What factors in rural and remote extended clinical placements may contribute to preparedness for practice from the perspective of students and clinicians?

Australian rural medical students' perceived readiness for work as a junior doctor: A cross-sectional national survey

OBJECTIVE

To report self-perceived readiness for work as a junior doctor in a national cohort of rural clinical school students.

DESIGN

Cross-sectional study using a self-report questionnaire. Independent variables included 14 individual readiness items related to clinical and professional tasks, sociodemographic data and reported experience of rural clinical school (RCS) training. Participants were 668 medical students (55.3% females) completing a full academic year in rural Australia. Multivariable analysis explored factors associated with overall readiness for work as a junior doctor.

FINDINGS

86% agreed that RCS experience prepared them to undertake the roles and responsibilities of a junior doctor. Self-ratings for specific clinical and professional tasks varied from a mean score of 5.9-8.0 out of 10, and 13 of the 14 items were associated with the outcome (p-value <0.001, except for performing spirometry). Lowest readiness scores were seen for some aspects including raising concerns about a colleague (mean score 6.1) or responding to workplace bullying (mean score 6.0). Aspects of the RCS experience that were strongly associated with overall readiness included: feeling a valued team-member (OR 9.28, 95%CI 2.43-35.39), feeling well-supported academically (OR 6.64, 95%CI 3.39-13.00), having opportunity for unsupervised but supported clinical practice (OR 4.67, 95%CI 1.45-15.00), having a rural mentor (OR 3.38, 95%CI 1.89-6.06) and having a previous health professional qualification (OR 2.7, 95%CI 1.32-5.54).

DISCUSSION

Most RCS students felt ready for work as a junior doctor. Important aspects of RCS experience are likely to include students feeling integrated within the clinical team and having opportunities for authentic clinical roles. There remains a significant challenge for medical school curricula to address professional areas where graduates felt less prepared.

The value of extended short-term medical training placements in smaller rural and remote locations on future work location: a cohort study

OBJECTIVES

To investigate the effects of extended short-term medical training placements in small rural and remote communities on postgraduate work location.

DESIGN AND SETTING

Cohort study of medical graduates of The University of Queensland, Australia.

PARTICIPANTS

Graduating medical students from 2012 to 2021 who undertook a minimum of 6 weeks training in a small rural or remote location. Some participants additionally undertook either or both an extended short-term (12-week) placement in a small rural or remote location and a long-term (1 or 2 years) placement in a large regional centre.

PRIMARY OUTCOME MEASURE

Work location was collected from the Australian Health Practitioner Regulation Agency in 2022, classified as either rural, regional or metropolitan and measured in association with rural placement type(s).

RESULTS

From 2806 eligible graduates, those participating in extended small rural placements (n=106, 3.8%) were associated with practising rurally or regionally postgraduation (42.5% vs 19.9%; OR: 2.2, 95% CI: 1.1 to 4.6), for both those of rural origin (50% vs 30%; OR: 4.9, 95% CI: 2.6 to 9.2) or metropolitan origin (36% vs 17%; OR: 2.8, 95% CI: 1.7 to 4.8). Those undertaking both an extended small rural placement and 2 years regional training were most likely to be practising in a rural or regional location (61% vs 16%; OR: 8.6, 95% CI: 4.5 to 16.3). Extended small rural placements were associated with practising in smaller rural or remote locations in later years (15% vs 6%, OR: 2.7, 95% CI: 1.3 to 5.3).

CONCLUSION

This work location outcome evidence supports investment in rural medical training that is both located in smaller rural and remote settings and enables extended exposure with rural generalists. The evaluated 12-week programme positively related to rural workforce outcomes when applied alone. Outcomes greatly strengthened when the 12-week programme was combined with a 2-year regional centre training programme, compared with either alone. These effects were independent of rural origin.

Strength of cross-sector collaborations in co-designing an extended rural and remote nursing placement innovation: Focusing on student learning in preference to student churning

AIM

To describe the strength of a cross-sector and multi-university collaboration in co-designing an extended nursing placement innovation in rural and remote Australia.

CONTEXT

Registered nurses are Australia's largest health workforce. Short-duration placements can limit nursing student exposure to rural and remote practice, impacting student capacity to tailor and contextualise their practice, navigate complex inequities, establish a sense of belonging and consider rural practice post-registration. Extended nursing placements have been recommended to address these challenges, but there are no guidelines governing their development and limited resources to support implementation.

APPROACH

Methods adopted in program development included the following: (1) collaboration establishment; (2) co-defining challenges confronting nurse education in these contexts; (3) co-developing guiding principles; (4) co-designing a new approach to nurse education, the Extended Nursing Placement Program (ENPP); and (5) the co-contribution of stakeholders to program design, implementation and evaluation. Regional stakeholders include a NSW and Victorian Local Health District/Service, three Aboriginal health services and the Royal Flying Doctor Service of Australia. University participants include two metropolitan universities, a University Department of Rural Health and final-year Bachelor of Nursing students. Program implementation in Semester 1 of 2022 with seven final-year nursing students.

CONCLUSION

The authors propose that the adoption of collaborative approaches can contribute to re-framing student nurse education and the development of a rural-ready nursing workforce. These approaches can provide regions and universities with the opportunity to avoid student churn whilst promoting the attainment of skills required to work, live and thrive in these locations.

Effect of national curriculum reform on medical students' preparedness for practice: a prospective cohort study from undergraduate to postgraduate periods

BACKGROUND

In recent years, a national curriculum reform was implemented in undergraduate medical education in Taiwan to reduce clinical rotation training from 3 years to 2 years. The last generation of the old curriculum and the first generation of the new curriculum both graduated in 2019. This study aimed to compare the learning outcomes of the medical students in these two curriculum groups in terms of preparedness for practice during the transition from undergraduate to postgraduate study.

METHODS

This was a 3-year prospective, longitudinal, comparative cohort study between 2017 and 2020. Medical students from both the 7-year and 6-year curriculum groups received biannual questionnaire surveys starting 18 months before graduation and running until 11 months after graduation. The measurement tools were the Preparedness for Hospital Practice Questionnaire (PHPQ) and Copenhagen Burnout Inventory (CBI). Personal demographic information was also collected. Linear mixed models were used to determine the effect of curriculum change on learners' preparedness and burnout levels.

RESULTS

A total of 130 medical students from the two cohorts provided 563 measurements during the study period. Compared to their counterparts following the old curriculum, the participants following the new curriculum showed a lower level of preparedness when first entering clinical rotation (p = 0.027) and just after graduating (p = 0.049), especially in the domains of clinical confidence (p = 0.021) and patient management p = 0.015). The multivariate linear mixed model revealed gradual increases in preparedness and burnout in serial measurements in both curriculum groups. Students following the new curriculum, which involved a shortened clinical rotation, showed a slightly lower overall preparedness (p = 0.035) and the same level of burnout (p = 0.692) after adjustment. The factor of year of change did not show a significant effect on either preparedness (p = 0.258) or burnout (p = 0.457).

CONCLUSION

Shortened clinical rotation training for medical undergraduates is associated with a decrease in preparedness for practice during the transition from undergraduate to postgraduate study. Clinical confidence and patient management are the main domains affected.

Self-assessment scale for the community-based and emergency practice

BACKGROUND

For current medical education, community-based primary care for the elderly is an essential topic. This study aimed to establish a scale of community-based assessment for clinical and emergency practice (C-CEP).

METHODS

A self-assessment scale for C-CEP was developed according to four steps. Initially, we reviewed publications from the societies of the United States, British, and Japan regarding educational goals. In addition, we searched MEDLINE for educational goals regarding attitude, skills, and knowledge. Getting together, we established 23 items as the educational goals of the C-CEP. Second, we collected responses for these 23 items from 5th-grade medical students (n = 195). Third, we conducted an exploratory factor analysis (EFA) using their responses to determine the fundamental structure of the self-assessment scale. Finally, a confirmatory factor analysis (CFA) was performed to assess the fitness of the self-assessment scale developing the EFA, resulting in modification of the items.

RESULTS

In EFA and CFA results, C-CEP Scale consisted of four factors with 15 items: "Attitude and communication in emergency care," Basic clinical skills," "Knowledge of community healthcare," and "Knowledge of evidence-based medicine perseverance." The model fit indices were acceptable (Goodness of Fix Index = 0.928, Adjusted Goodness of Fit Index = 0.900, Comparative Fit Index = 0.979, and Root Mean Square Error of Approximation = 0.045). The values of McDonald's omega as an estimate of scale reliability were more than 0.7 in all four factors. As for test-retest reliability, the intraclass correlation coefficients were ≥ 0.58 for all factors. All four factors of the C-CEP Scale correlated positively with the Medical Professionalism Evaluation Scale subscales.

CONCLUSIONS

We developed a valid and reliable self-assessment scale to assess student competence.

Exploring the learning environment afforded by an Aboriginal Community Controlled Health service in a rural longitudinal integrated clerkship

OBJECTIVES

Despite the extensive literature regarding longitudinal integrated clerkships (LICs), there is very little evidence about this model in non-traditional settings, such as Aboriginal Community Controlled Health Organisations (ACCHOs). This study explored the key elements of the learning experience in a rural LIC programme, within an ACCHO from the perspective of multiple stakeholders including medical students, the general practice supervisory team, Aboriginal health workers (AHWs) and cultural mentors.

METHODS

The study was conducted using a qualitative case-study design. Participants included Year 3 medical students and the health care team (general practitioners, practice nurse, AHWs, and a practice manager in the role of cultural mentor) from an ACCHO in regional Queensland. Data was collected through semi-structured interviews and analysed using inductive thematic analysis.

RESULTS

Three key features were identified within the learning experience of students undertaking an LIC in the ACCHO setting. This study showed it was a safe context for learners to learn about 'culturally safe practice', 'putting relationships at the centre', and to 'try new things', reinforcing ACCHO as an invaluable site for learning.

CONCLUSION

The extended clinical placement in an ACCHO setting afforded an increase in the number of opportunities to develop students' cultural safety, communication skills and relationships with patients and the supervisory team, including AHWs and cultural mentors.

Identifying features of quality in rural placements for health students: scoping review

OBJECTIVES

To explore and synthesise the evidence relating to features of quality in rural health student placements.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, CINAHL, Embase, ProQuest, Informit, Scopus, ERIC and several grey literature data sources (1 January 2005 to 13 October 2020).

STUDY SELECTION

The review included peer-reviewed and grey literature from Organisation for Economic Co-operation and Development listed countries that focused on quality of health student placements in regional, rural and remote areas.

DATA EXTRACTION

Data were extracted regarding the methodological and design characteristics of each data source, and the features suggested to contribute to student placement quality under five categories based on a work-integrated learning framework.

RESULTS

Of 2866 resulting papers, 101 were included for data charting and content analysis. The literature was dominated by medicine and nursing student placement research. No literature explicitly defined quality in rural health student placements, although proxy indicators for quality such as satisfaction, positive experiences, overall effectiveness and perceived value were identified. Content analysis resulted in four overarching domains pertaining to features of rural health student placement quality: (1) learning and teaching in a rural context, (2) rural student placement characteristics, (3) key relationships and (4) required infrastructure.

CONCLUSION

The findings suggest that quality in rural health student placements hinges on contextually specific features. Further research is required to explore these findings and ways in which these features can be measured during rural health student placements.

Transformative learning through participation: experiences at a rural clinical training site in South Africa

BACKGROUND

Distributed training has been cited as an opportunity that offers transformative learning experiences in preparing a future workforce to address local needs. For this reason, rural and longitudinal placements are increasingly being adopted by medical schools across the world. Place, participation and person are considered integral in the process of transformation of medical students into responsive graduates on the distributed platform. This article aims to explore the experiences and perceptions of student learning on a rural training platform in South Africa while considering the interrelation between person, place and participation as a process of transformation to becoming a health care professional. The research forms part of a 5-year longitudinal case study, initiated in 2019 to explore a university-rural hospital collaboration on students, staff and the local health care system.

METHODS

Data was collected using interviews and surveys from 63 purposively selected and consenting participants between January and November of 2019. All qualitative data were inductively analysed using an interpretivist approach to thematic analysis for the purposes of this article. All quantitative data was analysed descriptively using Microsoft Excel. Ethics and permission for this research was granted by the Stellenbosch University Human Research Ethics Committee, the Undergraduate Students Programme Committee and the Northern Cape Department of Health, South Africa.

FINDINGS

Four themes, namely: authenticity of context; participation in a community of practice and social activities; supervision and reflection; and distance support were extracted from the data. These findings contribute to the theory of transformative learning on the distributed platform by expanding on the interrelationship of person, place and participation, specifically as it relates to participation within various communities and practices. The value of active participation in reflection and supervision, distance academic support and social support systems are explored.

CONCLUSIONS

The three dimensions and interrelationship of person, place and participation in the process of transformative learning on the rural training platform can be further unpacked by exploring the types of participation that have facilitated student learning in this research context. Participation in interprofessional teams; supervision, reflection and distance support appear to be the most crucial elements during this transformative learning process.

Longitudinal training models for entrusting students with independent patient care?: A systematic review

OBJECTIVE

The participation of students from both undergraduate medical education (UGME) and postgraduate medical education (PGME) in independent patient care contributes to the development of knowledge, skills and the professional identity of students. A continuing collaboration between students and their preceptor might contribute to opportunities for students to independently provide patient care. In this systematic review, we aim to evaluate whether longitudinal training models facilitate the independent practice of students and what characteristics of longitudinal training models contribute to this process.

METHOD

This systematic review was performed according to the PRISMA guidelines. In May 2020, we performed a search in three databases. Articles evaluating the impact of longitudinal training models on the independent practice of students from both UGME and PGME programmes were eligible for the study. A total of 68 articles were included in the study. Quality of the included studies was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

RESULTS

Both UGME and PGME students in longitudinal training models are more frequently allowed to provide patient care independently when compared with their block model peers, and they also feel better prepared for independent practice at the end of their training programme. Several factors related to longitudinal training models stimulate opportunities for students to work independently. The most important factors in this process are the longitudinal relationships with preceptors and with the health care team.

CONCLUSION

Due to the ongoing collaboration between students and their preceptor, they develop an intensive and supportive mutual relationship, allowing for the development of a safe learning environment. As a result, the professional development of students is fostered, and students gradually become part of the health care team, allowing them the opportunity to engage in independent patient care.

Supporting health students on rural placements: A scoping review

OBJECTIVE

To review Australian literature on initiatives used to provide support for pre-registration health students undertaking a rural placement.

DESIGN

A scoping literature review.

SETTING

Rural, regional and remote areas of Australia.

PARTICIPANTS

Publications were sourced from scientific databases including Ebscohost and CINAHL. Grey literature and journal citations were searched to identify other relevant articles.

MAIN OUTCOME MEASURE

Identification of the various initiatives used to support students, evaluation of the success of these initiatives, and the feasibility and sustainability of implementing these initiatives.

RESULTS

There were 36 articles included in the final analysis. The findings identified support initiatives specific to individual professions, not on supporting health students as a whole cohort. The key findings were grouped into identification of support initiatives and the alignment of these to students feeling a sense satisfaction, belonging and connectedness. Constraints to support health students undertaking rural placements identified disparity and inequity of support initiatives available for health students with medical students provided more support than other health students.

CONCLUSION

This review highlights the importance of students developing a sense of belonging and building connections to community, which are strongly aligned with rural placements and student satisfaction. The need for socio-cultural, organisational and institutional support is linked to higher student satisfaction and intention to practice rurally. A centralised collation of support initiatives would benefit students, higher education institutions and stakeholders in their efforts to attract students to undertake rural placements and be immersed in these unique learning experiences.

Transitioning from university to postgraduate medical training: A narrative review of work readiness of medical graduates

CONTEXT

Work readiness is often described in terms of the clinical competence medical graduates bring to day 1 of internship. Despite being increasingly viewed as a key graduate outcome, work readiness has remained poorly defined.

OBJECTIVE

This narrative review draws on the international literature to explore how different research methods provide differing insight into what constitutes work readiness of medical graduates. From this, we explored contributory factors and developed a conceptual framework to better understand work readiness.

METHODS

Databases were searched using the terms including "ready," "readiness," "preparedness," "medical graduates," "intern," and "junior doctor." Information was summarized using a textual description template that included information on study setting, participants, methodologies, limitations, and key result areas (including measures/themes and study conclusions). Consensus discussions between authors led to the naming and understanding of the key themes.

RESULTS

Seventy studies were included in the review. Study participants included final-year medical students (n = 20), junior doctors early in internship (n = 24), and junior doctors late in internship or postgraduate year 2 and above (n = 23). Most studies explored work readiness through the retrospective self-report of the students and/or junior doctor participants. Quantitative research methods elaborated on key skills-based competencies, whereas qualitative research methods provided insight into key contextual and individual characteristics that contributed to preparedness.

CONCLUSIONS

Different research methods provided insight into competencies, as well as individual and contextual aspects, associated with preparedness for practice. The transition from university to clinical practice is significant and requires personal capability and confidence, as well as a supportive training context. Enabling students to engage authentically in clinical environments enhanced preparedness by promoting understanding of role and responsibility. Individual resilience is important, but contextual factors, including provision of adequate support and feedback, can enhance or subtract from feeling prepared. We propose a novel conceptual framework for better understanding work readiness.

Development and sustainment of professional relationships within longitudinal integrated clerkships in general practice (LICs): a narrative review

BACKGROUND

Longitudinal integrated clerkships (LICs) are a relatively new model of clinical medical education, whereby students participate in patient care over time and develop relationships with those patients', their clinicians, and other health care staff involved in the care of those patients. It has been called 'relationship-based education' but, to date, no review has investigated the development and impact of these central relationships within this curricula model.

AIMS

The aim of this study is to review the literature pertaining to relationships in LICs, specifically to understand how they come about and how they affect learning.

METHODS

The search strategy systematically explored PubMed, ERIC (EBSCO) and Academic Search Complete, using key words and MESH terms. Original research published in peer-reviewed journals between January 2007 and August 2020 that were written in the English language were included in the review.

RESULTS

After applying set inclusion and exclusion criteria, 43 studies were included in this review. A qualitative thematic analysis was undertaken, and results were synthesised narratively. Four distinct categories were identified: defining relationships in LICs, developing relationships in LICs, relationship maintenance and multi-stakeholder impact.

CONCLUSIONS

The longitudinal integrated clerkship model of clinical education facilitates the development of meaningful triangular relationships between student, clinical teacher and patient, which are the central drivers of successful learning within the context of an LIC. These relationships are nested in a set of important supporting relationships involving other supervisors, the medical school and university, the practice clinical and administrative team and peers.

Factors impacting the solo remote placement experiences of undergraduate James Cook University medical students: A mixed-methods pilot study

OBJECTIVE

To determine the factors impacting the experiences of James Cook University medical students on solo placements in remote towns.

DESIGN

This 2018 pilot study used an exploratory sequential mixed-methods approach to explore the recent solo remote placement experiences of James Cook University medical students. Qualitative interviews were performed initially to elicit context sensitive themes for the self administered survey. The survey went on to use Likert-scale questions in addition to pre-validated survey instruments.

SETTING

Focus groups and interviews took place at James Cook University Medical School in Townsville in late 2018 after students returned from their rural rotation. Two telephone interviews were conducted for Year 6 students unable to attend the focus groups.

PARTICIPANTS

James Cook University medical students in years 2, 4 and 6 students who experienced a solo placement in a remote (MMM 6 or 7) town during 2017 or 2018 were invited to be part of the study. Only Townsville-based students were involved. A total of 14 students participated in the focus groups (n = 14) and a further 31 students completed the survey (n = 31).

MAIN OUTCOME MEASURE(S)

Interviews identified themes negatively or positively impacting solo remote placement experience, while bivariate analysis identified factors associated with having an 'excellent' overall experience.

RESULTS

Student interviews identified five main themes impacting student experience in remote communities: culture of the medical facility; quality and quantity of clinical experiences; quality of accommodation; placement length; and community infrastructure and services. Negative impacts could result in students experiencing social isolation. Students reporting an 'excellent' solo remote placement experience in the survey were more likely to have: felt very welcome in the community; felt the health staff supported them; heavily involved themselves in clinical activities; enjoyed the experiences remote communities can offer; positive rural career intentions; reported they 'bounce back during and after life's most stressful events'; and come from a rural or remote hometown.

CONCLUSIONS

Solo remote placements provide medical students with opportunities to further knowledge, clinical capabilities, social experiences and careers, but can have negative aspects. However, negative aspects are often modifiable management issues or can potentially be avoided if prospective students are better informed of the challenges associated with remote communities.

New-graduate physiotherapists' perceptions of their preparedness for rural practice

OBJECTIVE

Providing health care in a rural or remote setting requires physiotherapists to adapt to a number of unique challenges. New-graduates working in rural or remote settings must respond to these challenges in addition to those of being a novice practitioner. This study investigated the perceived preparedness of new-graduate physiotherapists for work in rural or remote settings.

DESIGN

A qualitative general inductive approach.

SETTING

Rural and remote Queensland.

PARTICIPANTS

New-graduate physiotherapists   working in rural or remote locations were contacted via a snowballing recruitment strategy.

MAIN OUTCOME MEASURE

Semi-structured interviews.

RESULTS

Four key themes emerged from the data: (a) adjusting to rural life, (b) embracing opportunities, (c) stepping up to the plate and (d) preparing through authentic experiences.

CONCLUSION

New-graduate physiotherapists perceived rural and remote practice to be a challenging but valuable opportunity with many social and professional rewards. The complex clinical demands and unique cultural factors inherent in rural and remote locations were experienced as additional obstacles to the transition from student to clinician. New-graduate physiotherapists were satisfied that their entry-level training provided the necessary skills required to practise rurally and remotely; however, they expressed 'shock' at the rapid adaptations needed to provide effective service in these settings. New-graduates are confident that exposure to authentic rural and remote clinical practice during their training was integral to their preparedness.

Context Matters: Findings from a Qualitative Study Exploring Service and Place Factors Influencing the Recruitment and Retention of Allied Health Professionals in Rural Australian Public Health Services

Chronic health workforce shortages significantly contribute to unmet health care needs in rural and remote communities. Of particular and growing concern are shortages of allied health professionals (AHPs). This study explored the contextual factors impacting the recruitment and retention of AHPs in rural Australia. A qualitative approach using a constructivist-interpretivist methodology was taken. Semi-structured interviews (n = 74) with executive staff, allied health (AH) managers and newly recruited AHPs working in two rural public health services in Victoria, Australia were conducted. Data was coded and categorised inductively and analysed thematically. The findings suggest that to support a stable and sustainable AH workforce, rural public sector health services need to be more efficient, strategic and visionary. This means ensuring that policies and procedures are equitable and accessible, processes are effective, and action is taken to develop local programs, opportunities and supports that allow AH staff to thrive and grow in place at all grade levels and life stages. This study reinforces the need for a whole-of-community approach to effectively support individual AH workers and their family members in adjusting to a new place and developing a sense of belonging in place. The recommendations arising from this study are likely to have utility for other high-income countries, particularly in guiding AH recruitment and retention strategies in rural public sector health services. Recommendations relating to community/place will likely benefit broader rural health workforce initiatives.

What students and new graduates perceive supports them to think, feel and act as a health professional in a rural setting

OBJECTIVE

Clinical placements in rural locations are perceived by students to provide positive learning experiences to support their transition to practice. This study explores how clinical placements in a rural health setting might influence students and new graduates to think, feel and act as a health professional.

DESIGN

A qualitative study comprising focus group discussions was conducted.

SETTING

The study was conducted in a rural health service in Queensland, Australia.

PARTICIPANTS

Allied health students (n = 12) on placement and new graduates (n = 11) working in a regional health service.

MAIN OUTCOME MEASURES

This study identified allied health student and new graduate perspectives on clinical placement factors which support them to think, feel and act as a health professional.

RESULTS

Thematic analysis was used to understand student and new graduate perceptions of how rural placements support thinking, feeling and acting as a health professional. Suggestions for supporting learning included the following: Development of learning partnerships between students and clinical educators with inbuilt expectations and opportunities for reflection and supervision. Creating a culture where students are welcomed, valued and encouraged to take meal breaks with the team supported connectedness. The importance of balancing student autonomy with educating and grading support to increase independence.

CONCLUSIONS

Findings show clinical placement experiences identified by allied health students and new graduates which support them to begin to think, feel and act as a health professional. Suggestions provided by students and new graduates can be used to inform implementation of clinical placement experiences.

Cultural Competency Interventions During Medical School: a Scoping Review and Narrative Synthesis

Many medical accreditation bodies agree that medical students should be trained to care for diverse patient populations. However, the teaching methods that medical schools employ to accomplish this goal vary widely. The purpose of this work is to summarize current cultural competency teaching for medical students and their evaluation methods. A scoping review was completed by searching the databases PubMed, Scopus, MedEdPORTAL, and MEDLINE for the search terms "medical education" and "cultural competency" or "cultural competence." Results were summarized using a narrative synthesis technique. One hundred fifty-four articles on cultural competency interventions for medical students were systematically identified from the literature and categorized by teaching methods, length of intervention, and content. Fifty-six articles had a general focus, and ninety-eight articles were focused on specific populations including race/ethnicity, global health, socioeconomic status, language, immigration status, disability, spirituality at the end of life, rurality, and lesbian, gay, bisexual, transgender, and queer. About 54% of interventions used lectures as a teaching modality, 45% of the interventions described were mandatory, and 9.7% of interventions were not formally evaluated. The authors advocate for expansion and more rigorous analysis of teaching methods, teaching philosophies, and outcome evaluations with randomized controlled trials that compare the relative effectiveness of general and population-specific cultural competency interventions.

Twelve tips for distributed health professions training

Increasing numbers of health professions students are being trained in healthcare facilities that are geographically removed from central academic hospitals. Consequently, studies have evaluated this distributed training, assessed the impact that it has on student learning as well as on the facilities where the training occurs, and explored factors that enable and constrain successful clinical training at such sites. The 12 tips presented in this article have been developed from a longitudinal project that has focused on developing a framework for effective distributed health professions training through an extensive review of the literature and a national consultative process. These 12 tips should, therefore, have applicability across multiple contexts. The purpose of this article is to assist people in implementing, adapting, upscaling, maintaining, and evaluating the distributed training of students in the health professions.

Health Profession Education in Remote or Geographically Isolated Settings: A Scoping Review

Remote health has been differentiated from rural health in Australia and defined as isolated, with poor service access and a relatively high proportion of Indigenous residents, necessitating different models of care. Educational strategies for remote health practice are often needs driven and the characteristics of remote health may be used to categorise remote health professional education. This scoping review aims to identify the purpose of health professional education for remote settings, the type of educational strategies implemented and the reported outcomes. A broad search of published literature available in online bibliographic databases was conducted. A total of 33 articles met the review inclusion criteria. A further 7 articles were identified for inclusion in the review through citation searches and the authors' networks giving a total of 40 articles. Six primary themes were established based on the educational purpose: (1) cultural competency; (2) social accountability; (3) rural and remote skill development for the general workforce; (4) remote specialisation; (5) specialist skills required for a remote workforce; and (6) remote teaching. These themes also reflect the philosophical change over time recognising remote health as a separate discipline and its value as a distinctive and efficacious learning environment. The concept of education for remote practice is proposed to describe this unique leaning environment which encompasses critical pedagogy to develop a sense of agency and social accountability, embedding the delivery of primary health care through service learning and developing relationships in a context which is transformative.

What supports allied health students to think, feel and act as a health professional in a rural setting? Perceptions of allied health staff

OBJECTIVE

Clinical placements in rural locations provide student health professionals with diverse learning opportunities. Engaging in clinical work and learning from role models and peers in the workplace are primary ways students develop professional skills, behaviour and identities as a health professional. The purpose of this study was to examine the influences supporting allied health students undertaking clinical placements in a rural health service to think, feel and act as a health professional from the perspective of allied health staff.

DESIGN

A qualitative study comprising focus group discussions was conducted.

SETTING

The study was conducted in a rural health service in Queensland, Australia.

PARTICIPANTS

Seventeen allied health staff whose roles support clinical placement education in the health service MAIN OUTCOME MEASURES: This study identified clinical placement factors which can support allied health students thinking, feeling and acting as a health professional.

RESULTS

Thematic analysis was used to understand staff perceptions of how rural placements support students to think, feel and act as a health professional. Key placement actions included taking advantage of the diverse learning experiences in a rural area, facilitating student connectedness in the workplace and grading learning to support independence and autonomy for practice.

CONCLUSIONS

Findings from this study show that the diverse work environment and experiences in a rural setting provide unique opportunities for students to begin to think, feel, and act as a health professional. Strategies identified might be applied in other similar contexts.

Does medical training in Thailand prepare doctors for work in community hospitals? An analysis of critical incidents

BACKGROUND

Compulsory 3-year public service was implemented in 1967 as a measure to tackle the maldistribution of doctors in Thailand. Currently, therefore, most medical graduates work in rural community hospitals for their first jobs. This research explored doctors' perceptions of preparedness for practice using a critical incident technique.

METHODS

A self-administered critical incident questionnaire was developed. Convenient samples were used, i.e. Family Medicine residents at Ramathibodi Hospital who had worked in a community hospital after graduation before returning to residency training. Participants were asked to write about two incidents that had occurred while working in a community hospital, one in which they felt the knowledge and skills obtained in medical school had prepared them for managing the situation effectively and the other in which they felt ill-prepared. Data were thematically analysed.

RESULTS

Fifty-six critical incidents were reported from 28 participants. There were representatives from both normal and rural tracks of undergraduate training and community hospitals of all sizes and all regions. Doctors felt well-prepared to provide care for patients in emergency situations and as in-patients, but under-prepared for obstetric and paediatric emergencies, out-patient care, and palliative care. Moreover, they felt poorly prepared to deal with difficult patients, hospital administration and quality assurance.

CONCLUSIONS

Long-term solutions are needed to solve the rural doctor shortage. Medical graduates from both normal and rural tracks felt poorly prepared for working effectively in community hospitals. Medical training should prepare doctors for rural work, and they should be supported while in post.

Adverse health events associated with clinical placement: A systematic review

OBJECTIVE

Clinical placement is a fundamental aspect of student learning and skill development across healthcare disciplines. However, participation in clinical placements can also present significant risk to students. This systematic literature review sought to examine the range of risks and hazards encountered by students across healthcare disciplines during their clinical placements.

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines were utilised in conducting this exploratory systematic review.

DATA SOURCES

The CINAHL Complete, Medline Complete, and PsycINFO databases were searched. Reference lists of eligible records obtained via database searching were screened, and a supplementary key author search was conducted. Research published between 2013 and 2018 and conducted in the context of comparative international healthcare systems was the focus of this study.

REVIEW METHODS

Study titles and abstracts were screened, and the full text of potentially relevant records was perused. Records meeting key eligibility criteria by addressing risk posed to students in healthcare disciplines within a clinical placement context were included in the final synthesis.

RESULTS

The search identified 46 eligible records. The literature highlighted the worrying trend that students, most notably in the nursing discipline, can be exposed to a wide range of risks and adverse health events during clinical placement.

CONCLUSIONS

As risks in unpredictable clinical environments cannot be eradicated, this review demonstrated a critical need for educative action to enable students to competently and confidently manage risks, and to reduce occurrence of adverse health events.

Learning relationships in community-based service-learning: a social network analysis

BACKGROUND

Little is known about the social learning of students within community-based clinical placements and ways in which it can be supported. In an allied health service-learning program, we analysed students' learning relationships to quantify what, and from whom students learnt.

METHODS

We conducted a social learning network survey in four domains of learning (clinical knowledge, procedural skills, professional development, and complex determinants of health) to explore learning relationships (ties) with other people (alters) that students (egos) formed during their placement. We quantified how different roles (supervisors, health professionals, administrators, peers, schoolteachers, and clients) contributed to the students' learning in each of the four domains. We used exponential random graph models (ERGMs) to test which relational processes contributed to the structure of the observed learning networks.

RESULTS

Data was available from a complete cohort of 10 students on placement in a network of 69 members, thus providing information on 680 potential learning relations. Students engaged in similar ways in the domains of clinical knowledge, procedural skills, and professional development. Learning relations with academic supervisors were significantly more likely. Also students reported reciprocal learning relations with peers - i.e. they formed learning pairs. This effect was absent in learning networks about complex determinants of health (including socio-economic and cultural factors). Instead, local administrative staff were significantly more often the source of learning about the local contextual factors.

CONCLUSIONS

Understanding the structure of student learning networks through social network analysis helps identify targeted strategies to enhance learning in community-based service-learning programs. Our findings suggest students recognised important learning from each other and from administrative personnel that is unrelated to the content of their placement. Based on this insight clinical educators could prepare students to become agentic learners, learning with each other and from sources outside their program.

Stakeholder views of rural community-based medical education: a narrative review of the international literature

CONTEXT

Rural community-based medical education (RCBME), in which medical student learning activities take place within a rural community, requires students, clinical teachers, patients, community members and representatives of health and government sectors to actively contribute to the educational process. Therefore, academics seeking to develop RCBME need to understand the rural context, and the views and needs of local stakeholders.

OBJECTIVES

The aim of this review is to examine stakeholder experiences of RCBME programmes internationally.

METHODS

This narrative literature review of original research articles published after 1970 utilises Worley's symbiosis model of medical education as an analysis framework. This model proposes that students experience RCBME through their intersection with multiple clinical, social and institutional relationships. This model seeks to provide a framework for considering the intersecting relationships in which RCBME programmes are situated.

RESULTS

Thirty RCBME programmes are described in 52 articles, representing a wide range of rural clinical placements. One-year longitudinal integrated clerkships for penultimate-year students in Anglosphere countries were most common. Such RCBME enables students to engage in work-integrated learning in a feasible manner that is acceptable to many rural clinicians and patients. Academic results are not compromised, and a few papers demonstrate quality improvement for rural health services engaged in RCBME. These programmes have delivered some rural medical workforce outcomes to communities and governments. Medical students also provide social capital to rural communities. However, these programmes have significant financial cost and risk student social and educational isolation.

CONCLUSIONS

Rural community-based medical education programmes are seen as academically acceptable and can facilitate symbiotic relationships among students, rural clinicians, patients and community stakeholders. These relationships can influence students' clinical competency and professional identity, increase graduates' interest in rural careers, and potentially improve rural health service stability. Formal prospective stakeholder consultations should be published in the literature.

Shaping medical student's understanding of and approach to rural practice through the undergraduate years: a longitudinal study

BACKGROUND

Over the last two decades medical schools have increased rural practice learning opportunities for students in an effort to improve recruitment to the rural workforce. James Cook University's (JCU) medical school was established in northern Australia in 2000 with a specific focus on meeting the health needs of people in rural and remote areas. As part of a longitudinal study this paper explores the situational and motivational learning factors contributing to the development of JCU's medical students' understanding of and approaches to rural medical practice.

METHODS

After completing each consecutive, compulsory rural clinical placement in Year Two, Four and Six of their MBBS program, JCU medical students were asked to complete a survey about their rural learning experiences. The survey consisted of a combination of single choice, Guttman and Likert scales and open response questions. Data from two open response questions were coded and thematically analysed. Content analysis enabled the predominant value of each theme to be calculated.

RESULTS

Collation of the survey data revealed 680 answers to both questions resulting in 1322 comments for analysis. Nine themes were categorized into clinical practice issues and person issues. The evolution of scope of practice across the years, the importance of inspirational mentors, access to urban areas and a sense of community were key findings. Positive rural clinical placement experiences inclusive of supportive ongoing learning opportunities and rural community living contribute positively to medical students' interest in future rural medical practice. However, the ability to work for periods of time in both rural and urban settings suggested a possible need for a new additional model of practice.

CONCLUSION

Clear links between a sense of community and belonging both professionally and socially as well as combined rural-urban practice options were important factors in the education and development of future rural practitioners. Ways to establish and support practice models incorporating both rural and urban locations needs to be investigated.

Medical Education in Decentralized Settings: How Medical Students Contribute to Health Care in 10 Sub-Saharan African Countries

PURPOSE

African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities.

METHOD

Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences.

RESULTS

The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students.

CONCLUSIONS

Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments.

Decentralised training for medical students: a scoping review

BACKGROUND

Increasingly, medical students are trained at sites away from the tertiary academic health centre. A growing body of literature identifies the benefits of decentralised clinical training for students, the health services and the community. A scoping review was done to identify approaches to decentralised training, how these have been implemented and what the outcomes of these approaches have been in an effort to provide a knowledge base towards developing a model for decentralised training for undergraduate medical students in lower and middle-income countries (LMICs).

METHODS

Using a comprehensive search strategy, the following databases were searched, namely EBSCO Host, ERIC, HRH Global Resources, Index Medicus, MEDLINE and WHO Repository, generating 3383 references. The review team identified 288 key additional records from other sources. Using prespecified eligibility criteria, the publications were screened through several rounds. Variables for the data-charting process were developed, and the data were entered into a custom-made online Smartsheet database. The data were analysed qualitatively and quantitatively.

RESULTS

One hundred and five articles were included. Terminology most commonly used to describe decentralised training included 'rural', 'community based' and 'longitudinal rural'. The publications largely originated from Australia, the United States of America (USA), Canada and South Africa. Fifty-five percent described decentralised training rotations for periods of more than six months. Thematic analysis of the literature on practice in decentralised medical training identified four themes, each with a number of subthemes. These themes were student learning, the training environment, the role of the community, and leadership and governance.

CONCLUSIONS

Evident from our findings are the multiplicity and interconnectedness of factors that characterise approaches to decentralised training. The student experience is nested within a particular context that is framed by the leadership and governance that direct it, and the site and the community in which the training is happening. Each decentralised site is seen to have its own dynamic that may foreground certain elements, responding differently to enabling student learning and influencing the student experience. The insights that have been established through this review have relevance in informing the further expansion of decentralised clinical training, including in LMIC contexts.

Social learning in a longitudinal integrated clinical placement

Recent research has demonstrated that longitudinal integrated placements (LICs) are an alternative mode of clinical education to traditional placements. Extended student engagement in community settings provide the advantages of educational continuity as well as increased service provision in underserved areas. Developing and maintaining LICs require a differing approach to student learning than that for traditional placements. There has been little theoretically informed empirical research that has offered explanations of which are the important factors that promote student learning in LICs and the relationships between those factors. We explored the relationship between student learning, student perceptions of preparedness for practice and student engagement, in the context of a rural LIC. We used a sequential qualitative design employing thematic, comparative and relational analysis of data from student interviews (n = 18) to understand possible processes and mechanisms of student learning in the LIC. Through the theoretical lens of social learning systems, we identified two major themes; connectivity and preparedness for practice. Connectivity described engagement and relationship building by students, across formal and informal learning experiences, interprofessional interactions, social interactions with colleagues, interaction with patients outside of the clinical setting, and the extent of integration in the wider community. Preparedness for practice, reflected students' perceptions of having sufficient depth in clinical skills, personal and professional development, cultural awareness and understanding of the health system, to work in that system. A comparative analysis compared the nature and variation of learning across students. In a relational analysis, there was a positive association between connectivity and preparedness for practice. Connectivity is a powerful enabler of students' agentic engagement, collaboration, and learning within an LIC. It is related to student perceptions of preparedness for practice. These findings provide insight for institutions wishing to develop similar programmes, by encouraging health professional educators to consider all of the potential elements of the placements, which most promote connectivity.

'Knowledge leech' to 'part of the team': students' learning in rural communities of practice

BACKGROUND

Keele Medical School has a small accommodation hub for students placed within ten associated general practices in a predominantly rural area of England. Groups of up to eleven final year students spend fifteen weeks learning generic and transferable clinical skills in these practices.

AIM

To explore the evolving perceptions on students on their experiences throughout their placements.

METHOD

All ten students placed at the hub between August and December 2013 were invited to participate in focus groups in weeks zero, seven, and fifteen. Analysis was qualitative and thematic.

RESULTS

Ten, five and eight students chose to participate in successive focus groups. Five themes were identified from the data; acceptance, learning opportunities, relationships, development, and injustice with a subtheme of isolation.

CONCLUSION

The placements had a powerful impact on students' learning and development. Their perceptions changed from seeing themselves as 'knowledge leeches' to legitimate contributors to health care over the course of fifteen weeks. They did not recognise that managing perceived adversity led to personal development. This illustrates the need to both identify perceived adversity and explicitly signpost and scaffold life learning. The students described experiences which challenged them intellectually and offered them opportunities to recognise the breadth and complexity of general practice.

Comparing a longitudinal integrated clerkship with traditional hospital-based rotations in a rural setting

CONTEXT

Longitudinal integrated clerkships (LIC) are widely used as an educational method, particularly in rural areas. They are good for facilitating hands-on learning and deep relationships between student, patients, and supervisors.

OBJECTIVES

This study sought to examine and compare learning experience of third-year rural medical students studying specialties (women's health, aged care, child and adolescent heath, mental health, general practice) by either a traditional hospital-based rotation or a LIC in a rural general practice setting.

METHODS

Data was collected from two groups of rural students (LIC; traditional hospital-based) over two academic years, utilizing focus groups to investigate general experiences of living and learning rurally, within the different educational models.

RESULTS

Results reaffirmed that there was no perceived academic disadvantage to studying medicine rurally. Studying medicine in a rural area provides increased access to patients, more hands-on experience, and close relationships with patients and colleagues. LIC students reported increased confidence in clinical skills, felt better prepared for internship, however experienced more social isolation than students in hospital-based rotations.

CONCLUSIONS

Students undergoing a rural LIC feel more confident in their clinical skills and preparedness for practice than other rural students. This study supports the use of LICs as a powerful educational tool.

A prospective survey of chiropractic student experiences with pediatric care and variability of case mix while on clinical placement in Rarotonga

OBJECTIVE

To compare chiropractic students' perceptions of preparedness for practice before and after a clinical placement in Rarotonga and to report demographics from these experiences.

METHODS

The students completed deidentified pre- and postplacement surveys assessing pediatric practice preparedness. Students tallied the patient numbers, age, and chiropractic techniques used per visit for each day of clinic placement. On completion of the program, participating students (27/34, or 79% of the student cohort) did a postplacement survey on their perception of practice preparedness. Data were analyzed with the Spearman rho correlation, the Mann-Whitney U test, and regression analysis.

RESULTS

There was an increase in perceived preparedness for pediatric practice, ranging from 24.1% of the student cohort at the start of the study to 82.1% following clinical placement in Rarotonga. The change in student preparedness to practice with children was positively correlated with the total number of children managed (r_s = .05, p = .01) and the number of children managed who were under 10 years of age (r_s = .60, p = .001). Multiple regression analysis demonstrated a medium positive effect for postprogram preparedness (F [4, 20] = 3.567, p = .024).

CONCLUSION

Clinical outreach to Rarotonga provided a broad case mix of patients and a change in student perceptions of preparedness to practice with children, which was positively affected by the total number of children managed and the number of children managed who were under 10 years of age.

Effectiveness of a rural longitudinal integrated clerkship in preparing medical students for internship

BACKGROUND

We interviewed graduates from the first two cohorts of a postgraduate medical program that had a senior year longitudinal integrated clerkship (LIC) in a practice setting in rural New South Wales, Australia to determine how well their training prepared them to be junior doctors (3-4 years after graduation), and what aspects of that training they thought were particularly useful.

METHODS

In-depth interviews.

RESULTS

Fourteen junior doctors were interviewed. Participants reported feeling well prepared in ability to develop close relationships with clinical supervisors, good clinical and procedural skills, ability to work autonomously and work in teams, knowledge of health systems, ability to ensure self-care, and professionalism. Consensus view was that a rural placement was an excellent way to learn medicine for a variety of reasons including relationships with clinicians, less competition for access to patients, and opportunities to extend their clinical skills and act up to intern level.

CONCLUSION

The advantages we found in the training these junior doctors received which prepared them well for internship were integral both to the longitudinal, unstructured placement, and to the fact that it was carried out in a rural area. The two aspects of these placements appear to act synergistically, reinforcing the learning experience.

Gaining a 'proper sense' of what happens out there: An 'Academic Bush Camp' to promote rural placements for students

Undergraduates who undertake rural placements often choose a rural career. Reluctance from universities to send students to rural settings limits placement numbers. The Western Australian Centre for Rural Health (WACRH) invited allied health and nursing academics and clinical placement coordinators from Western Australian (WA) universities to an Academic Bush Camp. Based on situated learning theory, this camp modelled student programs through experiential learning and structured workshops. It aimed to build relationships and showcase innovative rural learning opportunities.

OBJECTIVE

To build relationships and showcase innovative rural learning opportunities.

DESIGN

An evaluation of a residential camp based on situated learning theory.

SETTING

The camp stated and finished in Geraldton, WA and was centered in Mt Magnet, WA a remote town 600 kilometres northeast of Perth.

PARTICIPANTS

WACRH invited allied health and nursing academics and clinical placement coordinators from Western Australian (WA) universities.

INTERVENTION

This camp modelled student programs through experiential learning and structured workshops. Online pre- and post-camp questionnaires included open-ended questions and questions on a 5-point Likert scale. Responses were analysed in SPSS 22 using descriptive statistics and Wilcoxon signed-rank test. Follow-up phone interviews six months later assessed longer-term reflections and changes in student placement practice.

MAIN OUTCOME MEASURES

The main outcome measure was whether the camp met participants' expectations, and their knowledge about and interest in WACRH's programs.

RESULTS

Twelve academics from five WA universities and seven health disciplines attended. Nine had previously lived or worked rurally. The camp met participants' expectations and all would recommend the opportunity to a colleague. Many valued the interaction with community and clinical placement partners and would have preferred more of this. The camp increased awareness of WACRH's programs and benefits of longer rural placements and a service-learning environment. Six months later, participants' familiarity with WACRH's placement model, supports and staff had led to an enhanced willingness to place students.

CONCLUSION

Rural academics can influence rural placement intentions by demonstrating the infrastructure, learning and academic support available. A camp experience increases metropolitan academics' awareness of rural placement programs and willingness to encourage student participation. Participants with rural backgrounds appeared more receptive to rural learning possibilities.

Common concepts in separate domains? Family physicians' ways of understanding teaching patients and trainees, a qualitative study

BACKGROUND

Medical education is increasingly expanding into new community teaching settings and the need for clinical teachers is rising. Many physicians taking on this new role are already skilled patient educators. The purpose of this research was to explore how family physicians conceptualize teaching patients compared to the teaching of trainees. Our aim was to understand if there is any common ground between these two roles in order to support faculty development based on already existing skills.

METHODS

Semi-structured interviews with twenty-five family physician preceptors were conducted in Vancouver, Canada and thematically analyzed.

RESULTS

We identified four key areas of overlap between the two fields (being learner-centered; supporting the acquisition, application and integration of knowledge; role modeling and self-disclosure; and facilitating autonomy) and three areas of divergence (aim of teaching and setting the learning objectives; establishing rapport; and providing feedback).

CONCLUSIONS

Finding common ground between these two teaching roles would support knowledge translation and inquiry between the domains of teaching patients and trainees. It would furthermore open up new avenues for improving training and practice for clinical teachers by better linking faculty development and continuing medical education (CME).

Remote supervision of medical training via videoconference in northern Australia: a qualitative study of the perspectives of supervisors and trainees

OBJECTIVES

Telemedicine has revolutionised the ability to provide care to patients, relieve professional isolation and provide guidance and supervision to junior medical officers in rural areas. This study evaluated the Townsville teleoncology supervision model for the training of junior medical officers in rural areas of North Queensland, Australia. Specifically, the perspectives of junior and senior medical officers were explored to identify recommendations for future implementation.

DESIGN

A qualitative approach incorporating observation and semistructured interviews was used to collect data. Interviews were uploaded into NVivo 10 data management software. Template analysis enabled themes to be tested and developed through consensus between researchers.

SETTING

One tertiary level and four secondary level healthcare centres in rural and regional Queensland, Australia.

PARTICIPANTS

10 junior medical officers (Interns, Registrars) and 10 senior medical officers (Senior Medical Officers, Consultants) who participated in the Townsville teleoncology model of remote supervision via videoconference (TTMRS) were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Perspectives on the telemedicine experience, technology, engagement, professional support, satisfaction and limitations were examined. Perspectives on topics raised by participants were also examined as the interviews progressed.

RESULTS

Four major themes with several subthemes emerged from the data: learning environment, beginning the learning relationship, stimulus for learning and practicalities of remote supervision via videoconference. While some themes were consistent with the current literature, new themes like increased professional edge, recognising non-verbal cues and physical examination challenges were identified.

CONCLUSIONS

Remote supervision via videoconference provides readily available guidance to trainees supporting their delivery of appropriate care to patients. However, resources required for upskilling, training in the use of supervision via videoconference, administration issues and nursing support, as well as physical barriers to examinations, must be addressed to enable more efficient implementation.

Students' and junior doctors' preparedness for the reality of practice in sub-Saharan Africa

BACKGROUND

Evidence tailored to sub-Saharan Africa on outcomes of innovations in medical education is needed to encourage and advance their implementation in this region.

AIM

To investigate preparedness for practice of students and graduates from an innovative and a conventional medical curriculum in a sub-Saharan African context.

METHODS

Using mixed methods we compared junior doctors and fifth-year students from two Mozambican medical schools: one with an innovative problem- and community-based curriculum and one with a conventional lecture- and discipline-based curriculum. A questionnaire on professional competencies was administered, semi-structured interviews were conducted, and work diaries were collected. The findings were integrated in a conceptual model.

RESULTS

Six areas of tension between global health care ideals and local health care practice emerged from the data that challenged doctors' motivation and preparedness for practice. Four elements of the innovative curriculum equipped students and graduates with skills, attitudes and competencies to better cope with these tensions. Students and graduates from the innovative curriculum rated significantly higher levels on various competencies and expressed more satisfaction with the curriculum and its usefulness for their work.

CONCLUSION

An innovative problem- and community-based curriculum can improve sub-Saharan African doctors' motivation and preparedness to tackle the challenges of health care practice in this region.

Understanding rural clinical learning spaces: Being and becoming a doctor

CONTEXT

Calls for health professions education that can foster transformative educational experiences have been voiced. Studies suggest that extended clinical training at rural sites potentially provides transformative learning spaces. This article explores 'being and becoming' as a construct for understanding the student experience at a rural clinical school (RCS).

METHODS

Sixty-two in-depth interviews were conducted over a three-year period with RCS students, graduates (as interns) and intern supervisors. Thematically analysed data were mapped according to the adapted Kirkpatrick model for appraising educational interventions. Drawing on realist perspectives, findings were further analysed to discern the mechanisms influencing the being and becoming of junior doctors.

RESULTS

Responses provided evidence of changed attitudes and behaviour, and the adoption of professional practice that was seen to influence patient outcomes. Analysis highlighted sharing of values through role modelling, engagement with preceptors, being respected as part of a team, and being trusted to assume responsibility for a patient as key mechanisms. The outcome was confident, competent and caring interns.

DISCUSSION

Rural clinical learning spaces influence the 'being and becoming' of a junior doctor. Understanding this process in the context of place (rural platform), participation (community of practice) and person can inform expanded agendas for students' clinical learning.