Abstract
Background: The South African–Cuban Medical Collaboration programme aims to alleviate the critical shortage of practitioners in local South African rural settings. The students who return from Cuban-based facilities in their fourth year experience difficulty, especially in clinical settings, upon joining the MB ChB final-year student programme at the University of KwaZulu-Natal. Attempts to support their skills acquisition for local practice have led to an investigation of their prior clinical skills exposures, the curricular context and exposures in Cuba in which skills had been acquired, and students’ perceptions of their competence in clinical skills.
Methods: This descriptive, cross-sectional study explored the clinical experiences of the 2013 cohort of students. Qualitative and quantitative data were collected through questionnaires that explored the curricular approach and setting of clinical skills training in Cuba, the students’ exposure to clinical skills and their perceptions of their competence at performing these skills.
Results: Students experienced the Cuban curriculum as didactic and lecture intensive as opposed to the systematic, problem-based curriculum offered in South Africa. Clinical training in Cuba occurs in hospital wards while local students first train in a clinical skills laboratory prior to hospital exposures. The majority of students self-reported a lack of clinical exposure to 35 of an overall 75 core-skills list as identified by the undergraduate UKZN curriculum. In addition, they reported an inability to perform 71 of the 75 (95%) skills independently.
Conclusion: This study has highlighted a mismatch between the focus and scope of clinical training offered to students studying in Cuba and those at a South African institution.
Introduction
South Africa’s (SA) critical shortage of doctors is reflected in the ratio that estimates the number of doctors as being approximately 0.57 per 1 000 people. This ratio compares poorly with the average 2–5 doctors per 1 000 people as reported in developed countries.Citation1 The shortage is even more apparent in rural areas where approximately 43% of the population often face greater health challenges such as having access to a mere 12% of the medical workforce.Citation2 Efforts to address the critical health worker shortage have seen the SA government entering into various initiatives. The collaboration with the Cuban government to train local SA students in Cuban medical facilities was undertaken with the ultimate aim to return to local, rural medical practice.Citation3
The first group of 92 students began their Cuban medical training in 1996.Citation4 The South African–Cuban Medical Collaboration (SACMC) programme entails the recruitment of black, disadvantaged high school graduates from rural provinces in SA for medical training in Cuba. All students on this programme are offered a full scholarship with the understanding that they would return to SA rural provinces to practise in the public sector in rural and underserved areas of SA for the same amount of time they spent training in Cuba.Citation4
Students on the programme study in Cuba for the first 6 of a 7.5 year programme. The first year at the Cuban institute involves receiving premedical bridging training during which students become proficient in Spanish for instruction at the Cuban facilities. The SACMC students then spend two years studying the basic sciences followed by three years of clinical sciences at one of three collaborating Cuban medical training facilities. After these six years of university training in Cuba, the SACMC students join one of eight SA medical schools for 18 months of SA training. At the time of the study, the University of KwaZulu-Natal (UKZN) had a five-year MB ChB.
Students on the SACMC scholarship programme who returned to the Nelson R. Mandela School of Medicine (NRMSM) of the UKZN in 2013 joined the local fourth-year class in the second semester of their training. They spent four to six months adjusting to the SA clinical setting without having had to take any of the examinations. The SACMC students joined the local fifth-year class at the start of the new academic year to continue in the SA curriculum. This entailed participating in clinical rotations, attending ward rounds, clerking patients, keeping logbooks and completing the block assessments and clinical examinations with their peers who were completing the local medical programme at the NRMSM. During this time the students became familiar with the SA health care system to complete their training as required to practise as an intern in SA. In general, the SACMC students complete the SA examinations and a final examination as set by examiners in Cuba and then graduate with their medical degree. Figure provides a diagrammatic overview of the structure of the SACMC programme and the students’ movement between the programmes and the countries.
Figure 1: Process and flow of SACMC students.
The SACMC students return to SA before having reached the end point in the Cuban curriculum. Interactions with SACMC students who join the SA group suggest that they face many challenges during their reintegration. The challenges include adjusting to the academic and social context in SA. The SACMC students experienced specific difficulty in passing the clinical examinations in the fifth year of the SA MBChB programme. Prior to the conduct of this study in 2013, records indicated that 50% of SACMC students repeated one or more clinical blocks of the fifth year.Citation5
In an attempt to assist the collaboration students with their transition and adaptation, the school instituted a formal programme in 2012 to supplement their academic experiences. Local academics who are involved in the training of the students do not always understand the full extent of the students’ prior clinical experience in Cuba, nor do they know with certainty how the SACMC students’ prior curriculum had prepared them for local practice. The successful design of any intervention programme, however, rests on an accurate diagnosis of the academic needs of the students. In the absence of local and international research comparing the design and outcomes of the SACMC training institutions and their programmes, this study investigated the nature and scope of the SACMC students’ clinical training prior to joining the local institution.
Findings from this study are important since the SA–Cuban medical training collaboration programme is set to continue for at least another decade with plans to increase the student intake to meet the growing health care demands.Citation6 There is thus a great need to ensure that the students are adequately supported and competent to practise in predominantly rural communities.
At the time of the study, the SA medical curriculum consisted of a five-year problem-based learning programme.Citation7 Years one to three includes a set of clinical and procedural skills that is taught in combination with the various modules which the programme comprises. The clinical skills are demonstrated and taught in a clinical skills laboratory. Physical examination techniques are demonstrated on simulated patients and on plastic models. Procedural skills are demonstrated on models and communication skills are demonstrated using simulated patients who have been trained to act like patients and are therefore able to give the relevant responses to questions. Another characteristic of the NRMSM MB ChB programme is vertical integration of content, which allows for the repetition of essential skills within the three years. As an example, basic resuscitation skills are repeated and presented in an increasingly complex way over three years. Students gradually develop their expertise in clinical skills. Once a student has entered the fourth year of study, these basic skills are considered part of the required core knowledge.Citation8 This study was thus conducted to determine the curricular approach and setting of clinical skills training received by the SACMC programme students in UKZN, their exposure to clinical skills and their perceived competence in clinical skills.
Methods
Research design
This descriptive, cross-sectional study was conducted at the NRMSM in the second semester of 2013. Quantitative and qualitative data were collected on the SACMC collaboration programme students’ prior clinical skills training experiences in terms of the curricular approach and settings, their exposure to clinical skills and their perceptions of their clinical competence upon reintegration into the South African medical landscape. An inductive phenomenological approach was chosen over the traditional positivist methodology as the study does not intend to prove or disprove any hypothesis but seeks to explore perceptions of students’ reality.
Study area/setting
The NRMSM has been involved with the SACMC programme from its onset. Students have been coming to the university for over a decade.
Study sample
Purposive sampling was used, which means that a sample is purposely selected for its potential to yield insight into the phenomenon. The participants of the study are selected to serve a specific purpose, i.e. to gather data from information-rich sources. The purposive sample of all 11 South African students who had studied on the SACMC programme and who returned to SA during the fourth year of the UKZN MB ChB programme were invited to participate. This sampling strategy offered the greatest potential to yield insight into the clinical skills experience and perceptions of the participants.Citation9
Data collection
Data were collected through two self-administered questionnaires that were completed sequentially. The first questionnaire dealt with general demographic details, and the philosophy and setting of clinical skills exposure in the Cuban curriculum. The second questionnaire was a clinical skills questionnaire that elicited information on 75 clinical skills relating to 9 categories including: communication, resuscitation, adult examination, newborn examination, general procedural skills, specimen collection, obstetrics and gynaecology procedures, airway management procedures and radiological interpretation. The selected skills (see Table in addendum) are the core requirement for undergraduate students studying on the MB ChB programme at the NRMSM.Citation8
Table 1: Matthews’ (2012) list of skills within nine clinical skills categories at NRMSMCitation8 (moved to addendum)
For each of the listed clinical skills, participants indicated:
| (a) | the setting in which the skill had been taught (lecture, ward, or skills laboratory); | ||||
| (b) | their exposure to the skill (taught the skills yes/no); | ||||
| (c) | their perceived ability to perform the skill (i.e. able to perform the skill independently; able to perform with supervision, able to perform after revision, not willing to attempt it at all). | ||||
Data analysis
Quantitative data collected from the clinical skills questionnaire were entered onto an Excel™ (Microsoft Corp, Redmond, WA, USA) spreadsheet and each item was analysed with basic descriptive statistics. Qualitative data from the first questionnaire concerning the curricular approach and the settings of clinical skills teaching were analysed in response to the questions.
Ethical approval was obtained from the Humanities and Social Science Research Ethics Committee of the UKZN. Individual consent was obtained from each respondent after he/she had been informed of the nature and purpose of the study; his/her rights in terms of voluntary participation; and having been given assurance of confidentiality and anonymity. All 11 students agreed to participate and signed the informed consent form.
Limitations of the study
Questionnaires were used to collect students’ perception of performance rather than assessing their performance. The questionnaires were administered to the students after a week-long exposure to an orientation-intervention programme, which included an overview of clinical skills from the UKZN curriculum perspective. Students’ very recent exposure to the skills might have impacted on their confidence.
Results
Demographic characteristics
Eleven students from the SACMC programme joined the NRMSM at UKZN in 2013. All 11 students agreed to participate in the study. All the students are SA citizens, four students are female and the average age of the group at the time of the study was 26 years. Students had attended the local rural schools in their respective areas while growing up. For five this included schools in the Limpopo province; another five matriculated from KwaZulu-Natal and one was from the Eastern Cape.
Curriculum approach and setting
The students attended one of three universities during their six-year medical training period in Cuba. Four students in this sample studied at Cienfuegos, three at Villa Clara and the remainder at Sancti Spiritus. The style of teaching at the Cuban institutions was predominantly a didactic and theoretically oriented curriculum as reported by six of the students. Four students studied in a problem-based learning curriculum and one student indicated that theoretical lectures and problem-based learning methods were equally used during her studies in Cuba. Clinical skills for all 11 students were taught either theoretically in lectures and tutorials or during ward rounds, with no exposure to simulated clinical skills laboratories. All the students reported having had inadequate time and exposure to patients on whom to practise clinical skills.
Table presents the clinical skills in the nine categories on which students were asked to rate themselves. They rated their exposure to the clinical skills and their perceived competence in the listed skills. Students who studied in Cuba reported no exposure to 35 of 75 skills. They therefore had some or good exposure to 40 skills in total. Table also gives a breakdown of the data on students’ perceived competence in the skills that they had been exposed to in Cuba.
Table 2: Skill exposure and perceived competence in clinical skills
There were only 4 of a possible 75 skills where at least six SACMC students perceived themselves as being competent. The skills were general history taking, respiratory history taking, gastrointestinal history taking and the taking of body temperature.
Discussion
The discussion will first deal with the curricular approach and the setting in which the SACMC students received clinical skills training, then the students’ clinical skills exposure in Cuba and their perceived competence in the listed clinical skills.
Curricular approach and setting
As far as the setting and curricular approach in which the students received clinical skills in Cuba are concerned, the results indicate that the SACMC students reported having received predominantly theoretical information on most of the clinical skills in lectures and wards with no exposure to simulated laboratories. Skills training at the NRMSM entails a system where students first receive a theoretical and practical overview of the skill. They then practice on low-fidelity models and peers and ultimately revisit the skill when working under supervision with patients. Research on clinical skills acquisition using traditional methods of clinical medical education versus simulation-based methods with deliberate practice shows that clinical skills acquired in simulated settings are superior to traditional ward-based settings and transfer directly to better patient care and outcomes.Citation10 However, the use of simulation does not intend to replace the need for learning in clinical working environments; it simply serves to help students prepare for clinical environments and ultimately to improve their clinical experiences.Citation11
Clinical skills exposure
The results indicate that the students lacked exposure to adequate clinical skills training with exposure to only 40 of the 75 skills. The lack of clinical skills exposure possibly relates to misalignment of the curricula both in terms of student placement at a particular institution and in terms of the academic year when the skills are taught in the curriculum and the setting where skills teaching occurs. For example, in the teaching of resuscitation skills, the use of a defibrillator and CPR is introduced much later in the Cuban curriculum than in the UKZN curriculum.Citation12 Local Cuban students who continue and complete the degree in Cuba would therefore receive adequate exposure to the skills after their fifth year of study in Cuba.Citation11 The students who, however, join the SA programme have missed exposure and need additional sessions to cover the missed skills. The fact that the exchange students return to SA before reaching the end point in the Cuban curriculum leaves them poorly prepared and disoriented upon entering the last 18 months of the SA curriculum.
Perception of skills competence
The SACMC students’ perception of competence in clinical skills was poor. Of 75 clinical skills the students perceived themselves to be competent in 4 skills. Students felt poorly prepared in the majority of listed clinical skills to which SA students had been exposed during the first three years. It is also possible that their perceptions might stem from an inability to transfer their knowledge between the different heath care contexts and environments. Perceived incompetence could be due to issues around cultural competence affecting student confidence levels. The interplay among language, culture and environmental differences would affect students’ adaptation to a new training institution. The context of clinical practice differs in terms of disease profiles, the majority of patients being Zulu language speakers as opposed to Spanish speakers, as well as differing in socio-economic status and the poor knowledge and understanding of health by the local population as opposed to the more knowledgeable Cuban population.Citation13 The implication of curricular misalignment also impacts on students’ confidence since they are expected by clinical teachers to perform the skills as well as their local peers. It is also possible that students’ self-perception of their competence is not an objective assessment of their ability.Citation14
The use of the skills laboratory and simulated environments from the first year of study would impact on the students’ confidence. Ward-based, primary care environments sometimes offer fewer practice opportunities and less control over clinical exposures than planned-for simulated environments. The literature shows that medical students tend to perceive themselves as more competent when given the opportunity to practise their skills.Citation15 Coberly noted that procedural performance correlates well with feelings of competency.Citation14 Since participants in this cohort did not have sufficient exposure or practice in clinical procedures prior to joining UKZN, the lack of performance is likely to have influenced their perceptions of competence in clinical skills.
Recommendations
The SACMC students have already spent a substantial period in Cuba and have adequate theoretical knowledge and therefore require supplementation of their clinical skills to be prepared for the local SA health care context. This preparation needs to be part and parcel of the SACMC programme to ensure that the students are adequately prepared to meet the requirements of the university and the health care needs of the population that they will ultimately serve. Governmental policies between the Cuban and SA governments should also reflect that this has been taken into consideration and adequately implemented.
For the continued success of the collaboration programme we can recommend better alignment of the curricula between Cuba and SA to facilitate the ease of transition by students. SA universities receiving students from Cuba must therefore plan a well-structured orientation and intervention programme in clinical skills to ensure that students receive adequate preparation to complete their studies successfully. It is therefore recommended that participating schools share information relating to the sequence and philosophies of their training programme to improve the alignment of the curricula between training in the different settings. This will ensure that the intended learning outcomes expected from students in the ultimate practice setting become transparent and attainable.
Recommendations for policy and practice include the responsibility of universities to understand the problems and challenges facing incoming students and facilitate good remedial programmes to assist in attaining cultural competence. This will ensure that students are able to continue with their studies with minimal problems and graduate as soon as possible. Such intervention programmes should include language and terminology acquisition, such as the learning of isiZulu, the local national language, the learning of medical terminology in English, the ethics of dealing with HIV-positive patients and acquisition of more patient-centred approaches.
Conclusions
This study has provided valuable insight into the perceptions and perceived competence of the SAMC students in clinical skills upon joining the final year at the NRMSM. It has identified the skills in which students require additional training for future practice. There seems to be some misalignment between the content and approaches followed in clinical training programmes offered in Cuba and at the NRMSM. There is a need to ensure that training be aligned to ensure that students can make an easier transition when returning to the locally assigned medical school to complete their medical training. Further research on the SACMC programme would enable us to correct some curricular misalignments as well as develop the local remedial programme and make it more effective in serving the needs of all students.
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