2015, 37: 589–594

Understanding rural clinical learning spaces: Being and becoming a doctor SUSAN C. VAN SCHALKWYK, JUANITA BEZUIDENHOUT & MARIETJIE R. DE VILLIERS Stellenbosch University, South Africa

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Abstract 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.

Introduction In 2013, World Health Organization guidelines called for the ‘Transforming and scaling up of health professionals’ education and training’ to address the severe shortages and maldistribution of health care workers across the globe. This report recommended that curricula be adapted to meet population needs (World Health Organisation 2013). These sentiments echoed those of an earlier Lancet Commissions article, which explored the future of health professions education, arguing that medical education is not in step with the challenges that health care provision faces globally (Frenk et al. 2010). These authors called for global reform that would lead to ‘transformative education’ and ‘interdependence in education’—this at the level of instructional and institutional renewal, respectively (Frenk et al. 2010, p. 1924). Transformative education implies a shift in focus. While not negating the process of knowledge acquisition and skills development, the transformative element resides in the emergence of a professional identity as the student moves towards graduation (Mann 2011; Jarvis-Selinger et al. 2012). Teaching for such transformation can be fostered though the adoption of approaches that encourage participation and expose students to real-life contexts where they become part of a community of practice (Mann 2011). Characteristics of

Practice points 

 





Transformative educational and training experiences are required to ensure a health care workforce that can respond to global needs. Rural clinical learning spaces have the potential to provide such transformative learning spaces. Evidence of these transformative learning experiences include changed attitudes and behaviours, and the adoption of professional practice that can influence patient outcomes. The construct of ‘being and becoming’ can inform our understanding of how students transition to junior doctors. The dimensions of person, participation and place provide a framework within which the mechanisms that enable such being and becoming can be considered.

this way of thinking about medical education include aspects of integration across curricula; encouraging appropriate habits of mind that foster a questioning and critical disposition; and a focus on the development of a professional

Correspondence: Susan van Schalkwyk, Centre for Health Professions Education, Faculty of Medicine and Health Sciences, PO Box 19063, Tygerberg 7505, South Africa. Tel: 27 21 9389874; Fax: +27 21 938 9046; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/060589–6 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.956064

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identity as a medical doctor (Bleakley et al. 2011; Jarvis-Selinger et al. 2012). The notion of the construction of a professional identity within a particular community of practice resonates with work on social identity development in general. In the context of medical education, it has been argued that it is within communities of practice that student learning experiences shape identities in the process of ‘being and becoming’ (Mezirow 2003; Bleakley et al. 2011). ‘Transformation’ accordingly acquires a different guise underpinned by a distinctive suite of education theories (Mezirow 2003). The idea of ‘being and becoming’ draws its roots from beyond the domain of medical education. In today’s complex and unpredictable, technology driven world, Barnett (2009, p. 431) argues for ‘a wider form of human being’. His recommendations for curricula that foster such ‘being’ highlight the need for generative, authentic learning that encourages students to be resilient and confident to take risks (Barnett 2009). The emphasis on space or the place of learning becomes important (Reid 2011; Van Schalkwyk et al. 2014) as ‘knowing is always situated . . ., and thus transforms from the merely intellectual to something inhabited and enacted: a way of thinking, making and acting. Indeed, a way of being’ (Dall’Alba & Barnacle 2007, p. 682). We previously described the establishment of a medical education innovation in the form of a rural clinical school (RCS), highlighting the potential of the RCS to prepare students for their role as junior doctors in the South African health care system (Van Schalkwyk et al. 2014). Focussing on the first year of implementation of the RCS and drawing on inputs from students and clinical supervisors (medical specialists), our findings showed how students valued the rural space as an enabling and different clinical environment; how the role of the clinical supervisors was seen as generative; and how the community immersion influenced their attitudes, specifically with regard to socio-economic realities and the importance of social accountability (Blitz et al. 2014; Van Schalkwyk et al. 2014). This article, which draws on three years of accumulated data from an ongoing five-year longitudinal cohort study, follows on this earlier work. Our research question seeks to probe beyond a description of the enhanced student experience, to understand why the rural context is described as such a rich learning space. Ultimately, our aim is to build theory that will inform our understanding of the rural clinical learning space and its potential to foster transformative learning.

Methods The over-arching longitudinal study is set in an interpretive paradigm. However, as our intention for this specific investigation is to understand the deeper, causal mechanisms at play in the rural context, we adopt a realist perspective (Maxwell 2012; Pawson & Manzano-Santaella 2012; Wong et al. 2012). Maxwell (2012) advocates for the use of such an approach in qualitative research, arguing against the necessity of a separation between realism and interpretivism. Importantly, realism is enabling in the development of theory (Pawson & 590

Table 1. Number of interviews conducted. Figure in brackets indicates size of RCS cohort.

Cohorts RCS 2011 (8) RCS 2012 (20) RCS 2013 (21) Total

Interviewed as final year students

Interviewed as graduates (interns)

Interviews with intern supervisors

8 9 11 28

8 9

8 9

17

17

Manzano-Santaella 2012; Wong et al. 2012) and as such fits well with our aim in this study. Our data were generated from several different sources. Individual in-depth interviews were conducted with RCS students in 2011 (eight interviews), 2012 (nine interviews) and 2013 (11 interviews) to elicit their perceptions of the RCS experience, focusing on their learning and clinical training. In 2011, all the students who had chosen to go to the RCS were interviewed. In successive years, purposive sampling was applied as larger cohorts elected to attend (2012: n ¼ 20; 2013: n ¼ 21). These interviews were all conducted towards the latter part of the students’ year at the RCS. Follow up in-depth interviews were conducted approximately 10 months later in 2012 and 2013 at the sites where the graduates then worked as interns in the government health system. In addition, individual semistructured interviews were conducted with these graduates’ internship supervisors in 2012 and 2013 (Table 1). Ethics approval was obtained (HREC reference: N12/03/014) and a written informed consent was received from the participants. All interviews were conducted by members of the research team according to a schedule based on our reading of the literature. Interviews of between 30 and 60 min were audiorecorded and transcribed. As analytical framework, we used an amended version of Kirkpatrick’s levels for appraising educational interventions (Boet et al. 2012). Despite the critique against this model challenging the assumptions upon which it rests (Yardley & Dornan 2012), it has been applied effectively in education (Cilliers & Herman 2010) and is popular in medical education contexts (Boet et al. 2012), facilitating a stratified process of analysis. All three authors, at first individually and later collectively, were involved in the iterative process of mapping the data initially working with the individual data sets, subjecting these to thematic analysis, and then selecting quotes on each level across the three respondent groups.

Results Seven data sets (62 interviews) were generated over the three years from the three different groups (students, interns and supervisors) describing aspects of the RCS experience and its influence on the student’s preparedness for internship. By drawing on the voices of these three groups, triangulation could be established. In this section, a sample of illustrative quotes are organised under each of Kirkpatrick’s levels.

Understanding rural clinical learning spaces

Level 1—Perceptions of the learning experience For the students, the learning experience was less about book learning and more about taking responsibility and the practical experience of ‘being’ a doctor.

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Being more hands-on with patients, having to set up your own management plan, having to write prescriptions and then ask the doctor and go back and correct your mistakes —that facilitates your learning. It’s not like [at the tertiary hospital] where you just get spoon fed everything. (RCS13_2013)1 Being a self-directed learner, taking responsibility for one’s own learning has been documented as an important attribute in medical education (Murdoch-Eaton & Whittle 2012). There were also several comments about the meta-learning that emerged from the RCS context. This was strongly linked to the relationships that were established with their supervisors which were described as being fundamental to shaping their ‘becoming’. Being treated with respect and challenged to think for themselves, created an affirming context for the students and also noted by the interns. I feel like I’ve become a better student, as in when you have a relationship with your supervisors . . . and you are able to ask them . . . and they tell you that you’re doing better at this, or I notice that you are not confident at this, or you don’t know this, let’s work on it. (RCS04_2013) However, the doctors were really . . . they were not only doctors who taught you, they were really role models to us. (RCS14_2012,T) I think we are taught the right values and that is good . . . (IN_RCS13_2013, T) The value of the RCS training was confirmed by the intern supervisors: That [the RCS training] would actually make a lot of sense to me as to why she was so proactive because first and foremost she has actually had exposure prior to internship to what the actual working environment is like, I think. Her skills were quite up to date in comparison to the group . . . (IS_RCS01_2013) The influence of role-models and the exposure to authentic contexts in enhancing students’ personal and professional development has been described before (Daly et al. 2013) and points to the importance of faculty development for those who are called upon to be responsible for training on the rural platforms (Blitz et al. 2014).

Level 2a—Modification of attitudes/ perceptions A realist approach can make use of ‘thought experiments’ (Wong et al. 2012, p. 92) as a means of identifying

mechanisms. For example, responses to a question about how a particular experience influenced a respondent can provide insight. The students’ responses indicated a shift in their perceptions as to what was important in terms of their learning. To me it is more important to practically know what to do with a patient—rather than to know five random lists off by heart. (RCS11_2013,T) This sentiment was echoed by an intern: One other thing which I’ve also realised was in rural school that is not in . . . the main campus . . . is I don’t think they have this thing of promoting health, and that’s one thing that I really felt like, like the whole South Africa needs to have. (IN_RCS06_2013) Students also described a deeper awareness of the patient both as individual and a member of a family and community. It affects you . . . it sort of opens your eyes to seeing that the patient is not just an individual. They come with a family; they come with children and grandchildren. It’s a contextual thing, and you need to be aware of that and be sensitive to it as well . . . those are the moments that I think I will always remember (RCS11_2012) In their study of the lived experiences of medical students on an integrated rural clerkship, Konkin et al. (2012, p. 594) describe these students ‘growing understanding of the importance of care and compassion; receptivity and responsibility as part of expert clinical care’. This resonates with our findings.

Level 2b—Modification of knowledge and skills A recurring theme in studies that describe perceptions of students towards extended rural placements is that of enhanced clinical skills, due to relevant, personal, clinical training (Barrett et al. 2011). The RCS context was seen as providing opportunities for practical application and longer term patient management that led to confidence in their competency. Students repeatedly described how they felt ready for internship. This was again confirmed by the responses from the interns and further verified by the intern supervisors. Here it’s more you’ve done it, you’ve seen the patient, you’ve seen the clinical findings, you’ve done the management, you know how to reason around it. So I think just the confidence that you gain by practically being able to apply your textbook knowledge, your theoretical knowledge. (RCS02_2012) So my first week at [government hospital] I saw how interns that work in tertiary hospitals didn’t know how to do basic things like fill out a drugs

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form. You know, that’s the sort of thing that we learnt at [the RCS] and how to do that basic, basic absolute function for example. (IN_RCS03_2012) Importantly, this confidence was grounded in an established knowledge base which was noted by the intern supervisors.

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Very good. There were a lot of things that we didn’t need to teach him [intern from the RCS]. We were teaching him really more advanced things like CVPs and so on, but coming to the normal procedures and the normal approach to illnesses and so on, I think he’s done very well. (IS_RCS03_2012)

Level 3—Behavioural change The confidence that students described in terms of their clinical skills appeared to translate into observable behaviour. It manifested in their clinical reasoning and adopting a handson approach—attributes that they felt would inform their behaviour for the rest of their professional careers. My clinical experience here, I work with the patient from the moment they come in the door, I don’t know what’s wrong with them, and then I work them through until I figure out what’s wrong with them, and that’s like what I’m going to be doing for the rest of my life. I never had the chance to do that all those years while I was at [the main teaching hospital] (RCS12_2012) Similarly, behaviour patterns moulded at the RCS were entrenched at intern level and noted by supervisors, both in terms of ability and in terms of taking responsibility for their learning. They were like ‘how do you know how to do this and how to stay calm in this situation and know the different steps?’ I said it’s because we did it every few weeks, and they really drilled it into us. (IN_RCS12_2012) So for the entire two months . . . There was no need for reprimanding her as far as any patients not being prepared for theatre; she was a good intern, very proactive. The stuff that she did not learn and then that was actually told to her to go and read, she actually was one of the few people who would go and read, which we need more of, to be totally honest with you. (IS_RCS_01_2013)

Level 4a—change in professional practice ‘Being’ a professional was personified in two specific areas. First, that of functioning as part of team at the RCS and, second, coping with the day-to-day challenges in the hospitals where they worked as interns. 592

We worked together as a team. We all ended at half past three in casualty in order to clear the patients, allowing everybody to have a meal and also not to leave patients at the end of the day to be sorted out by the guy who is on call. It is a different mentality to work like this and that integrity to support your team that you learn there is extremely valuable and you’ll apply that again sometime in the future. (IN_RCS12_2013) While the interns spoke of functioning in a team with ease, it is the students’ descriptions of how they were taken up into ‘the firm’ that was instrumental. So I feel comfortable to work in the hospital set-up. I mean . . . I think we function in any case as interns in the district hospital, because I mean, you get the responsibility to do today’s clinic and then you do the whole clinic. If you do not know something, then you go and ask quickly and they’ll tell you immediately, but you carry on with what you have to do. (RCS11_2013,T) The graduates’ ability to perform effectively as junior doctors, and with confidence, was also highlighted by the intern supervisors: We were all very impressed with [graduate from the RCS] because he joined as a first year intern surrounded by second year interns, and he was already at a level higher than they were . . . So he actually went far above than was expected of him, and his knowledge already from the beginning was very good. He was very confident and competent from the beginning . . . (IS_RCS01_2012) Daly et al. (2013) describe how their students responded to the opportunity to adopt the ‘doctor-role’ in the rural context and how this enabled their immersion into the community of practice.

Level 4b—benefits for patients At this stage of the study, we rely on the voices of the intern supervisors and their observation of the two RCS cohorts at work as interns in the hospitals in which they have been placed to offer some insight into any potential benefits for patients that may come as a result of the RCS training. This is a limitation that is being addressed in year four and five of the longitudinal study by incorporating patient and community voices. Nevertheless, the responses do provide some preliminary insights. She really was clued up in terms of getting her investigations done, what investigations needed to be done. Again, she also learnt different management for different patients, which was good. I was impressed with her overall. (IS_RCS12_2013)

Understanding rural clinical learning spaces

We normally have an academic meeting at two, she [RCS graduate] said she would be slightly late for the meeting. When I asked why . . . she said she wanted to finish off her MVAs, and to my surprise, she had done eight by herself. Look, you cannot see that she never finished in a tertiary centre. (IS_RCS13_2013)

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Immediately evident is the perceived competence of the interns, their willingness to learn and their ability to take decisive and appropriate action. By association, and given the under-resourced context within which interns often function, we can infer at least a potential for enhanced patient outcomes. Being and becoming: person, participation and

Discussion

Figure 1. place.

Our analysis according to the Kirkpatrick model offers insight into the being and becoming of students—later interns—and suggests that as an educational intervention, the RCS is a potentially transformative space that can ultimately contribute to enhanced patient outcomes. Our interest, however, lies in the mechanisms that enable these transformative learning outcomes. These mechanisms appear interrelated—enhanced skills leading to confidence resulting in the uptake of additional opportunities which in turn fosters enhanced skills—all emphasising a process of ‘becoming’. At the same time, this process resides within a particular system—in this case the rural training platform—which is described as enabling. We propose that there are three dimensions present in this case—the person, the participation in the community of practice and the place. There is support for this threedimensional thinking. Critical realist Margaret Archer highlights the interplay among structure, culture and agency, where structure represents the material aspects of the system, culture the norms and values at play within that system, and agency indicating the human actor within the system (Archer 2000). Consideration of the students’ being and becoming as influenced by their legitimate participation (Wenger 2000) in a community of practice (as ‘one of the team’) within a particular space (the rural platform) provides us with a framework within which we can better understand the mechanisms that enable this process. Figure 1 offers a graphic depiction of this system which sees the student’s participation nested within the rural place, while the person’s being and becoming is temporal going beyond the final year of study. On a material level, the RCS represents an environment that is quite different from what students experience at the tertiary hospital. The hospital is smaller, there are fewer students and the profile of presenting conditions represents reality in the community. Students also spend time in community clinics and conducting home visits in underserved areas. It is the engaging in this place that facilitates students to be and become junior doctors (Reid 2011). Legitimate participation in a particular community of practice has been identified as a powerful learning

mechanism (Wenger 2000). Being ‘part of the team’ and recognised as making a contribution was a golden thread running throughout the interview transcripts. Going beyond notions of situated learning, Wenger describes legitimate participation in a particular community of practice as a powerful learning mechanism that presupposes ‘understanding the enterprise well enough to be able to contribute to it . . . being able to engage with the community and be trusted as a partner . . . to have access to [a shared repertoire]’ (Wenger 2000, p. 229). Students became fully-fledged participants ‘by modelling themselves on insiders’ (Jacobs 2005, p. 477) and adopting the norms and values of the profession. Ultimately, however, the student’s being and becoming is a factor of their how they exercise their agency within the particular context. Students described taking responsibility for their own learning, and for their patients—a characteristic that has been identified in other studies that have investigated rural placements (Crampton et al. 2013; Daly et al. 2013). Changed perspectives with regard to the realities faced by their patients, shifted their own thinking and influenced their practice. As graduates, this change or difference manifests not only in the clinical competence but also in their commitment as described by the intern supervisors. The approach adopted in analysing the data has largely painted a positive picture of the RCS experience and these findings echo work that has been done elsewhere, emphasising the importance social learning spaces (Crampton et al. 2013; Daly et al. 2013). Instances where the RCS experience (as the educational intervention) generated negative responses related to, for example, logistics on the rural platform, being away from home and access to formal programmes were, however, also encountered (Van Schalkwyk et al. 2014). Although not reported in the context of this analysis, they have also influenced the ongoing process of curriculum revision. In addition, the tracking of cohorts of students from the tertiary hospital into the intern year has recently commenced to facilitate comparison and to provide data on where our graduates eventually decide to work.

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Conclusion In this article, we have endeavoured to identify the underlying mechanisms that are at play at the RCS and how they influence the journey towards being and becoming a junior doctor. We do not make a claim for an extended rural experience as a panacea to all ills, and recognise the need for further and ongoing research in this area to be able to track graduates well into their careers. Rather we aim to build on existing theory and argue that the rural experience offers potentially transformative learning opportunities for students who will need to work in underserved communities. In so doing, we hope to inform current debates around students’ clinical learning across increasing numbers of distributed training sites. Dall’Alba and Barnacle (2007) have argued that knowing and being are conjoined. We have shown that in the rural place, knowing (and being) becomes capable of transforming who we are. It is instructive to note how this experience is not always about academic learning and typically defies quantification or visible identification (Bleakley et al. 2011). It is much more about the intangibles: the sharing of values, being respected and accepted as part of a team, being trusted and confident to assume responsibility for a patient who is both individual and community at the same time. Ultimately, it implies that we think differently about our teaching, that we have expanded agendas for our student’s clinical learning and that we intentionally consider what this means for ‘transforming and scaling up’ what we do.

Note 1. RCS13_2013 indicates RCS student (13) interview conducted in 2013. IN, Intern; IS, Intern supervisors; T, translated.

Notes on contributors SUSAN VAN SCHALKWYK, PhD, is an Associate Professor in the Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa. JUANITA BEZUIDENHOUT, MBChB, MMed, PhD, is a Professor of Anatomical Pathology currently affiliated with the Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa. MARIETJIE DE VILLIERS, MB, ChB, MFamMed, FCFP, PhD, is a Professor of Family Medicine and Deputy Dean: Education, Faculty of Medicine and Health Science, Stellenbosch University, South Africa.

Acknowledgements B. van Heerden, H. Conradie, T. Fish, N. Kok and J. Blitz are acknowledged for their contribution to the project. We also thank all the respondents who participated in this study. Declaration of interest: The authors report that they have no declarations of interest. Funding from the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI), which is supported by the President’s Emergency Plan for AIDS relief (PEPFAR) through 594

HRSA under the terms of T84HA21652, is gratefully acknowledged.

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Understanding rural clinical learning spaces: Being and becoming a doctor.

Calls for health professions education that can foster transformative educational experiences have been voiced. Studies suggest that extended clinical...
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