On being agents of change: a qualitative study of elective experiences of medical students at the faculty of health sciences; university of cape town; south Africa

Background. Student electives during the 5th year of the University of Cape Town (UCT) medical curriculum provide a 4-week work experience in the health system. The reflective reports of past students indicate that the electives may significantly shape their developing identities as health professionals and agents of change. Objective. To better understand how 5th-year medical elective students perceive themselves as agents of change to strengthen the elective programme in the Faculty of Health Sciences; UCT. The hypothesis was that the more choice that students are given over their learning; the greater is their sense of agency. Methods. Thirteen 5th-year student volunteers participated in four focus group discussions soon after completing their electives in district; regional or tertiary health facilities in the South African health system. Thematic analysis of the transcripts was performed independently by two of the authors. Results. Key themes were the importance of providing holistic patient-centred care; becoming a competent health professional; working within the health team and advocating for a better health system. The elective experience helped students to be more confident in their abilities and to better understand how to effect change at a clinical and health system level. Conclusion. This study supported the hypothesis that the more choice students have over their learning; the greater is their sense of agency. The electives are appreciated as opportunities to develop clinical skills and competencies and to better understand the role of future doctors within the health team and health system. The value of the UCT elective programme could be enhanced by greater promotion; funding for rural electives; and post-elective peer-topeer feedback sessions. This study will inform planning for an extended 2016 medical elective programme in the Faculty

The Retention of Community Service Officers at District Hospitals in KwaZulu Natal; Eastern Cape and Limpopo Provinces

Background: Community service (CS) is an effective recruitment strategy for underserved areas; using legislation as the driver; however it is not a retention strategy. By the end of each year; most CS officers working in district hospitals (DH) are skilled; valued and valuable members of the health team; able to cope with the demands of working in the public health service within the resources available at DHs. Their exodus at the end of each annual cycle represents a net loss of valuable skills and experience by the public service; measured by the time and effort required to orientate and induct the following cohort of CS officers. This in turn has a negative effect on the level of service delivery and the quality of patient care. This study sought to understand the motivations of CS officers to continue working at the same DH for a subsequent year after their obligatory year was over. The objectives were to determine the number of CS officers who actually remained at the same DH after completing their CS in 2002; the major factors that influenced them to remain; and factors that would encourage the 2003 cohort of CS officers to remain for an additional year at the same DH. Methods: A descriptive cross- sectional study design was employed using qualitative methods with the cohort of CS officers who had completed their compulsory CS year in 2002 and who were still working at the same DH in July 2003. This was followed by a quantitative survey of CS officers doing their CS at DHs in KwaZulu-Natal (KZN); Eastern Cape (EC) and Limpopo Province (LP) in November 2003. Results: 22/278 (8) of the 2002 cohort of CS officers in KZN; EC and LP remained at the same DH in the year following their CS. The reasons given; in order of decreasing priority; were that they were close to home; had been allocated as part of their CS; were personally recruited; had bursary commitments; had heard about the hospital from friends; had visited the hospital prior to starting community service; and had visited as a medical student. Four others did not specify reasons. In the larger quantitative study 150 / 221 questionnaires were returned. More than 80of the respondents felt that there had been opportunities to develop confidence in their own ability to make independent decisions; that they had had good relations with the hospital staff; and that they had been able to make a difference in health care delivery. Between 67and 76of respondents felt that they were providing a good standard of care; that there were learning opportunities; that they were doing worthwhile work and saw CS as excellent work experience. However only 52of respondents felt that there had been opportunities for personal growth; 38felt that appropriate equipment was available; 37had a supportive mentor figure and 29felt that there were adequate levels of staffing at the hospital. In total 24 (16) of the 150 who responded to the questionnaire indicated a willingness to remain at the same DH after completion of their year of CS. The intention to continue for a further year was statistically significantly associated with the following factors: ethnic group; province; rural origin; allocation priority and bursary commitment. Conclusions: The retention in the same DH of only 8of the CS officer cohort in 3 rural provinces indicates a serious loss of skills on a recurrent annual basis. Local hospital management can do much to strengthen the factors that would attract CS officers to stay on by improving orientation; mentoring; teamwork; professional development opportunities; medical equipment and accommodation

The community involvement of nursing and medical practitioners in KwaZulu-Natal

Background: The basis of the health system in South Africa is purported to be primary health care (PHC); as defined by the Alma Ata Declaration of 1978. This approach emphasises community involvement in all health-related activities; but it would appear that a very limited or selective PHC approach is actually being pursued in South Africa; without meaningful community participation or ownership. This study explores the involvement of exemplary medical and nursing clinical practitioners in non-clinical community-wide activities in terms of the primary health care approach; which demands a broader scope of practice than primary medical care. Methods: The objectives of the study were to identify exemplary medical and nurse practitioners in primary health care; to document their practices and perceptions with regard to their community involvement; to analyse the common themes arising from the findings; and to present recommendations based on the findings. Seventeen primary care clinicians in KwaZulu-Natal; half of whom were professional nurses and the rest medical practitioners; were purposively selected through their district managers. A team of four medical students was trained to collect the data and interviewed the subjects in their places of work using open-ended questions. The interviews were recorded; translated where necessary; and transcribed. Content analysis was carried out as a team; with the identification of major and minor themes.Results: The findings of this study were consistent with studies from other countries; with some interesting differences. The major themes that emerged from the data included the wide range of activities that subjects were involved in; the importance of relationships; the context of poverty; the frustrations of this kind of work; and the respondents' motivations. These are illustrated by numerous verbatim quotes from the respondents. Minor themes were the roles that the respondents play in the community; the difficulty of obtaining funding; and experiences in starting up. Significantly; the fact that the role of clinicians in the community emerged as only a minor theme rather than a major theme in this study indicates the absence of expectation and policy in this area of practice in South Africa. In the light of the supposed centrality of the primary healthcare approach in the national health system; this is a serious gap.Conclusion: The lack of a clearly defined role in the community outside of the clinical role that deals with the individual patient who presents for care is discussed in relation to the policy of the primary health care approach. The concept of community-oriented primary care provides a framework for a more systematic approach to community engagement; and this study serves as a basis for further research into the subject