Health professionals’ perceptions of the Walter Sisulu University’s integrated longitudinal clinical clerkship on service delivery in rural district hospitals in Eastern Cape Province, South Africa | BMC Medical Education

Description of the sample population

Thirty-three (n = 33) health professionals from the six study sites participated in the study (Table 1). The data collection tool did not capture demographic information such as sex and age of the participants. The maximum number per site was six, and the minimum was five. Three sites had six participants each, and the other three sites had five.

The participants were a multidisciplinary team of health professionals from clinical (28/35) and non-clinical positions (5/35) (Table 2).

Major themes

The researchers found nine major overarching themes after scrutinizing and discussing the data (Table 3). There was a balance in terms of the impact on workload, with an equal number of positive and negative effect. The positive themes that emerged as impact on service delivery, outweigh the negatives.

Impact of WSU’s ILCC on health professional’s workload.

The results reveal that WSU’s ILCC was perceived by the majority of participants to have a positive effect on workload of healthcare professionals in rural district hospitals. It was suggested that they contributed in a positive way and with competency, thus easing clinicians’ workload. However, the results also show that the presence of students at the district hospitals had a negative effect on personnel workload.

Reduced workload of health professionals

Health professionals indicated that students positively affect workload as they reduce the clinician’s workload by providing patient care. Students participated in almost all patient care activities, including but not limited to independent consulting and managing patients, performing different medical and surgical procedures, and managing emergencies. Even though students were learning, they also contributed to patient care.

Extra-hands in managing patients

Students are valuable resources serving as extra-hands in triaging patients, taking detailed history, initiating treatment, and reducing patient waiting times.

“Students become extra hands here…, where we have this chronic shortage of doctors. They consult patients on their own even though they do not make final decisions. They play an essential role in managing lines, managing wards, becoming messengers, and more importantly, managing patients.” (Participant 13).

“…these students are senior…. There is a smooth patient flow that reduces waiting times.” (Participant 7).

“It is quite helpful to have medical students around. Even in the mornings before ward rounds, they have checked the results and made clinical notes.” (Participant 25).

“… they come here early in the morning, and they try to manage patients while we are waiting for a medical officer.” (Participant 27).

Perform clinical procedures

The participants also admitted that students reduce personnel workload since they performed different time-consuming medical and surgical procedures, including insertions of intravenous lines, insertion of chest drains, catheterisation, applying Plaster of Paris (POP), and wound dressing. Medical students assist in reducing the workload, especially for the doctors.

“Students reduce our workloads because they assist us with taking blood, insertions of intravenous lines, catheterisation of patients, and before they leave, they even insert chest drains.” (Participant 15).

“The nurses become so excited when students are here because students do all the procedures usually done by nurses like putting up IV lines, POP’s, suturing, giving injections, wound dressings.” (Participant 20).

“They even assist in managing emergencies when our doctors are busy in theatre.” (Participant 18).

Clinicians’ struggles to get time to teach students

Participants also mentioned some negative effects of hosting students on personnel’s workload, stressing clinicians’ struggles to get time to teach students. They felt this negative effect mainly during the early weeks of ILCC, after which students become an asset to the facilities.

Participant 19 shared that “The problem with having students, it is when they are still new where you have to spend a lot of time teaching (sic)…. you spend a lot of time like extra 10 minutes with each patient. And for an overpopulated hospital like ours with a shortage of doctors, this becomes a problem.…we do it because we know you only do the teaching for a week or two, then students become your assets doing most of the work.”

“Compared to the time the students are not there, a doctor working alone in 30 minutes can see several more patients than when students are around.” (Participant 32).

Effect of WSU’s ILCC on the quality of service delivery

The results of this study reveal that the majority of participants reported a positive effect of WSU’s ILLC on service delivery quality while the minority reported a negative effect of WSU’s ILLC on the quality-of-service delivery. Broadly, the health professionals indicated that students contributed to an improved quality of care by conducting quality improvement projects, community outreach, and bringing new ideas to patient care. The participants also reported that the student’s presence created a teaching environment that impacted the healthcare teams and the quality of care. Health professionals also noted that students contributed to enhanced quality of patients’ experiences in the facility.

Improved quality of health service delivery

Students improved the quality of health service delivery by conducting quality improvement projects. Most of them indicated that these students’ projects resulted in increased care efficiency and sustained care practice changes.

“Our medical students do quality improvement projects… They identify gaps in how we do things and come up with implementable plans to close those gaps. In the end, it is not just a paper project, but they implement and evaluate showing sustainability.” (Participant 14).

“I will make an example of the quality improvement project they did last year as part of their 20-week rotation…, they came up with practical solutions on how to improve our services to the community.” (Participant 19).

The participants also reported that students presented new approaches to patient care, including new treatment guidelines, clinical audits, booking card systems, and filing systems resulting in enhanced service delivery.

“Last year’s group came up with new treatment guidelines or protocols; they even assisted us to download an app in our smartphones with all those protocols. Another group presented topics in terms of how we can improve some of the ways we do things.” (Participant 13).

The participants highlighted that student research projects provided evidence-based knowledge on how to improve service delivery.

“Students also do mini-research where they assist us in improving some of our programs. Furthermore, their preceptor also takes them to the clinics and schools for outreach. The outreach exposes them to the community.” (Participant 2).

“Students always come with new researched knowledge leading to medical changes in our facility. These changes contribute to improved quality of healthcare delivery”. (Participant 11)

Students also visited local clinics and schools to do health education/promotion; do in-service training activities for the nurses in hospital.

“They also do health education… They help clients by educating them on acceptable healthy standards, healthy living ways.” (Participant 21).

“Student held a small in-service training on family planning. They came up with ways on how to reduce termination of pregnancies, how to get scholars to use family planning, and all those things”. (Participant 22)

The quality of health service delivery improved during the rotation period of the students. According to the participants, these improvements are sustained even after the rotation period of the students. This is so mainly because they were achieved through translation into practice from activities such as quality improvement projects, research, health promotions, and evidence-base current approaches to patient care.

Stimulate health professionals to learn Another favourable finding on the implications of hosting students on service delivery that emerged from the interview data was that students stimulated health professionals to learn and improve their clinical knowledge in advance of teaching.

“The main advantage that I can think of is that all my doctors, they get to learn and be updated on the current information because a student will just ask something, for instance, the current guideline in managing…meningitis, you give them may be the last update of those guidelines, they will tell you: ‘…doc, no today, I read somewhere…’… they probe the doctors to go and check the recent information before going into tutorials.” (Participant 32).

“Students ask lots of questions, and no one wants to appear like they do not know anything in front of students. This happens to both the nurses and doctors.” (Participant 11).

Create a learning environment

Participants also reported that the presence of students creates a learning environment in the facilities. They indicated that academic meetings and presentations with students help them to update both clinical and academic knowledge. The participant also mentioned that when students are around, they felt responsible for imparting knowledge and were obliged to revisit reference materials. “Students help us updating both our clinical and academic knowledge. When they are around, we have academic meetings and presentations that we would not normally have.…all doctors have to read to prepare for these.” (Participant 14).

Health professionals adhere to correct clinical procedures

Participants reported that professionals were thorough when providing care to patients, especially when carrying out procedures and manoeuvres in the presence of students.

“When demonstrating or teaching students you, stick to principles or correct manoeuvres. You do not do shortcuts. Students need to learn the correct procedure or movement.” (Participant 6).

Enhanced quality of patients’ experiences

Students’ presence in the facility resulted in enhanced quality of patients’ experiences. Participants felt that students had a positive attitude towards patients and thus improved their attitudes towards students. They felt that patients do not feel the shortage of clinicians during the rotation period of students. They also reported that patients are happy with the thoroughness of care provided by students.

The district hospitals experienced improvements in patients’ rights because the medical students had positive attitudes toward patients. Participants felt that patients considered students more polite, compassionate, and genuinely concerned about their well-being. They noted that these positive attitudes improved patients’ experiences in the facilities.

Participant 8 said “students always have positive attitudes towards patients. Our patients are very satisfied with the students. These guys treat them with respect and courtesy.”

“It is not helpful when you come, and there are no doctors to see you. They are so glad when they are here. There is no waiting for a doctor if they are here, these student doctors.” (Participant 3).

“…our patients are doctor orientated, and when they see students, they see doctors.” (Participant 9).

Patients recognised students for the thorough physical examination they perform on them and follow-ups after referrals. Several noted that patients appreciated this increased attention given to them by the students.

“Patients are happy with students, you know, they like that physical examination, I mean thorough physical examination. Most doctors do not do that these days; they just put the stethoscope all over you without even undressing you.” (Participant 12).

“Our patients are very satisfied with the students. Students examine patients thoroughly, people like that.” (Participant 15).

Extended ward rounds

It also emerged from the interview data that students’ presence had some negative implications on the quality-of-service delivery in rural district hospitals. The participants reported that students’ presence slows service delivery at the beginning of their rotations because of the time required to teach students, which usually prolongs ward rounds.

“…the rounds take longer because students ask lots of questions and you spend time teaching them.” (Participant 25).

Maternity patients prefer not to be attended by students

The participants also indicated that patients in the maternity ward do not trust students and preferred that students should not attend to them.

“Our patients in maternity do not like to be attended by students.” (Participant 6).

“Maternity is a critical place. When maternity patients come to the hospital they always want to be seen by a doctor.” (Participant 7).