Louis Jenkins

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.

Non-compliance with treatment by epileptic patients at George Provincial Hospital

Abstract Background Non-compliance with anti-epileptic drug treatment in the George area, resulting in recurrent seizures and visits to the emergency department of the George Provincial Hospital, has been identified as a social and economic problem. The aim of this study was to determine the socio-economic and medical factors, the information given to patients by healthcare workers, and the understanding of patients living with epilepsy who presented to the emergency department with seizures. Methods A descriptive study design was employed and the data-collection tools were a questionnaire and structured interview. Results The median age of the study population was 32 years. The patients had suffered from epilepsy for a median of two years and visited a clinic for a median of seven times a year. The median education level was primary school and three quarters had no employment or government grant. The majority did not understand the disease, the side effects of the medication and why they should be on medication. In addition, it became apparent from patient reports that healthcare workers showed a lack of counselling skills, time and appropriate knowledge. Conclusions There is a general lack of understanding of epilepsy by the patient. Not only were the patients uninformed, but they also showed apathy towards the management of their condition.

The national portfolio for postgraduate family medicine training in South Africa : a descriptive study of acceptability, educational impact, and usefulness for assessment

BackgroundSince 2007 a portfolio of learning has become a requirement for assessment of postgraduate family medicine training by the Colleges of Medicine of South Africa. A uniform portfolio of learning has been developed and content validity established among the eight postgraduate programmes. The aim of this study was to investigate the portfolio’s acceptability, educational impact, and perceived usefulness for assessment of competence.MethodsTwo structured questionnaires of 35 closed and open-ended questions were delivered to 53 family physician supervisors and 48 registrars who had used the portfolio. Categorical and nominal/ordinal data were analysed using simple descriptive statistics. The open-ended questions were analysed with ATLAS.ti software.ResultsHalf of registrars did not find the portfolio clear, practical or feasible. Workshops on portfolio use, learning, and supervision were supported, and brief dedicated time daily for reflection and writing. Most supervisors felt the portfolio reflected an accurate picture of learning, but just over half of registrars agreed. While the portfolio helped with reflection on learning, participants were less convinced about how it helped them plan further learning. Supervisors graded most rotations, suggesting understanding the summative aspect, while only 61% of registrars reflected on rotations, suggesting the formative aspects are not yet optimally utilised. Poor feedback, the need for protected academic time, and pressure of service delivery impacting negatively on learning.ConclusionThis first introduction of a national portfolio for postgraduate training in family medicine in South Africa faces challenges similar to those in other countries. Acceptability of the portfolio relates to a clear purpose and guide, flexible format with tools available in the workplace, and appreciating the changing educational environment from university-based to national assessments. The role of the supervisor in direct observations of the registrar and dedicated educational meetings, giving feedback and support, cannot be overemphasized.

Drug interactions in primary health care in the George subdistrict, South Africa: a cross-sectional study

Abstract Objectives: To investigate the prevalence of potential drug-drug interactions in primary healthcare clinics in the George subdistrict, to determine which drugs were involved, and to identify associated risk factors. Design: A cross-sectional retrospective folder review was performed. Setting and subjects: Four hundred randomly selected patient files from four primary care clinics in the George subdistrict. Outcome measures: The prevalence of potential drug-drug interactions in primary care, drugs involved in potential drug-drug interactions and associated risk factors. Results: The prevalence of scripts containing at least one moderate potential interaction was 42%; severe potential interaction, 5.25%; and contraindicated combinations, 0.5%. The most common drugs involved were enalapril, aspirin, ibuprofen, furosemide and fluoxetine. The most common implicated drugs in potentially severe interactions were warfarin, aspirin, fluoxetine, tramadol and allopurinol. Two contraindicated combinations were found, namely verapamil plus simvastatin, and hyoscine butyl bromide plus oral potassium chloride. Advancing age and polypharmacy were associated with an increased risk of potential drug-drug interactions. Input from the regional hospital specialist departments greatly increased the risk of a patient being given a prescription that contained a potential drug-drug interaction. Eighty one per cent of severe interactions were from this group. Conclusion: The potential for drug-drug interactions occurring was common in primary healthcare clinics in the George subdistrict. Drug interactions are predictable and preventable. The risk factors identified in this study may assist in the design of interventions that reduce the risk.

Development of a portfolio of learning for postgraduate family medicine training in South Africa: a Delphi study

BackgroundWithin the 52 health districts in South Africa, the family physician is seen as the clinical leader within a multi-professional district health team. Family physicians must be competent to meet 90% of the health needs of the communities in their districts. The eight university departments of Family Medicine have identified five unit standards, broken down into 85 training outcomes, for postgraduate training. The family medicine registrar must prove at the end of training that all the required training outcomes have been attained. District health managers must be assured that the family physician is competent to deliver the expected service. The Colleges of Medicine of South Africa (CMSA) require a portfolio to be submitted as part of the uniform assessment of all registrars applying to write the national fellowship examinations. This study aimed to achieve a consensus on the contents and principles of the first national portfolio for use in family medicine training in South Africa.MethodsA workshop held at the WONCA Africa Regional Conference in 2009 explored the purpose and broad contents of the portfolio. The 85 training outcomes, ideas from the WONCA workshop, the literature, and existing portfolios in the various universities were used to develop a questionnaire that was tested for content validity by a panel of 31 experts in family medicine in South Africa, via the Delphi technique in four rounds. Eighty five content items (national learning outcomes) and 27 principles were tested. Consensus was defined as 70% agreement. For those items that the panel thought should be included, they were also asked how to provide evidence for the specific item in the portfolio, and how to assess that evidence.ResultsConsensus was reached on 61 of the 85 national learning outcomes. The panel recommended that 50 be assessed by the portfolio and 11 should not be. No consensus could be reached on the remaining 24 outcomes and these were also omitted from the portfolio. The panel recommended that various types of evidence be included in the portfolio. The panel supported 26 of the 27 principles, but could not reach consensus on whether the portfolio should reflect on the relationship between the supervisor and registrar.ConclusionA portfolio was developed and distributed to the eight departments of Family Medicine in South Africa, and the CMSA, to be further tested in implementation.

The national portfolio of learning for postgraduate family medicine training in South Africa: experiences of registrars and supervisors in clinical practice

BackgroundIn South Africa the submission of a portfolio of learning has become a national requirement for assessment of family medicine training. A national portfolio has been developed, validated and implemented. The aim of this study was to explore registrars’ and supervisors’ experience regarding the portfolio’s educational impact, acceptability, and perceived usefulness for assessment of competence.MethodsSemi-structured interviews were conducted with 17 purposively selected registrars and supervisors from all eight South African training programmes.ResultsThe portfolio primarily had an educational impact through making explicit the expectations of registrars and supervisors in the workplace. This impact was tempered by a lack of engagement in the process by registrars and supervisors who also lacked essential skills in reflection, feedback and assessment. The acceptability of the portfolio was limited by service delivery demands, incongruence between the clinical context and educational requirements, design of the logbook and easy availability of the associated tools. The use of the portfolio for formative assessment was strongly supported and appreciated, but was not always happening and in some cases registrars had even organised peer assessment. Respondents were unclear as to how the portfolio would be used for summative assessment.ConclusionsThe learning portfolio had a significant educational impact in shaping work-place based supervision and training and providing formative assessment. Its acceptability and usefulness as a learning tool should increase over time as supervisors and registrars become more competent in its use. There is a need to clarify how it will be used in summative assessment.

What keeps health professionals working in rural district hospitals in South Africa

Background The theme of the 2014 Southern African Rural Health Conference was ‘Building resilience in facing rural realities’. Retaining health professionals in South Africa is critical for sustainable health services. Only 12% of doctors and 19% of nurses have been retained in the rural areas. The aim of the workshop was to understand from health practitioners why they continued working in their rural settings. Conference workshop The workshop consisted of 29 doctors, managers, academic family physicians, nurses and clinical associates from Southern Africa, with work experience from three weeks to 13 years, often in deep rural districts. Using the nominal group technique, the following question was explored, ‘What is it that keeps you going to work every day?’ Participants reflected on their work situation and listed and rated the important reasons for continuing to work. Results Five main themes emerged. A shared purpose, emanating from a deep sense of meaning, was the strongest reason for staying and working in a rural setting. Working in a team was second most important, with teamwork being related to attitudes and relationships, support from visiting specialists and opportunities to implement individual clinical skills. A culture of support was third, followed by opportunities for growth and continuing professional development, including teaching by outreaching specialists. The fifth theme was a healthy work-life balance. Conclusion Health practitioners continue to work in rural settings for often deeper reasons relating to a sense of meaning, being part of a team that closely relate to each other and feeling supported.

The after-hours case mix of patients attending the George Provincial Hospital Emergency Centre

Background: The emergency care of patients in South Africa has improved with the establishment of Emergency and Family Medicine as specialities, the introduction of the Cape Triage Scoring (CTS), and the upgrading of emergency care services. The Western Cape Comprehensive Service Plan stipulates that 90% of care should be delivered through primary and district (level 1) services, 8% through general specialist (level 2) services and 2% through super-specialist (level 3) services. Many patients needing level 1 care present after hours at level 2 facilities. This study was undertaken to determine the after-hours emergency centre case mix and workload at George Provincial Hospital Emergency Centre. Method: This was a descriptive retrospective study. Using the CTS, emergency centre staff triaged 2 560 patients who presented for care after hours in May 2010. The data were entered and analysed in MS Excel®. The case mix and workload were then determined. Results: Adults comprised 75% of the case mix. Sixty-five per cent of patients had routine (CTS “green”) complaints, 27% had urgent (CTS “yellow”) complaints, 5% had very urgent complaints (CTS “orange”) and 2% needed immediate care (CTS “red”). Trauma, respiratory and gastrointestinal problems were the most common presentations. The workload during the study period from 1–31 May 2010 included 54 patients after hours on weekdays, 138 patients per 24-hour (08h00-08h00) weekend days and 147 on public holidays. Conclusion: This study showed that 47% of patients who presented after hours at the George Provincial Hospital Emergency Centre required primary or level 1 care. These patients could be more appropriately managed at a level 1 facility.

Reliability testing of a portfolio assessment tool for postgraduate family medicine training in South Africa

Abstract Background Competency-based education and the validity and reliability of workplace-based assessment of postgraduate trainees have received increasing attention worldwide. Family medicine was recognised as a speciality in South Africa six years ago and a satisfactory portfolio of learning is a prerequisite to sit the national exit exam. A massive scaling up of the number of family physicians is needed in order to meet the health needs of the country. Aim The aim of this study was to develop a reliable, robust and feasible portfolio assessment tool (PAT) for South Africa. Methods Six raters each rated nine portfolios from the Stellenbosch University programme, using the PAT, to test for inter-rater reliability. This rating was repeated three months later to determine test–retest reliability. Following initial analysis and feedback the PAT was modified and the inter-rater reliability again assessed on nine new portfolios. An acceptable intra-class correlation was considered to be > 0.80. Results The total score was found to be reliable, with a coefficient of 0.92. For test–retest reliability, the difference in mean total score was 1.7%, which was not statistically significant. Amongst the subsections, only assessment of the educational meetings and the logbook showed reliability coefficients > 0.80. Conclusion This was the first attempt to develop a reliable, robust and feasible national portfolio assessment tool to assess postgraduate family medicine training in the South African context. The tool was reliable for the total score, but the low reliability of several sections in the PAT helped us to develop 12 recommendations regarding the use of the portfolio, the design of the PAT and the training of raters.

An evaluation of factors underlying suicide attempts in patients presenting at George Hospital emergency centre

Background: Roughly 130 patients are seen daily in the emergency centre (EC) at George Provincial Hospital (GPH), of whom one or two will have attempted suicide. GPH serves the population of Eden and Central Karoo Districts. Little is known about the circumstances surrounding these suicide attempts. We examined this pattern and formulated a protocol for managing these patients. Method: All patients attending the EC after attempting suicide between December 2010 and April 2011 were identified from the EC register. Thirty nine patients gave consent and completed a questionnaire. The data were analysed in Excel®. Additional information was obtained from five members of a focus group. Results: Patients who attempted suicide had often attempted suicide previously. They came from a community with high levels of longstanding financial and domestic stress, violence, dysfunctional family relationships, alcohol abuse and poor coping skills. Suicide attempts generally involved impulsively taking prescription medication following an argument with a family member. Patients felt abandoned or alone, were physically or mentally abused, were subjected to alcohol abuse, or had underlying anxiety or depression. Conclusion: Patients who attempt suicide and attend GPH EC come from a chronically stressed community with dysfunctional family patterns and alcohol abuse and lack coping skills. A psychological support team has introduced a suicide-attempt protocol in the EC offering patients an opportunity to deal with their distress and learn better coping skills.