The developmental process, from conceptualisation to implementation, comprised three phases that included seven local, provincial and national, consultative workshops focusing on facilitating stakeholder input and dialogue reflective work sessions by the research team, as well as expert review. Approximately 240 people participated in the activities and initiatives that informed the development of the Framework and implementation tool between 2015 and 2018. Table 1 shows who the workshop participants were, how many attended per workshop, and the purpose and outcomes of each workshop. The dates in Table 1 provide a sense of the progression of the work over time. Stakeholder engagement with the National Department of Health (NDoH) and the Health Professions Council of South Africa (HPCSA) took place in February and March 2017. In keeping with the PAR process, analysis was undertaken throughout the course of the project. Ethics approval was received from the Stellenbosch University Faculty of Medicine and Health Science Research Ethics Committee # N16/03/034, as well as the funder.
Table 1: The seven consultative workshops
#
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Where
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When
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Who
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How many
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Purpose
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Outcomes
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Phase 1 – Establishing the foundation
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1
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Cape Town, Western Cape,
SA
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8&9 October 2015
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Representatives from all medical schools; and from National, Eastern and Western Cape Departments of Health
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33
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Initiate process to develop a framework for DHPT in undergraduate medical training
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Examples of current practice in DHPT at SA medical schools
Key factors for enabling DHPT established
Priorities, gaps and challenges in DHPT identified
Visual depiction of possible models [7]
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2
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Port Elizabeth, Eastern Cape, SA
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21 June 2016
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SAAHEa conference delegates (representing a range of health professions)
Representatives from (Medical/Health Sciences) Deans’ Committees
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28
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Provide opportunity for multi-professional engagement in developing a DHPT framework
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Definition of DHPT
Vision statement for DHPT
Components of this vision
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Phase 2 – Developing the Framework and the Implementation Tool
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3
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Cape Town, Western Cape, SA
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27 June 2017
|
SU FMHSb Faculty
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25
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Stakeholder input
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Verification of DHPT enabling factors
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4
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Potchefstroom, North West, SA
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5&6 July 2017
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SAAHE conference delegates (representing a range of health professions)
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41
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Develop strategies for effective DHPT
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Identification of challenges, barriers and bridges in DHPT revisited
Validation of enabling factors
Consensus statement on DHPT
Formation of SAAHE Special Interest Group in DHPT
Framework for DHPT
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Phase 3 – Implementing and refining the Framework
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5
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Durban, KwaZulu-Natal, South Africa
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27 June 2018
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SAAHE conference delegates (representing a range of professions)
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28
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Enable participants to implement the DHPT framework in their local context
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Implementation tool (Annexure A) piloted
Workshop format to use the implementation tool trialled
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6
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Mthatha, Eastern Cape, South Africa
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13&14 September 2018
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WSU FHSc faculty, clinical supervisors, students
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35
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Evaluate WSU DHPT programme using the implementation tool
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Implementation tool refined
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7
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Durban, KwaZulu-Natal, South Africa
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6 September 2018
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UKZNd College of Health Sciences faculty
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14
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Use the implementation tool
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Framework and tool applied a in another context.
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aSAAHE Southern African Association of health educationalists
bSU FMHS Stellenbosch University Faculty of Medicine and Health Sciences
cWSU FHS Walter Sisulu University Faculty of Health Sciences
dUKZN University of KwaZulu-Natal
Phase 1 – Establishing the foundation
As a foundation for the PAR activities, the research team conducted a scoping review to identify approaches to distributed training as found in current literature. This review provided an over-arching perspective on the topic, offering a first level of evidence to inform the development of the Framework. It identified student learning, the training environment, the role of community and leadership and governance as essential components for DHTP. [14] Workshop 1 formally initiated the process of participatory work. During this two-day event, participants representing all nine medical schools in SA, described current practice across their different institutions, and identified priorities, gaps and challenges for implementing DHPT. The group further proposed a preliminary set of key factors for enabling DHPT, clustered around the essential components that had been identified from the scoping review [7]. A year later, Workshop 2 engaged with these sets of ideas again, looking to concretise a definition and develop a vision statement for DHPT (Box 1), which was premised on a set of guiding principles (Box 2). This second workshop expanded the reach of the project by extending an open invitation to all interested health professionals who were in some way or another involved in the clinical training of HPE students.
Box 1: A Vision for effective DHPT
Effective DHPT facilitates learning that is transformative, reflective, socially accountable, community-engaged, self-directed, inter-professional, collaborative and peer-to-peer. The curriculum for distributed training is relevant, primary health care oriented, holistic, fit for purpose, and delivered in an integrated, continuous and longitudinal manner. Sufficient resources are made available for distributed training. Teachers and supervisors are motivated and suitably equipped for their task. Students embrace distributed learning.
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Box 2: Guiding principles
A shared vision: all stakeholders across all levels recognise the need to work towards a shared vision for distributed training as a catalyst for good quality, relevant health professions training addressing the health care and human resources needs of the country.
Social accountability: orientating the training of students towards the health needs of the community in order to foster the development of socially accountable health care workers who are motivated to work in underserved areas once qualified.
Continuity: immersed, longitudinal, distributed training in and with communities, fostering continuity of learning and relationships with health services, managers, health care teams, trainers, staff, training institution(s), students, patients/clients and the community.
Responsive adaptability: continuous renewal and adaptation of curricula, training methods and approaches, ensuring they are flexible but achieve educational equivalence in different settings so as to be responsive to community and health system needs.
Integration: fostering an integrated approach to learning, a curriculum that merges clinical and public health approaches and promotes inter-professional learning and collaborative practice across disciplines and various levels of care.
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The research team subsequently held a two-day reflective work session during which the findings of the scoping review, the key factors and visual artefacts (Workshop 1) and the vision for DHPT (Workshop 2), were revisited and synthesised through a process of shared critical reflection and sense making. Thematic analysis of the artefacts developed during or as a result of the workshops (group notes, reports, drawings, etc.), was also undertaken, using a process of individual review during which team members separately developed a set of codes, followed by collaboratively categorising these into over-arching themes. (For examples of artefacts see De Villiers et al. 2017). [7] This interpretive synthesis generated an expanded set of enabling factors (arising from the key factors identified in the scoping review) for effective DHPT that could inform the operationalisation of the essential components. [7] These were subjected to an expert review process (with 21 representatives from academic institutions and 12 from the health services) conducted electronically in May 2017, and were revised accordingly.
Phase 2: Developing the Framework and the Implementation Tool
Workshops 3 and 4 were held during this phase where participants reflectively engaged with the revised set of essential components and the enabling factors. The Adaptive Action approach of Eoyang and Holladay [29], an iterative planning process arising from complexity theory, was introduced to facilitate further refinement resulting in the final set of 41 enabling factors to facilitate the implementation of effective DHTP (Table 2).
Table 2: Essential components and their enabling factors (unabridged version)
Leadership and governance influences effective DHPT, through the decision-making processes and roles and responsibilities of stakeholders.
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- All role players, including the health services, community, and training institutions, engage in mutually beneficial and equitable partnerships.
- The roles and responsibilities of training institutions, health services, and communities, are clear to everyone involved.
- All levels of management are committed to effective collaboration to support students’ learning.
- Senior management of all role players demonstrate collaborative and visionary leadership toward a shared purpose.
- Champions take responsibility for distributed training.
- Funding for training initiatives is made available through a transparent funding model.
- Formal and informal communication channels exist across all levels and among multiple role players.
- Monitoring, evaluation, and research on distributed training initiatives are encouraged by leadership.
- The training institution:
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- implements institutional policies that support distributed training.
- supports and capacitates primary supervisors and other site staff involved with students (see also factor 31).
- builds and maintains relationships with the site.
- selects students most likely to practice in rural and remote areas.
- becomes familiar with each site’s strengths and challenges.
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The curriculum provides the scaffolding that informs the learning outcomes, content, mode of delivery, and assessment of students, and evaluation of the curriculum itself.
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10 Management of the training institution takes leadership in prioritising and implementing distributed training programmes.
11 Consistency amongst learning outcomes across training institutions is required for students to learn together at the same site.
12 Learning outcomes for distributed training include a focus on:
- Social determinants of health.
- Common, undifferentiated problems in primary health care.
- An integrated spectrum of health and illness.
- Cultural awareness.
13 The curriculum for distributed training uses:
- Various teaching and learning approaches (e.g., student-centered, interprofessional, competency-based, self-directed, debriefing and reflection).
- A patient-centered approach to care.
- Opportunities for developing a range of competencies.
- Flexibility to adapt to the realities of the individual site.
- On-site, integrated and continuous student assessment.
- Distributed training rotations should be of sufficient length to allow for immersion and integration for students, and continuity for the site.
15 Provision is made for regular and structured feedback from and to students.
16 Applicability of learning outcomes is assured by continuous monitoring, review, and modification of the curriculum.
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The community is defined as the population that utilises the local health facility where students are trained, and is the reference point for the curriculum.
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- Community stakeholders are identified and engaged.
- Strong partnerships are forged and maintained with community stakeholders at the training site.
- The community is involved in and supports the shared vision for the training initiative that meets their needs.
- Students and staff are aware of and oriented to community needs.
- Learning opportunities are available wherever health services are provided in the community, including home-based care.
- Students learn through being immersed in the community.
- Role players engage in collective celebration of accomplishments.
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The training environment includes (a) people who work at the distributed training site, and in the community, contributing to the training of the students; and (b) the training site as the context and physical environment within which the distributed training takes place.
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(a) people
- There is a dedicated person at the training site who coordinates the training and communicates with the training institution.
- Staff from various professions work with students at the site to facilitate their learning. They are provided opportunities to learn how to teach, developing an understanding of the importance of role modelling, resilience and professionalism.
- Before students arrive, staff at the site receive the information they need about learning outcomes and relevant guidelines to support students’ learning.
- Site staff who train students receive recognition from the training institution.
- Site staff provide feedback about student performance.
- Subject specialists support distributed training through regular outreach visits.
- At least one health professional is motivated and available to act as primary supervisor for students.
- The primary supervisor:
- develops, implements, and evaluates the training at the site.
- is involved in formative and summative assessment of students.
- receives the necessary support and training technologies.
- develops her/his own capacity in teaching and learning, which is made available by the training institution.
(b) Place
- The training site is selected collaboratively by stakeholders, including service providers, training institution, site management, and relevant others.
33 Site selection is based on patient profile, learning outcomes, quality of care, and other factors that will provide relevant learning opportunities.
34 Medical equipment, appropriate to the level of care of the facility and to the required learning outcomes, is available.
35 Sufficient space for training activities is made available.
36 Materials to enhance learning are made available on-site, preferably through internet connectivity and information technology equipment.
- Depending on location of the site, accommodation and transport for students are made available. Include community outreach and the use of community resources where appropriate.
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The students are learners enrolled for any programme in health professions at a training institution.
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- Students:
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- receive orientation before they begin a rotation.
- have academic and social support available when and where they need it.
- provide feedback after they complete a rotation.
- have adequate arrangements for safety and security.
39 Student-staff ratios are mutually agreed upon during site selection.
40 At least two students are assigned to a site to ensure peer engagement.
41 Reasonable logistical arrangements are made by the training institution.
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A further outcome from Workshop 4 was the approval of a national consensus statement for DHPT, developed by the research team, which was then adopted by the South African Association of Health Educationalists at their annual conference in June 2017 [8] (http://saahe.org.za/2017/07/consensus-statement-on-decentralised-training-in-the-health-professions/) and led to the establishment of a Special Interest Group for DHPT within the organisation. The consensus statement has subsequently been endorsed by at least 11 professional bodies and training institutions representing a significant proportion of the key role-players in HPE in South Africa. It was also at Workshop 4 that the Framework for effective DHPT (Figure 1) was conceptualised comprising the guiding principles and the essential components. Analysis had further pointed to the centrality of relationships and hence its placement at the heart of the framework while also emphasising the importance of wide stakeholder engagement, involving all sectors relevant to training health professionals in the country, to ensure the sustainability of programmes long term.
Throughout this phase, the research team continued to adopt a critically reflective process during regular project meetings, thus ensuring iterative cycles of data collection, reflection and action, while drawing on their own lived experiences and that of their participants. [26] A key realisation during this process was the need to facilitate the implementation of the Framework. This led to a final outcome from Phase 2 namely the Implementation Tool, which again drew on the principles of Adaptive Action and saw the reorganisation of the enabling factors into a set of ‘Simple Rules for Effective DHPT’ (Annexure A). This Tool was intended to guide the implementation of new programmes, assess and improve existing programmes, and engage stakeholders in sustainable design, implementation, and evaluation of distributed training initiatives.
Phase 3: Implementing and refining the Framework
During this final phase, the Implementation Tool was piloted during a series of workshops (5-7), while evolving drafts of the Framework and the Tool were presented at a number of national and international conferences and other events to key stakeholders (NDoH, HPCSA). This allowed for further refinement based on contextual input, thereby sustaining engagement and interest, and the identification of those elements of the tool which would be most useful in practice [30]. Further engagement with local communities is envisaged.
In summary, the process across the three phases has been characterised as iterative and complex. Each new engagement with stakeholders often took us several steps back before it took us forward. Figure 2 offers a visual representation of the project’s evolution showing the iterative cycles – the feedback loops described earlier - through the PAR episodes that enabled us to progress from the initial question of how to do distributed health professions training, to the development of the Framework and a tool to facilitate its implementation.