when providing feedback. Primary care clinic facilities were viewed by few students as an appropriate learning environment. The group leaders revealed that the lack of space in the clinics to support academic activities as one of the reasons that could have contributed to this perception of students’. In conclusion, the findings of the study indicated that students perceived their learning experience at the placements to be beneficial, except for the feedback. Furthermore, the organization of the placement and reception of students at the placement was also perceived as adequate by majority of the students. Clinic staff at the placements, who played the role of teachers and supervisors of the students were found to be supportive to students’ clinical learning. According to the students, more could be done to improve community primary care clinics as a learning environment. In light of these results, the Faculty needs to consider steps to improving feedback given to students while on placement, and improving primary care clinics to provide an optimal learning environment for students.

AFRIKAANSE OPSOMMING : Kliniese plasings word gebruik om die gaping tussen die klaskamer en die praktyk te oorbrug (Stupans et al., 2013). In die verlede het opvoedkundige inrigtings enkeldissipline-kliniese vakskappe (EKVs) ingestel in verskillende gesondheidsorgstelsels soos hospitale, primêresorg-eenhede en plattelandse sentra. Tog wys nuwe getuienis in die literatuur daarop dat ander plasingsmodelle benodig word om gewensde kliniese opleidingsuitkomste te bereik (Wamsley et al. 2009; Hirsh et al. 2012). Teen dié agtergrond is longitudinale geïntegreerde plasings (LGPs) aanvaarbare plaasvervangers vir tradisionele enkeldissipline-kliniese vakskappe (Strasser & Hirsh, 2011; Hauer et al., 2012; Hirsh et al., 2014). By die Universiteit van Botswana word ‘n benadering soortgelyk aan die LGP tans vir kliniese plasings gebruik. Die voorafgaande stelsel van ’n weeklikse rotasie deur verskillende eenhede is vervang deur ’n longitudinale plasing in primêresorg-klinieke in die gemeenskap. Gevolglik stel hierdie navorsing hom ten doel om die insigte van tweedejaar- mediese studente vas te stel, ten opsigte van hulle leerondervindings in die nuwe longitudinale plasings in primêresorg-eenhede. Vir die ondersoekontwerp is op ‘n deursnit-benadering besluit, en hiervoor is die ‘Manchester Clinical Placement Index’ (MCPI)-instrument gebruik om studente-insigte i.v.m. die nuwe plasingsmodel te bepaal. Die MCPI-vraeboog bestaan uit agt items wat verband hou met studente se ondervindings tydens kliniese plasings, en bied studente die geleentheid om hulle gesigspunte t.o.v. elke item te lig. Kwalitatiewe en kwantitatiewe gegewens is sodoende verwek wat afsonderlik ontleed is. Vervolgens is raaklyne tussen die twee stelle gegewens vasgestel wat tot verdere vertolking gelei het; hiervoor het die MCPI-items as raamwerk gedien. Ontleding van die kwantitatiewe gegewens dui daarop dat die meerderheid studente (meer as 60%) die onderrig van kliniese take in die longitudinale plasings hoog ag. Ander aspekte wat die meerderheid studente aanvaarbaar gevind het was leierskap tydens die plasings, studente se ontvangs by hulle aankoms, leerondersteuning verskaf deur kliniekstaflede, en toesig tydens die uitvoer van kliniese take. Daarteenoor was studente-menings meer uiteenlopend t.o.v. drie items, synde organisasie, fasiliteite en terugvoer. Net die helfte van die studente (51%) het die organisasie van die plasings as bevredigend beskou. Daar was ook aansienlike ontevredenheid met kliniekfasiliteite as ’n leeromgewing en met die terugvoer wat studente ontvang wanneer hulle kliniese take uitvoer: minder as die helfte van die studente was van mening dat die gehalte van dié twee items toereikend was. Die kwalitatiewe gegewens wat groepleiers verskaf het is omsigtig gebuik om moontlike redes vir studente se kwantitatiewe waardebepalings te verskaf. Groepleiers is van mening dat leierskap hoog aangeskryf word omdat die verpleegkundiges wat die klinieke meestal beman verantwoordelikheid vir die studente aanvaar en hulle toelaat om met pasiënte om te gaan. Ontvangs is positief beskou omdat die verwagtinge wat staflede van studente het met die intrapslag verduidelik word, wat die studente gevolglik tuis laat voel. Die groepleier-gegewens dui ook daarop dat kliniekstaflede studente ondersteun en dat hulle gewensde menslike eienskappe besit wat bydra tot die leerproses tydens die plasings. Die onderrig wat studente ontvang t.o.v. die uitvoer van kliniese take word vergesel deur duidelike voorskrifte. Toesig tydens die uitvoer van kliniese take is ook toereiekend en word verskaf deur ‘n verskeidenheid gesondheidsberoepspelers. In teenstelling hiermee beveel groepleiers aan dat die terugvoer wat studente gedurende die plasings ontvang verbeter moet word. Hulle is van mening dat die struktuur van die plasings, hulle inhoud, en beskikbare tyd dit vir staflede moelik maak om terugvoer te gee. Daar was ook min studente wat saamstem dat die fasiliteite in primêresorg-klinieke ’n toepaslike leeromgewing bied, en volgens groepleiers is ’n gebrek aan die nodige hulpmiddels in klinieke om akademiese aktiwiteite te ondersteun moontlik een van die redes waarom studente tot hierdie slotsom gekom het. Ter opsomming dui die bevindings van die ondersoek daarop dat studente hulle leerondervinding tydens die plasings as bevredigend beskou, met uitsondering van die terugvoer wat hulle ontvang. Baie studente ag die organisasie van die plasings en hulle ontvangs om toereikend te wees. Die optrede van kliniekstaflede as leerkragte en toesighouers by die plasings ondersteun die studente se kliniese leerproses. Die studente is van mening dat meer gedoen behoort te word om primêresorg-klinieke in die gemeenskap as ’n leeromgewing te verbeter.

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