The workplace as a teaching and learning environment for undergraduate medical education in Uganda
Kagawa, Mike Nantamu
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English: Introduction: Significant changes are taking place in health care delivery due to new health system expectations, clinical practice requirements and staffing arrangements. Contemporary medical education has also undergone major changes, from being characterised by traditional, teacher-controlled approaches, to newer approaches that involve student-directed learning, problem-based learning, the use of skills laboratories, and evidence-based medicine. These changes have important implications for the way medical students are prepared to provide quality health care once they qualify. It is not clear, however, whether clinical education at the workplace at Mulago National Referral and Taeching Hospital (MNRTH), Kampala, Uganda, has kept pace with or been responsive enough to these changes. The purpose of this study was to assess the suitability of a workplace, such as MNRTH in Kampala, Uganda, as a teaching and learning environment, by determining whether it fulfilled the requirements of the curriculum for undergraduate medical students of Makerere University College of Health Sciences (MakCHS), with the ultimate aim of generating recommendations for improving teaching and learning at the workplace so as to produce graduates who are responsive enough to the contemporary demands of medical practice, research and training. Research design: The study design was cross-sectional descriptive study with a mixed-methods approach. A mixed methods approach was adopted because of the complex nature of health and educational services research – neither a quantitative nor qualitative approach alone would have been sufficient to address this complexity. Using an interpretivist lens, the mixed methods approach explored the processes (curriculum), context (workplace), and experiences and perceptions of the stakeholders in their natural settings and variety; these elements are essential for the interpretive analysis of the interaction between the teaching and learning environment and the undergraduate medical curriculum at MakCHS. The methods used comprised a document review of the undergraduate curriculum to provide context, a self-administered questionnaire (adapted from the DREEM) and focus group discussions with undergraduate medical students, key informant interviews with administrators and teachers of undergraduates and a Delphi process to generate recommendations for improvement of the workplace as a teaching and learning environment. Results: The results of the document review indicated that the curriculum had clearly stated learning objectives, and used appropriate verbs in accordance with Bloom’s taxonomy. The expectations of the curriculum were also in accordance with Miller’s pyramid of competence development for the different student levels. The administrators, teachers and students perceived the workplace as both enabling and challenging and listed a number attributes that could facilitate or hinder the implementation of the undergraduate curriculum. The positive perception was premised on the availability, and variety of and accessibility to patients, thus creating authentic learning opportunities. The negative perceptions centred on overcrowding by both students and patients at the workplace, shortage of equipment and supplies, inadequate ICT facilities and poor social services. The teachers were perceived to be knowledgeable, though they exhibited certain deficiencies regarding their clinical teaching skills, as they did not offer students adequate opportunities for supported participation or practice with patients. The students, therefore, perceived and recommended that the teachers were in need of further training. On the other hand, the teachers perceived the students as lacking in learner agency – the intentionality and enthusiasm to learn. Conclusions: Implementation of the undergraduate curriculum could be facilitated at the workplace by enabling factors and positive attributes perceived by the stakeholders, such as availability and variety of patients that were accessible, which create authentic learning opportunities and therefore lead to the production of competent graduates. The challenges that created the negative perceptions need to be addressed by focussing on the specific areas of concern raised in order for the workplace to be supportive of teaching and learning. The challenges, though real, were considered by some key informants as reality checks that encourage students to be resilient and innovative in the face of shortages that were representative of the clinical practice settings that the students will be faced with when they qualify and, therefore, created medical practitioners that were fit for purpose. In an attempt to address the challenges identified, and create a positive perception of teaching and learning at the workplace, a three-phase Delphi survey was designed, which yielded 30 recommendations which, in the opinion of medical education experts, if adopted and implemented could lead to improvement in teaching and learning at the workplace at MNRTH and ultimately lead to the training of competent health professionals who can meet the demands of contemporary medical practice, research and training.