Perceptions of changes made to a clinical skills curriculum in a medical programme in South Africa: A mixed methods study

Abstract

Research While the evidence suggests that changes made to the new curriculum should help with this difficult transition, none of the research identified was conducted in the SA medical education context. The SA context provides unique challenges, including financial constraints, limited resources, a need for generalist, primary care over specialist training and a demand for doctors who can provide care in rural areas and meet the burden of the HIV epidemic. [17] Limited human resources, particularly of academic staff who have to meet a high clinical burden and find time for teaching, is a major constraint. [17] Our student group is diverse and comes from a wide range of educational backgrounds, including many underprivileged and previously disadvantaged students. [17] It is important to determine what influence these curriculum changes have had on students' preparation for their clinical years in the current context. One of the ways to evaluate the curriculum change is to explore the students' perceptions of how well prepared they felt for the clinical setting, based on their experiences in their clinical clerkships. The perceptions of students who were taught under the new and old curricula were compared with regard to the question: Have these changes had the desired outcome in the current context and to what extent have the problems identified been resolved? Methods An exploratory, sequential mixed methods study design was adopted, with a dominantly quantitative paradigm. [18] This is represented based on Creswell's notation in mixed methods research, as follows: Qual → QUANT → Interpretation. [18] As a suitable, validated quantitative tool could not be found, the researchers developed such a tool for the purpose of gathering data regarding the students' perceptions of their preparation for clinical clerkships by means of the clinical skills curriculum. Phase I was a narrative qualitative study. An open-ended question was used to identify the themes, ideas, concerns and perceptions of the students. These were used to inform the development of a tool for the collection of the quantitative data in the second phase of the study, which accurately measured these constructs while exploring the research question. The following question was posed in phase I: What is your perception of the fourth-year clinical skills curriculum's preparation of you for your clinical rotations in fifth year? Systematic sampling was used; every tenth fifth-year and sixth-year student on an alphabetised class list was emailed a link to an online system (Research Electronic Data Capture (REDCap)). A total of 62 students were sampled (31 from the fifth year and 31 from the sixth year). Phase II was a cross-sectional, comparative, quantitative study. A preliminary questionnaire was developed based on the objectives, a literature review and the researchers' experiences of teaching in the programme. The qualitative analysis of the narrative data from the open-ended question in phase I informed the modification of the phase II questionnaire to best reflect the students' ideas, concerns and expectations. This process included assessing the relevance and value of the questions already included in the questionnaire (13 questions) and 3 additional questions that measured the constructs identified as dominant categories, as described under Results, phase I, below. The questionnaire was piloted on the target population of the study (20 students from the fifth year and 20 from the sixth year, using systematic sampling). There were no problems or errors detected with the administration of the questionnaire, understanding of the questions or the collection of data. No changes were made to the data collection tool. In phase II, the refined questionnaire, consisting of 5-point Likert scale-type questions (n=16), was distributed to the entire target populations of the fifth-year (n=299) and sixth-year (n=291) students. The Likert scale questions had 5 options (strongly disagree, disagree, neutral/undecided, agree, strongly agree), which were assigned values of 1-5 to allow for numerical data for quantitative analysis. A research database was created using the REDCap (version 8.4.5) tool, and the link to the questionnaire was made available online. The link was then emailed to all students in the target populations, except those who had been invited to participate in the pilot study (fifth-year sample population (n=299); sixth-year sample population (n=291)). Data were collected for 80 days after distribution of the questionnaire to allow for maximum opportunity for responses within the time constraints of the study. Fifth-year students had completed at least one, and at most four, of their clinical rotations at the time of data collection. Data were captured anonymously using the REDCap tool, and were exported for analysis. Results Phase I Of the 62 students included in phase I, 28 responded-a response rate of 45%. An inductive and iterative approach was used to identify patterns, similarities and differences in the narrative texts. Data were coded into meaningful segments and then into frequent, dominant and significant categories for interpretation into findings and conclusions. Three categories emerged from the data. The first was that the students felt underprepared to detect actual pathology in the clinical setting. They indicated that, having learnt skills on healthy simulated patients and models, they struggled to confidently detect and interpret clinical signs and abnormalities, making transfer to the clinical setting difficult. The second category, closely related to the first, was that they felt that they had had insufficient exposure to real patients in their preparation for their clinical clerkships. The third category related to the high student-tutor ratio, which prevented students from getting hands-on experience with a skill and being able to perform the skill with guidance and feedback. All 13 questions of the preliminary, self-developed questionnaire were retained and 3 additional questions that measured the abovementioned constructs were added. Phase II Data from the Likert scale-type questions were analysed as ordinal, as although the categories have rank order, the distances between them cannot be presumed to be equal. [19] A total of 247 students (n=590) responded to the questionnaire, giving a response rate of 42%, which met the requirements for a 95% confidence level and a confidence interval (CI) of 5 for the total sample. Of the respondents, 149 were in their fifth year, giving a response rate of 50% for this class of 299 students. Of the sixth-year class (n=291), 98 students responded-a response rate of 34%. While neither of these subsamples met the requirements for a confidence level of 95% and a CI of 5, they were still above the average online response rate of 33% [20] and did meet