Developing a Post- Graduate Curriculum In Forensic Psychiatry In Zimbabawe

In the practice of forensic psychiatry in Zimbabwe, there have been problems in bringing psychiatric offenders to justice due to delays in assessment. This has been caused by a shortage of psychiatrists with the relevant skills. Practitioners need to be equipped with the required competencies to deal with both the civil and criminal domains of forensic psychiatry. They also need neuropsychological tools for the evaluation of offenders and victims, and knowledge of the appropriate tests to be used in each case. To date, the Department of Psychiatry at the University of Zimbabwe has had no formal curriculum in forensic psychiatry. To meet these needs, a forensic psychiatry curriculum was developed. The goals for the curriculum were for the students to: 1) acquire knowledge in the assessment and management of psychiatric conditions and their relation to criminal and civil legal issues; 2) attain attitudes that foster a focus on assessment of the patients’ mental health, not their innocence or guilt; 3) write court reports that facilitate the justice process. In addition to improving the current shortage of qualied physicians in forensic psychiatry, this curriculum aims to increase awareness among psychiatry students of forensic psychiatry as a career path.


Introduction
Africa, like many other areas, is characterised by lack of adequate psychiatric resources. Most countries have, on average, one psychiatrist per one million inhabitants. In 2010, Zimbabwe had seven psychiatrists serving a population of 12 million (1); that number increased to nine in 2012. In rural South Africa, the ratio of psychiatrists to the population is as low as 0.3 to one million (2). However, Africa is not alone. A study conducted in the US in December 2015 by the Association of American Medical Colleges showed that the US is facing a signi cant shortage of psychiatrists with most county's demonstrating an unmet need for prescribing psychiatrist (3).
Forensic psychiatry is a branch of psychiatry that deals with issues arising at the interface between psychiatry and the law. Forensic psychiatry has two broad categories i.e. criminal and civil domains. In the criminal domain, the psychiatrist is involved with the assessment and management of people who have committed crimes. It encompasses the assessment and treatment of offenders and prisoners who are mentally ill (4). The civil domain deals with private relations between members of a community.
Forensic services in Zimbabwe face signi cant delays in the process of bringing justice to psychiatric patient offenders. One major bottle neck is in the shortage of psychiatrists or other health professionals who are skilled and available to complete competency assessments and write court reports (5). This stems from both a shortage of psychiatrists and inadequate exposure during post-graduate Psychiatry training. The shortage of psychiatrists in Forensic Psychiatry Services had resulted in an average of a one-year delay in the assessment of mentality ill offenders.
In 2012, the University of Zimbabwe, College of Health Sciences (UZCHS) was in the process of a comprehensive curriculum review and transition to a competency based curriculum (6). As part of this review, the Department of Psychiatry sent four of its faculty members to join a UZCHS curriculum review training programme called 'Health Education and Leadership for Zimbabwe'(HEALZ) (7). As an assignment for this programme, a comprehensive needs assessment was done, and a curriculum was developed in Forensic Psychiatry.

NEEDS ASSESSMENT
The MMed psychiatry student at University of Zimbabwe College of Health Sciences has always had a four-month forensic attachment. The attachment comes in the third year of 4 years of the psychiatrist training programme. A review of all MMed curriculum documents revealed no formal curriculum in forensic psychiatry. A focus group discussion with the academic staff in the Department of Psychiatry found that the students were taught some relevant information regarding forensic psychiatry using a lecture-based and knowledge-focused curriculum. The topics covered were the violent patient/ challenging patient, risk assessment, assessment and management of victims and perpetrators of crime, personality disorders, sex offending, forensic services, the mental health act, and writing a psychiatric report/ giving evidence in court. There were no stated overall goals or competencies in forensic psychiatry. All topics were delivered by lecture. None of the lectures had associated learning objectives.
In addition to knowledge of issues related to Forensic Psychiatry, the practitioner needs to be able to evaluate the offender or victim, communicate his ndings to members of his team and write a court report (8). In order to effectively evaluate an offender or victim, a psychiatrist must effectively use neuropsychological tools (4). The forensic psychiatrist needs knowledge in the selection of the appropriate tests which include psychological investigations, risk assessment, measurement tools, neuropsychological investigations and Neuroimaging. Prior authors have noted that the health professions education system needs to improve competencies in use of neuropsychiatric assessment tools to bring objectivity and reproducibility to the assessment of offenders (9). Report writing is a unique competency speci c to forensic work as the function is different from the standard medical record. The mental status examination ndings cannot be separated from the assessment of mentally ill offenders who have committed a crime thus making court report writing an important competency (10). The psychiatrist needs to be equipped with competencies to deal with both domains. Hence the above factors brought about the need to develop a formal post-graduate curriculum in forensic psychiatry.

Goals And Objectives For The Post -Graduate Forensic Psychiatry Curiculum
A formal curriculum to be delivered during the forensic attachment was created. The goals for the curriculum were for the students to: Psychiatrists' assessment and testimony in a criminal or civil matter and its in uence on the judiciary's judgement have grave consequences in determining an individual's criminal or civil liability in a matter. Therefore, the teaching methods were based on constructivist learning theory to effectively empower the student to learn, practice and retain the goals and objectives outlined in the curriculum. Knowledge translation in health professional training based on the constructivist learning theory allows the learner to build upon the prior knowledge and experiences they already have for knowledge creation and application (11).
The students enter the MMed psychiatry programme having had traditional didactic lectures in forensic psychiatry during the diploma year. The students were initially given reference reading material (i.e. chapter in Kaplan) which the student would read and cross-reference. A library or access to e-resources (via good internet connectivity) with good resource material was of importance. The students then convened in a small group for a tutorial in a ipped classroom model. The ipped classroom is a method by which the student does research and views videos on a topic and then returns to the classroom to do exercises and for discussion (12). In this day and age of the worldwide web, students can also access online medical journals to add to their reading references.
Following this initial knowledge acquisition phase, the tutorial allowed for active discussion and application of the learning to real-life scenarios. Tutorials are an effective educational strategy as the tutor can quiz the students regarding the knowledge that they would have retained from the preparatory materials. In addition to this, tutorials are a great source of learning because it's a small group setting so the student can freely ask questions to gain clarity and understanding in the areas they did not grasp and the student can learn from other students (13,14). The students also prepared and presented a topic in the tutorial guided by the curriculum and the tutor. This was done for 2 hours once a week for 4 months (table 1). The attitude and skill that a Psychiatrist should have in a Criminal or Civil matter was taught using role play, mock trials and simulated interviews. Interviews with simulated patients acting as criminal perpetrators or civil litigants were designed to help students to develop skills in clinical assessment of the mentally ill. In a mock trial, the student role plays as an expert witness with a simulated acting prosecutor cross-examining them. This act allows the student to practice skills needed for effective testimony in a trial situation.
The student was then placed in a clinical setting and some attended actual courts once they were through with the above methods of learning. An attachment between 2013 and 2017 for a period of four months to a forensic psychiatric institution was also done as a part of the curriculum. The students were always supervised by a quali ed Psychiatrist in a clinical setting. This was done for 5 hours per day, two days a week for 4 months. In the clinical setting, the student would put into practice all the theoretical and practical knowledge that they had gained from the lectures, reading materials, tutorials, mock trials and cross examinations. The student practiced interviewing patients, conducting tests and writing court reports.

Student Assessment
The students were assessed on the theoretical and practical knowledge that they had attained from the curriculum.
Knowledge Assessment: The students' knowledge was assessed through summative written examinations. The students wrote an essay on forensic psychiatry in the sub-speciality paper that covered 2 other domains: Child Psychiatry and Community Psychiatry. The forensic questions were based on the assessment and management of psychiatric conditions, the Mental Health Act Policy, the different models of psychiatric services and aspects of advocacy.
Clinical Examination: The students went through formative assessment where they examined a patient, made a management plan and wrote court reports in the clinical setting. The psychiatrist would give feedback to the student's oral presentations and written reports. The students also examined a psychiatric patient offender and presented assessment ndings and their proposed management of psychiatric patient offenders in the form of a case report which was marked as a summative assessment.
Clinical reports: The students presented oral and written case reports. They kept a senior registrar logbook of the patients they assessed. The logbook ensured that the person had attended the clinic and that they attended to patients. The logbook showed whether the student had noted the patients' history, done a mental assessment, managed the patient, prescribed the proper drugs, written the correct report or a davit for the court. The logbook also showed the number of offenders assessed by the student.

Program Evaluation
Methods: The curriculum was evaluated through a composite analysis of all the students' results on each of the learner assessment methods. The students also lled an evaluation form in 2017 which asked whether the student was satis ed with the course content, module, educational strategies and the lecturers.

Results
The implementation of the curriculum was in 2013 and 6 postgraduate psychiatry MMed students have gone through the training by 2017. All six students passed their nal examinations with a mark above 50% on all written and practical assessments and completed evaluation forms.
All students demonstrated average or better knowledge in describing the models of psychiatric services and principles required to setup psychiatric services as determined by their exams. Students were less knowledgeable about the mental health act and policy (Fig. 1).
Approximately 83% (n = 5) of the students perceived they had average knowledge on the Mental Health Act and policies (Fig. 1).
Sixty-six per cent of the students perceived their attitudes as being fairly impartial in the assessment of mental health offenders (Fig. 2).
The students were not very con dent in the areas of advocacy (Fig. 2). The students perceived their skills were competent in carrying out assessments and treatments. The students perceived they were not very competent in the areas of report writing and court appearance.

Discussion
The curriculum in 2017 had been in use for 4 years. Overall, the curriculum was well received and appears to have resulted in appropriate achievement of the knowledge and skills described in the curriculum. Additional training appears necessary in the domains of advocacy and delivering court evidence.
The students' perceptions of their attitude towards the assessment and treatment of mentally ill offenders was impartial. Training in being Impartial in assessment and management runs across all the different disciplines of Psychiatry as stigma is a barrier in psychiatry as a whole (16). The students have impartiality drilled in them during psychiatric training from year 1 of the MMed programme.
There is a need to strengthening advocacy training by introducing additional skills training in awarenessraising, training, counselling, mediating, defending, and denouncing in mental health. We hope to do this by addition additional role playing, development of Information and Communication Technology (ICT) material, writing 'opposite the editorial page' Op-Eds and media presentation (17).
The low con dence levels noted in court appearance, report writing and giving evidence as an expert witness could be due to these aspects being new to them. In addition, it may also re ect incomplete implementation of the desired curriculum-speci cally failure to implement mock trials. This can be strengthened by more use of role-play in the implementation of the curriculum We plan to start forensic training earlier, increase visits to courts and prisons, carry out peer reviews of resident work in these spaces, and implement the moot courts in order to improve their competency levels.
Impact on forensic psychiatry and provision of services As of 2017, three of the six Psychiatrists who graduated, work in the forensic psychiatric units. Two are permanent and one is working on a voluntary basis. The forensic psychiatric institution has approximately 200 to 300 mentally ill alleged offenders waiting to be evaluated. The training has tripled the number of psychiatrists attending to forensic services in Zimbabwe.

Challenges and Barriers
There have been challenges since 2018 getting permission for students to access the forensic psychiatric institution due to changes in security clearance protocols. This has resulted in the clinical aspect being done in the general psychiatry outpatient clinic where the Police often bring one or two psychiatric offenders for court assessments. This means MMed clinical exposure is reduced and less structured.
The arranging and co-coordinating of mock court sessions with the judiciary system who are very busy and have back logs has been a challenge. These types of simulated encounters were intended to be done for 3 hours over the 4 months, however they have not been implemented yet. The students wait until they have their rst court case subpoena as an expert witness before they are in a court setting.

Conclusion
The curriculum has made Forensic Psychiatry a potential career path for post-graduate psychiatry students. The Forensic psychiatry curriculum has structured the teaching to empower the student both theoretically and practically to assess and manage psychiatric offenders and victims. The next step is to fully implement the desired curriculum and ensure more time is spent in forensic services. Future studies should evaluate the impact of this and other similar curricula on the quality of care provided to these vulnerable patients as well as the impact on the judicial system.

Declarations ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The work was part of our educational work. The scholars gave consent to ll in the evaluation questionnaires.

CONSENT FOR PUBLICATION
The curriculum development was part of a training programme called Health Education Advanced Leadership for Zimbabwe (Healz) with an output of publication of the curriculum development.

COMPETING INTERESTS
There was no competing interest in this work and publication.

FUNDING
The project was self-funded.

AUTHORS' CONTRIBUTIONS
The author, Walter Mangezi, conducted all the work in developing the curriculum under the supervision of Prof Eva Aagaard. Chido Mawoyo and Charity Shonai assisted in the literature review, analysis of results and writing of the paper. Figure 1 Self perceived Knowledge levels of post graduate forensic psychiatric students