Hoffie Conradie

The role of educational strategies to reverse the inverse performance spiral in academically-isolated rural hospitals

Abstract The importance of continuous professional development for health care workers is widely acknowledged, but the identification of optimal implementation strategies remains a challenge, particularly in academically isolated rural areas. We report the results of a qualitative study that evaluated the effect of an educational intervention aimed at rural doctors in the Western Cape Province, South Africa. We also present a conceptual framework for developing best practice educational strategies to reverse the inverse performance spiral in academically isolated rural hospitals. Doctors felt that participation in relevant learning activities improved their competence, increased the levels of job satisfaction they experienced, increased their willingness to stay in a rural environment, and impacted positively on the quality of services provided. However, the success of educational strategies is heavily dependant on the local environment (context), as well as the practical applicability and clinical relevance of the activities (process). Successful educational strategies may help to reverse the inverse performance spiral previously described in academically isolated rural hospitals, however, this requires effective local leadership that creates a positive learning environment and supports clinically relevant learning activities. The study findings also indicate the need for health care providers and institutions of higher education to join forces to improve the quality of rural health care.

Developing an educational research framework for evaluating rural training of health professionals: A case for innovation

Background: World-wide, rural clinical training of undergraduate medical students is looking to transform learning experiences, calling for the adoption of innovative approaches that create spaces for curriculum renewal and new ways of thinking. In order for these teaching models to gain acceptance and credibility among the relevant academic communities, it is critical that they be studied and evaluated. Aim: This article describes an innovative rural education intervention and a concomitant, intentional process that was adopted to establish a research framework within which the intervention will be evaluated. Methods: Key role-players participated in a one-day workshop aimed at developing the framework. A collaborative, structured process that moved through three phases of deliberation and reflection was followed. Results: The documentation and raw data generated during the workshop was used to generate the framework that will serve as a blueprint for ensuring the study and evaluation of the educational innovation. Conclusion: Establishing an educational research framework, by adopting a consultative and collaborative process, provides a vehicle for encouraging a culture of critical accountability that seeks to discern evidence of good practice in the training of health care workers in a rural context.

‘We have to flap our wings or fall to the ground’: The experiences of medical students on a longitudinal integrated clinical model

Background: In 2011, Stellenbosch University introduced a district hospital-based longitudinal integrated model for final-year students as part of its rural clinical school. The present study is an analysis of students’ experiences during the first 3 years of the programme. Methods: All 13 students who started the programme between 2011 and 2013 were interviewed. Thematic networks linking recurrent issues were developed and transcripts were analysed against this framework using ATLAS.ti. Results: Two major themes emerged. These were ‘preparation for being a doctor’ and ‘academic/exam preparation’. Students were overwhelmingly positive about the working atmosphere and their preparation for clinical practice and felt that their learning had been facilitated by the flexibility of the programme and the requirement to take responsibility. This contrasted with their academic (‘book’) learning, which was characterised by uncertainty about expectations, particularly regarding exams and parity with learning at the central teaching hospital. The flexibility of the integrated approach was seen as a problematic lack of structure when it came to academic learning. Negative academic emotions were compounded by some frustration about administrative issues early in the programme. Conclusions: The district hospital-based longitudinal integrated model has great potential as a teaching platform for final-year students; however, students remain concerned about academic learning. Potential strategies to reduce student anxiety include more opportunities for dialogue between rural students and specialist teaching platforms, clearly communicated expectations – both about what the students can expect from the programme and about what is expected from them – and administrative excellence.

Academic achievement of final-year medical students on a rural clinical platform: Can we dispel the myths?

Background: There is a growing body of literature relating to the establishment of rural clinical training platforms for medical students describing many positive outcomes, particularly in the case of extended placements. However, students’ fears about their academic achievement while at these sites remain a key concern. Objectives: The study set out to compare the academic achievement in end-of-rotation assessments and final examinations of final-year medical students at a rural clinical school (RCS) with those of their peers at the academic hospital complex (AHC). Methods: A cross-sectional study, comparing the marks of three successive cohorts of RCS and AHC students (2011 - 2013) using t-tests and confirmed with non-parametric rank-sum tests, was conducted. The consistency of the effect of these results across cohorts was assessed by fitting regression models with interaction terms between cohort and group, and tested for significance using F-tests. Independent t-tests were conducted to evaluate differences in the mark attained between the two groups. A p -value <0.05 was considered statistically significant. Results: Comparison of student marks attained across six of the disciplines offered at the RCS suggested there was no difference between the RCS and AHC in each of the three cohorts at baseline. A comparison of the end-of-rotation means showed that RCS students achieved significantly better results in some disciplines. A similar trend was observed for the final examination results across all seven disciplines. Conclusion: Despite small numbers, this study suggests that students who spend their final year at the RCS are not disadvantaged in terms of their academic achievement. Medical students’ concerns regarding academic achievement for those placed at rural clinical sites appear to be unfounded. Students who potentially could be placed at these sites should be made aware of this evidence.

Building quality mHealth for low resource settings

Abstract In low- and middle-income countries (LMIC), community health care workers (CHCW) are the primary point of care for millions of people. Mobile phone health applications (mHealth app) are the preferred technology platform to deliver clinical support to CHCW. In LMIC, limited regulatory oversight exists to guide quality and safety for medical devices, including mHealth. During the development of a mHealth app to assist CHCW with patient assessment and clinical diagnosis in rural South Africa, we applied human-centred design (HCD) and a bioethics consultation. The HCD approach enabled us to develop a mHealth app that responded to the needs and capacities of CHCW. The bioethics consultation prompted early consideration of safety concerns, social implications of our mHealth app and our technology’s impact on the CHCW-patient relationship. In this study, we found that combining a HCD approach with bioethics consultation improved the design quality and reduced safety concerns for our mHealth app.

Challenges to creating primary care teams in a public sector health centre: A co-operative inquiry

Abstract Background Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care, family-orientated care, and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs. Methods A co-operative inquiry group, consisting of two facility managers, an administrator, and medical and nursing staff, met over a period of nine months and completed three cycles of planning, action, observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care could be created within a typical CHC. Results The CHC established three practice teams, but met with limited success in maintaining the teams over time. The group found that, in order for teams to work, the following are needed: A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors, but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of “chronics”. Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available. Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an “assistant” who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation, while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks, thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available, while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs, who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs, however, the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialize. Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day, to be cognisant of the limitations of the building design, to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered, and not just that for the doctors and nurses. Conclusion Key lessons learnt included the need to engage with a transformational leadership style, to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team, due to their hospital duties, was a critical factor in the breakdown of the teams. The CHC plans to further develop practice teams, to learn from the lessons so far and to continue with the co-operative inquiry.

A medical audit of the management of cryptococcal meningitis in HIV-positive patients in the Cape Winelands (East) district, Western Cape

Abstract Background: Cryptococcal meningitis (CM) has become the most common type of community-acquired meningitis. CM has a poor outcome if the initial in-hospital treatment does not adhere to standard guidelines. The aim of this audit was to improve the quality of the care of human immunodeficiency virus (HIV) positive patients with CM in the Cape Winelands District. Method: Following an initial audit in 2008, the researchers and a new audit team introduced interventions, and planned a second audit cycle. The folders of 25 HIV-positive adults (admitted to three district hospitals, one regional hospital, and one tuberculosis hospital) were audited. Results: Spinal manometry was performed more consistently in the regional hospital, than in the district hospitals. Reasons for failing to reach the 14-day amphotericin B target were in-patient deaths, drug stock problems, and renal impairment. The renal monitoring of amphotericin B treatment was suboptimal. The quality of care at district hospitals appeared to be comparable to that found at the regional hospital. The in-patient referral for antiretroviral treatment (ART) counselling was better in the district hospital setting. However, both levels of care had difficulty in achieving the four-week target between the onset of amphotericin B and onset of ART. Conclusion: Deficiencies in the quality of care remained. Between the prior and current audit cycles, there was no consistent improvement in care at the regional hospital. An integrated care pathway document has been developed, and adopted as policy in the Cape Winelands district. Its impact on the quality of care will be evaluated by a dedicated audit team in the future.

The learning plan as a reflective tool for trainers of family medicine registrars

Van Deventer C, MBChB(Stell), MFamMed(MEDUNSA) Principal Family Physician and Senior Lecturer, Unversity of Witwatersrand Conradie HH, MBChB(Stell), DCH(SA), MPraxMed(MEDUNSA) Senior Family Physician and Senior Lecturer, University of Stellenbosch Moosa SAH, MBChB(Natal), PHC Mgmt(Wits), MMed(FamMed)(MEDUNSA) Family Physician and Lecturer, University of Witwatersrand Morris G, MBChB(Pret), DTM&H(Wits) MPraxMed(MEDUNSA) Family Physician and Lecturer, Nelson Mandela Medical School Smith S, MBChB(UOVS), MPraxMed(Pret) Family Physician and Senior Lecturer, University of Pretoria Van Rooyen M, MBChB(Pret), MMed(FamMed)(Pret) Family Physician and Senior Lecturer, University of Pretoria Derese A, MD, PhD Centre for Education Development, Department of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Ghent University De Maeseneer J, PhD Head of Department of Family Medicine and Primary Health Care, Chairman Interuniversity Co-operation for Family Medicine training in Flanders

Teaching Medical Students in a New Rural Longitudinal Clerkship: Opportunities and Constraints

Background: Medical schools in Africa are responding to the call to increase numbers of medical graduates by up-scaling decentralized clinical training. One approach to decentralized clinical training is the longitudinal integrated clerkship (LIC), where students benefit from continuity of setting and supervision. The ability of family physician supervisors to take responsibility for the clinical training of medical students over a longer period than the usual, in addition to managing their extensive role on the district health platform, is central to the success of such training. Objective: This study investigated the teaching experiences of family physicians as clinical supervisors in a newly introduced LIC model in a rural sub-district in the Western Cape, South Africa. Method: Nine semi-structured interviews were conducted with six family physicians as part of the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) five-year longitudinal study. Code lists were developed inductively using Atlas.ti v7, they were compared, integrated, and categories were identified. Emerging common themes were developed. Findings: Three overarching themes emerged from the data, each containing subthemes. The rural platform was seen to be an enabling learning space for the LIC students. The family physicians’ experienced their new teaching role in the LIC as empowering, but also challenging. Lack of time for teaching and the unstructured nature of the work emerged as constraints. Despite being uncertain about the new LIC model, the family physicians felt that it was easier to manage than anticipated. Conclusion: The centrality of the rural context framed the teaching experiences of the family physicians in the new LIC, forming the pivot around which constraints and opportunities for teaching arose. The African family physician is well positioned to make an important contribution to the upscaling of decentralized medical training, but would need to be supported by academic institutions and health service managers in their teaching role.

Integrating tuberculosis/HIV treatment: an evaluation of the tuberculosis outcomes of patients co-infected with tuberculosis and HIV in the Breede Valley subdistrict

Abstract Background: The Infectious Disease Clinic of Worcester Hospital introduced an integrated tuberculosis/human immunodeficiency virus (HIV) service in July 2009 to provide comprehensive management to patients who were co-infected with tuberculosis and HIV. Method: In a retrospective cohort study that was carried out from 1 July 2009 to 31 March 2010, the tuberculosis outcomes of co-infected patients attending the Infectious Disease Clinic for antiretroviral (ARV) treatment and receiving their tuberculosis medication at the Infectious Disease Clinic, were compared with those of patients receiving ARV treatment at the Infectious Disease Clinic and tuberculosis treatment at their local clinic. Results: Seventy-four per cent of patients completed their treatment and 26% were cured, with no defaults or deaths, in the tubercuolosis/HIV integrated cohort. Thirty-eight per cent completed their treatment, 45% were cured, 9% died and another 9% defaulted in the cohort receiving their tuberculosis treatment at a local clinic. This indicates that there was a significantly better tuberculosis outcome in the tuberculosis/HIV cohort (p-value < 0.05). Conclusion: The significantly better tuberculosis outcome that resulted when tuberculosis and HIV services were integrated led to services being integrated in the Breede Valley subdistrict.