Education for Health

ORIGINAL RESEARCH ARTICLE
Year
: 2020  |  Volume : 33  |  Issue : 3  |  Page : 87--94

Learning experiences of medical and pharmacy students at a student-run clinic in south africa and the development of a framework for learning


Deanne Johnston1, Patricia McInerney2, Shirra Moch2,  
1 Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
2 Centre for Health Science Education, Faculty Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence Address:
Shirra Moch
Centre for Health Science Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
South Africa

Abstract

Background: Trinity Health Services (THS) is a free clinic that serves the homeless community of Braamfontein. The clinic is run by pharmacy and medical students registered in the Faculty of Health Sciences at the University of the Witwatersrand, assisted by academic staff. This setting provided an ideal space to document the interprofessional experiences between these two groups of students outside of formal lectures or clinical exposures. Therefore, the research question for this study was: What are the learning experiences of medical and pharmacy students working at an inner-city student-driven clinic? Methods: A convenience sampling method was employed. All students, who volunteered at the clinic on one or more occasion, were invited to participate in a discipline-specific focus group discussion (FGD). Four FGDs were held with between six and eight participants in each. The FGDs were facilitated by a faculty member not involved with the clinic. The recordings were transcribed verbatim and analyzed thematically, using Tesch's eight steps. Results: The following three themes emerged relating to learning experiences: “add more tools to your toolbox;” learning from supervisors and peers, and “we can really make a difference.” These themes formed the framework for learning at THS. Patient care is placed at the core of the framework, and recognizing that learning occurs through serving, three learning outcomes were identified, namely health and homelessness; communication; clinical and communication skills as well as primary health care. Learning was facilitated through interactions with peers, supervisors, and interprofessional relationships. Discussion: The authentic learning experience led to development of accountability, communication, and responsibility. A framework emerged for learning from opportunities central to patient care.



How to cite this article:
Johnston D, McInerney P, Moch S. Learning experiences of medical and pharmacy students at a student-run clinic in south africa and the development of a framework for learning.Educ Health 2020;33:87-94


How to cite this URL:
Johnston D, McInerney P, Moch S. Learning experiences of medical and pharmacy students at a student-run clinic in south africa and the development of a framework for learning. Educ Health [serial online] 2020 [cited 2021 Sep 17 ];33:87-94
Available from: https://www.educationforhealth.net/text.asp?2020/33/3/87/311320


Full Text



 Background



A student-run clinic (SRC) has been defined as a setting where students take the lead in providing health-care services supervised by licensed health-care professionals.[1] Most SRCs provide health care to the underserved including the poor, homeless, and/or jobless members of the society.[2] SRCs are increasing in number globally; a study completed in 2014 identified that over a hundred SRCs are present in 75% of medical schools in America.[3]

The advantages of SRCs to both the students and community have been documented. Students report learning new skills and application of theory taught in lectures,[2],[4],[5] as well as learning to take responsibility[4] and developing social accountability.[6] SRCs provide a quality health-care service[7],[8],[9] in nontraditional clinical sites which are ideally located in close proximity to the communities they serve.[2]

There is less information documenting pharmacy students' involvement in SRCs and their learning experiences. Pammet et al.[10] identified tasks in which pharmacy students were involved. These included medication reconciliation, medical assessments, and medication education for patients and health-care providers. Derington et al.[11] describe pharmacy students' clinical and administrative roles in which they took the lead in chronic disease medicine management. Both studies confirmed the importance of including pharmacy students in traditional and nontraditional roles in SRC as part of the interprofessional team.

There are a few SRCs in South Africa,[12] with little published information available regarding how they operate, their volunteers, and communities they serve.[5],[13],[14] All of these involve medical students, whereas pharmacy students are only present at one of these sites.

Many studies report that students learned knowledge and skills while volunteering at SRCs, however this was only objectively measured in two studies.[4] Before this can be measured, it needs to be established what knowledge and skills were learned and valued by the students. Therefore, the research question for this study was: What were the learning experiences of medical and pharmacy students working at an inner-city SRC?

Description of the setting

Students from the University of the Witwatersrand established Trinity Health Services (THS) at an inner-city church in Johannesburg in 2004.[15] THS is a SRC providing free primary health-care services for mainly acute conditions to the homeless community in Braamfontein on alternate Monday nights. The clinic consists of three consultation rooms and a pharmacy.

The church, a sanctuary for the homeless, provides regular meals and support to the community. Students and staff from the Faculty of Health Sciences at the University of the Witwatersrand in collaboration with the church formed THS which provides much-needed health-care services to this homeless community. The patient consultation is outlined in [Figure 1].{Figure 1}

 Methods



This study formed part of a larger project which aimed to describe the perspectives of stakeholders of THS using a grounded theory approach. Stakeholders in the clinic were defined as groups or individuals having a vested interest in the continuation of the clinic and included students, supervising doctors, the church, and the homeless community. The context for this study, illustrated in [Figure 2], describes the relationship between these stakeholders.{Figure 2}

The findings presented here form part of the larger study and describe the learning experiences of pharmacy and medical students volunteering at THS. Data were collected through discipline-specific focus group discussions (FGDs). Ethical approval was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (Clearance Certificate No. M161140).

Students who had volunteered at THS on at least one occasion were invited to participate in a FGD. Students who met this criterion were approached through an E-mail, inviting them to participate in the FGD. The FGDs were facilitated by a member of staff, not involved in THS, from the Faculty Development Office. Participants were asked primary and probing questions [Table 1], which pertained to their experiences of volunteering at the clinic. The audio recordings from the FGDs were transcribed verbatim. Data analysis began with reviewing the transcriptions line by line, inductively generating the initial codes. Tesch's eight steps[16] were used to guide analysis to form themes. The data collected after each FGD were reviewed, informing the next discussion as described in the constant comparative method.[17]{Table 1}

The following annotation system is used to illustrate the source of the statement. The “M” and “P” after each quote refers to medical and pharmacy students, respectively, and the number denotes either the first or second FGD. The subsequent number refers to the participant number in each FGD. For example: P1, #3 refers to the first pharmacy students FGD and is a quote from participant three. Four FGDs were held, two per discipline.

 Results



THS provides opportunity for students to learn through serving. Volunteering in the clinic falls outside of the formal curriculum, and there are no prescribed learning objectives and outcomes. The following three themes emerged relating to learning experiences: “add more tools to your toolbox;” learning from supervisors and peers, and “we can really make a difference.”

Add more tools to your toolbox

Students reported learning new information and skills which were described by a student as “tools” which they could add to their “toolbox.” Three categories contributed to this theme, namely homelessness and health, primary health care, and communicating with patients.

Homelessness and health

Students began to identify the interconnectedness between environmental factors and health. This is evident in the following comments from pharmacy students:

“…patients that come almost every Monday with the same illness, and it's usually because we're treating what you have. But you're still going back to the place that's causing what you have” (P2; #4).

“…this patient came in and she told me that she had been diagnosed with HIV, but she hadn't taken her pills because she doesn't have food to eat” (P1, #9).

Patients follow the instructions given by health-care professionals, which may include taking the medication with or after meals. In following these instructions, patients who have no food to eat, do not take the medication, which in turn may lead to treatment failure.

In providing this service to the homeless community, the students started to question why these patients did not seek assistance from public clinics and hospitals. They began to understand the gap which THS fills in the health service and advocated for the needs of the patients. This is reflected in these comments:

“it just exposes people (meaning students) as well to what the realities of healthcare in South Africa (are)” (M1; #6).

“I saw how much it actually helps, because on top of the fact that it's quicker for them to get there and also, it doesn't cost them and the lines are not as extreme as having to go to like a hospital” (P2, #9).

While government clinics do not charge for their services, the cost to patients of attending includes transport and loss of daily income or time spent in a queue. Large patient volumes in public facilities lead to less personalized services. These are barriers to health care the students were able to describe following these interactions with the community. Acknowledging these factors enabled students to recognize the contribution they were making to the health of the homeless.

Primary health care

It was evident that students at THS learned about primary health care in a different way from that espoused in the formal curriculum. The latter tends to focus on the hospital environment and primary health care tends to be given minimal attention. This, in turn, was concerning for one medical student with the proposed rollout of a national health insurance (NHI) in the near future:

“(The) healthcare system is pushing towards this NHI which is largely primary healthcare based and someone mentioned earlier, we don't learn that, we don't get taught that very well…” (M1, #5).

In primary health care, patients present differently from those seen more frequently by the students in the hospital setting. Patients presenting in the clinic are undifferentiated and students need to apply their knowledge and skills in establishing a diagnosis, as described in this comment:

“So, it is really nice to actually see patients who also, where the pathology is a little more subtle, or it's the beginning stage of a disease, and it is proper primary healthcare…” (M1, #6).

Communicating with patients

Both groups of students feared communicating with patients before volunteering at the clinic. One student stated:

“I am very scared. I don't have confidence and I feel like I am lost, in terms of, if I am put there, in a situation, I have to talk to them, I have to think while talking, I have to really, you know, make decisions, write down something, be confident about it…” (M1, #1).

While another reflected:

“I was really bad like with people, like interacting with other people. Like that was my weakness…” (P1, #1).

Students learned to engage with patients and gained confidence when counseling patients regarding their condition and medication. One student described it as follows:

“…at Trinity I think we've got a really great space where you can talk to the patients…giving information about drug adherence, TB (medication) adherence, HIV and ARV's…also learning how to engage with patients…” (M1, #6).

As students identified their need to improve their communication skills, they also seemed to be learning something about themselves and were embarking on a process of self-development.

Learning from supervisors and peers

Students working in the clinic are supervised by qualified pharmacists and doctors, many of whom are not academic members of staff. Supervisors role model professional behaviors for students but do not overtly facilitate learning and interprofessional collaborations. Students described learning from not only supervisors but also from their peers. The two categories within this theme were engaging with supervisors and peer learning.

Engaging with supervisors

Supervising professionals impart practical information cherished by students. Students seemed to acknowledge that this was not information found in a textbook, as one student noted:

“These little gems of knowledge these doctors have… that makes it easier, and I was picking up all these things, standing behind the [doctor]…” (M2, #3).

The pharmacy students confirmed that their experiences in the consultation rooms depended on who was supervising. One pharmacy student described the supervising doctor encouraging contribution from both students present:

“I was working with (a medical student) and the…supervising doctor was very interactive. So, we had a patient where we weren't actually sure what was wrong. She was just complaining of headaches and pain. So, me and the student doctor actually worked together… Then the doctor would come and he would like examine, and then he would say, okay, pharmacist, you tell her first…what medication you would give” (P2, #7).

Peer learning

As shown in [Figure 1], THS recruits medical and pharmacy students from across the years of study and provides an opportunity for them to interact. This is in contrast to the formal curriculum where students tend to only mix with students in their class. One student noted that:

“(In class) we're all very much in our own squads, in our own groups” (P1, #6).

Through interacting at the clinic, students learn from each other:

“generally students pay attention more to what other students say, and they remember more than what like a lecturer says” (M1, #4).

Having both medical and pharmacy students in the consultation rooms contributes to a collaboration between the disciplines. Medical students often need help in prescribing as their therapeutic pharmacology knowledge is perceived as insufficient. A medical student expressed the contribution that each of the disciplines makes, as follows:

“we have the clinical knowledge and they have the pharmacology knowledge and to like exchange it and see this…come together in a treatment plan is the most beautiful thing” (M2, #2).

Through these interactions, relationships are built between students that extend beyond working in the clinic.

“I've had that with one of the pharmacy students that I've befriended here that, just approaching one of my exams…I just sent him a text and I was like 'please help me I don't understand', he helped me understand, explained it to me” (M1, #5).

Learning in a different space

Students working in the clinic described it as an authentic environment and contrasted it to the clinical encounters within the curriculum. They interacted with patients, and relationships were formed when patients returned for further care. Students also described feeling a sense of responsibility to both patients and the clinic. Despite the responsibility felt by the volunteers, it was also described as a safe space to learn where students felt comfortable to ask questions. Therefore, the categories identified in this theme were continuity of care, taking responsibility, and it is a very safe space.

Continuity of care

Students, when volunteering on a continuous basis, may see patients they had previously seen. Patients returning for further care often discussed their progress when seeing the students who previously cared for them. One student described being able to see the outcome of the care provided, as follows:

you can actually see the difference you're making, because patients come back, and you can see the progress that has been made (M1, #2).

I actually made an impact on this person's life (P2, #5).

Taking responsibility

Students also felt accountable as they were actively involved in tasks such as prescribing medication and writing the referral letters.

You have a lot more responsibility on your shoulders and I think that that is something that kind of ingrains into your mind (M1, #3).

As a SRC, students take the leading role in managing and maintaining the clinic. These tasks include staffing of the clinic through implementing a roster system, recruiting volunteers through social media, fundraising, as well as working in the clinic. This adds to the sense of responsibility felt by the students to ensure sustainability of the services.

It is a very safe space.

The clinic was described as a safe place to learn and ask for help. A medical student described this as follows:

“It seems to be this culture, you can chat to doctors, you can chat amongst yourselves and really just struggle with cases and you learn to think about them and in a safe space” (M1, #6).

As volunteering at the clinic falls outside the mandated curriculum and does not contribute to the assessment of learning, it becomes a learning environment where students are focused on serving without academic concerns.

The minute you take the academic stress away, it just becomes, solely your place of learning and a place of helping your patient (M1, #5).

This safe and authentic learning environment was appreciated by students and was contrasted to the traditional learning spaces. To encapsulate these findings, a framework for learning at THS was formed.

A framework for learning at Trinity Health Services

The learning experiences highlight the content and context of learning as well as identify aspects that facilitate learning. Although it was not the initial intention of the study, a framework for learning at THS emerged from the findings [Figure 3]. This framework consists of three concentric circles.{Figure 3}

The innermost circle represents patient care for the homeless. Those seeking care are the reason the clinic exists and so form the focus.

The middle circle provided a layer of learning through serving. The learning described by the students has identified three core areas, namely health and homelessness, primary health care, and skills, that may be regarded as learning outcomes with more clearly identified objectives to be learned within each. As a patient-centered SRC, what students gain in each of these outcomes is dependent on their level of interaction and engagement in the clinic.

Learning about health and homelessness includes understanding the challenges the homeless community face, for example, access and affordability to health care. Through the patient consultation process, students practice clinical skills such as history taking, measuring of vital signs, physical examination, and dispensing of medications. Inherent in all of these skills is learning to communicate.

The outermost circle is the capsule that supports learning through interactions with supervisors and peers as well as interprofessional collaborations. Without these interactions, learning would not take place. Through these encounters, students were able to articulate their role as well as that of other professionals in providing a holistic health-care approach.

This framework for learning depicts the importance of the clinic from the students' perspectives. These are the learning experiences identified by students, which motivate them to volunteer at the clinic despite the time constraints and pressures imposed by the formal curricula and demonstrate the positive epistemological and axiological value to students in their development as health-care professionals.

 Discussion



This study described the learning experiences of pharmacy and medical students when volunteering in an SRC. Three themes were identified, namely “add more tools to your toolbox,” learning from supervisors and peers, and learning in a different space. The identified themes contributed to the development of a framework for learning in the clinic. The framework forms the basis for the discussion.

The framework describes the learning opportunities and the factors that facilitate learning at THS and the resources needed to enhance the learning opportunities. The learning opportunities are not fixed and may well develop further as students grow in confidence. Furthermore, they provide a stimulus for encouraging others to participate at the clinic, while at the same time offer some guidelines to those participating for the first time. This suggests that a “curriculum” has evolved, however, this “curriculum” may be experienced differently by students.

The inner circle of the framework places patient care centrally as opposed to learning. This represents that all patient care decisions made should be evaluated first and foremost for their potential impact. The balance between serving and achieving education goals is pivotal in a SRC.[18]

The second layer identifies three key areas of learning. The first refers to learning about homelessness and how this impacts on the health of the individual. Indigent communities are most in need of health-care services. It has been found that medical students who have engaged with the homeless have more positive attitudes toward these communities.[19] Furthermore, students are more likely to return to work with the homeless if they have volunteered at SRCs serving these communities.[20] In a systematic review of service learning and community-based medical education, Hunt et al.[21] found that concepts such as social determinants of health, barriers to health care, and health disparities are difficult to teach using the traditional teaching methods. The authors noted that encountering patients in community settings facilitates the learning and understanding of these concepts. Working in these clinics sensitizes students to the barriers in a health-care system and promotes patient advocacy.[22]

The second section within this layer refers to the skills learned by students. Important triggers to learning include real-life situations and taking responsibility for patient care[4] as opposed to learning in simulated settings. Skills that have been reported to have been learned in SRCs include presenting a patient to a physician and a variety of clinical skills.[2],[5] However, it is essential that students do not perceive the homeless as a convenient opportunity to practice their skills. Supervising professionals need to ensure that the well-being of the patient is always placed first and before potential learning.[18]

Both the medical and pharmacy students valued the interactions with patients and found that volunteering at THS improved their communication skills. Although it is noted that SRCs provide students with an opportunity to improve their communication with patients,[18] little has been documented in this regard. The findings presented here indicate that students' confidence increased when communicating with patients in contrast to their clinical encounters in the formal curricula.

The third section refers to primary health care. Several different models of SRCs have been described, with a variety of services being offered.[2] The different types of services offered will in turn influence the learning experiences of students. The Crimson Care Collaborative was primarily developed to attract students to careers in primary health care and increased students' exposure to primary health care.[23]

Similar to our findings, Mendelsohn[5] reported that students working at the Students' Health and Welfare Centres Organisation of the University of Cape Town gained greater exposure to primary health care, which they, too, felt was not sufficiently emphasized in the medical curriculum. The treatment guidelines and formulary used in the clinic align to the Standard Treatment Guidelines and Essential Medicines List published by the Department of Health.[24] This, in turn, prepares students for future practice in the public sector.

The outermost layer of our framework depicts that learning is facilitated through interaction with peers, supervisors, and other health professionals. This learning opportunity is consistent with the findings of Lie et al.,[25] who reported that students in SRCs learn from supervisors, senior students, and other professionals as well as patients. Although patients are not included in this layer, it is argued that placing patient care centrally implies that students learn first and foremost from the patients.

In an earlier study that documented the experiences of pharmacy and medical students within the same university,[26] one of the themes identified was “shared teaching and learning,” where pharmacy students taught the medical students pharmacology and the medical students taught pharmacy students' clinical skills. However, it is important to note that in South Africa pharmacists and doctors working in community practices have minimal interaction.[27] Even though students may not see these professionals working as a team, from the findings, it is evident that students understand the importance of forming communities of practice in future.

The interprofessional space allows students to work collaboratively as a team,[10],[25] and SRCs have been described as ideal spaces for the development of interprofessional education.[28],[29],[30] The expansion of the interprofessional team at THS is guided by the needs of the community and not directed by the need to learn with and/or from other professionals.

Following the development of a framework for learning, future studies include testing the framework and developing it further through peer review with an expert group including the supervisors.

 Conclusion



This study described the experiences of students serving the homeless community in the inner-city of Johannesburg. Students learned through serving the homeless community. Not only did the opportunity provide an authentic learning opportunity but also contributed to the development of nontechnical skills such as accountability, communication, and responsibility. A framework for learning emerged from students' experiences describing the learning opportunities central to patient care.

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