Conceptual framework for this study

This study aimed to evaluate the Rehabilitation programme designed for the MBChB curriculum. As there were no other equivalent programmes at any of the other medical schools in SA it was not expected to find any established evaluation tools in the literature for the purpose of this study. Preliminary review of the international literature also failed to identify the use of tools to evaluate an undergraduate rehabilitation programme. In order to develop tools for this study, a conceptual framework had to be created. The researcher thus grouped the issues that have been raised earlier in this chapter together with other concerns highlighted such as logistical co-ordination of activities, optimum use of teaching methods, availability of lecturers, content of study guides and access to rehabilitation services as teaching platforms. This resulted in three main, but overlapping, areas of influence on the programme as depicted in the following figure.

ACADEMIC ENVIRONMENT MEDICAL:

•Influential bodies: HPCSA, WHO •Specialist driven MBChB curriculum •Position of CRS in FHS in US

EDUCATION:

•US: CTL

•Educational principles

•Programme and curriculum design and evaluation

UNDERGRADUAT E

REHABILITATION PROGRAMME

Know ledge, Skills and attitudes, Output

Family Physicians training medical

students

Rehabilitation as a speciality: Local and international training of medical students in rehabilitation, Content of programme Therapists training medical students SPECIALISED REHABILITATION CLINICAL PRACTICE ENVIRONMENT

•Rehabilitation doctors and other rehabilitation professionals making up the team

•Disability and rehabilitation principles such as interdisciplinary team w ork, medical and social models of disability

•Specialised rehabilitation services e.g. WCRC, community based rehabilitation

•Human and disability rights, rehabilitation policies

GENERAL CLINICAL PRACTICE ENVIRONMENT

•Health services available to persons w ith disabilities

•Role of GP/COSMO in managing persons w ith disabilities

•Policies governing clinical practice

Figure 1.1: Interrelationship of contextual factors in the US MBChB Rehabilitation programme

The three main areas were:

 The general clinical environment in which a large portion of health services are delivered to persons with disabilities which is in line with the CSP (DoH, 2005). This included the role of doctors in these services in managing persons with disabilities. The GPs role in this environment was critical, as the Rehabilitation programme is intended to prepare the graduate to be able to manage persons with disabilities in this environment, and GPs were involved in facilitating rehabilitation learning in the US Rehabilitation programme.

 The specialised rehabilitation environment included rehabilitation professionals who influence the content of the programme. It included overarching rehabilitation philosophies and attitudes as well as specific knowledge and skills which the doctor requires to manage the needs of persons with disabilities. The status of rehabilitation

as a speciality and its impact on undergraduate rehabilitation programmes nationally and internationally carried relevance here too.

 The academic environment included the infrastructure of the CRS, FHS and US, and the medical specialist-orientated milieu of the FHS. Educational principles, strategies and methods, curriculum and programme design and evaluation have had an influence on the MBChB Rehabilitation programme. External to the US, bodies such as the WHO, HPCSA had to be considered.

These three areas together determined the output of the Rehabilitation programme which is thus shown as the area of overlap of all three circles, this being a programme that aims to equip US MBChB graduates with the knowledge, skills and attitudes to manage persons with disabilities in the community.

Until this study was initiated, the CRS has dealt with the challenges as they have arisen by making changes to the modules concerned within the programme. Changes made however had to allow for equal learning opportunities for all the students in a particular year of study. Thus, problems detected through the year could only be addressed at the end of an academic year. This resulted in a cyclical scenario of trial-and-error. This approach could be likened to fighting fires rather than being pro-active in detecting problems.

The US MBChB Rehabilitation programme teaches medical students to detect problems and to be vigilant for a range of potential complications, preventing them before they arise. In the same way, the programme needed to have methods in place to not only identify problems that had come to the fore but also to explore the host of factors that could impact on its delivery before they presented as problems. Although figure 1.1 consolidated the concerns raised evident in 2007, the researcher questioned if this was an adequately comprehensive framework for this study. The literature was thus explored using this figure as a starting point.

The World Federation for Medical Education (WFME) Global Standards for basic medical education (website accessed on 24/08/2007), although relevant to the broader curriculum and not just a specific programme or module thereof, was found early in the literature search and the researcher considered it to be the most relevant and comprehensive, and it included the three main areas of influence on the programme as named above. All other literature found aligned with the WFME standards, but no educational model was as

comprehensive as the WFME standards. A summary demonstrating the association the WFME standards with these other educational models is contained in appendix 6a for reference.

1.7.1 The WFME Global Standards for basic medical education

The standards aspired to improve health of all peoples through high scientific and ethical standards in medical education (WFME task Force, 2000; Van Niekerk, Christensen, Karle, et al, 2003; WFME website accessed 24/08/2007; Karle 2007). The WFME global standards were developed by three international task forces. SA was represented by Professor JP Van Niekerk, Rehabilitation Medicine by Sweden with undergraduate student representation being included.

The standards, finalised in 2001, were endorsed by the WHO, with the basic standards being validated in pilot studies in 11 medical schools around the world (Van Niekerk, Christensen, Karle, et al, 2003; Grant, Marshall & Gary, 2005), further piloted in 24 medical schools with other authors using the standards for self studies (Hays & Baravilala, 2004; Khattab, Badrawi, Sheba, et al, 2004). Criticism of the standards that they promoted global core curricula was limited (ten Cate, 2002) but acknowledged by the WFME as regional appropriateness was encouraged by the standards. The researcher thus considered the WFME standards to be valid for this study, however, none of the articles reporting on the standards and piloting included any tools.

There were 36 basic standards which were divided into the following nine areas which formed the framework for this study:

1. The mission and objectives (of the training institution)

2. The educational programme: Methods, activities and linkage to the health care system (determining the content of the programme and further referred to as ‘content’)

3. Assessment of students

4. Students (selection, support and representation) 5. Academic staff (recruitment and development) 6. Educational resources

7. Programme evaluation

8. (University) governance and administration, (budget allocation, staff management) 9. Continuous renewal

Although most of the standards referred to the academic environment, the inclusion of “linkage to the health system” in the second area allowed for the inclusion of the general as well as the specialised rehabilitation environments which allowed for the application of the standards to a specific programme. In this way the standards linked with the conceptual framework in figure 1.1 and the literature is discussed accordingly. The application of the standards to a programme rather than a curriculum was approved by Professor Van Niekerk in an in-depth interview with the researcher on 01/12/2009.

1.7.2 Further models for education and training

The WFME standards were uncovered during literature search and the researcher noted that they were not referred to by educational experts at the US. The educational models that were suggested are mentioned here to demonstrate their inclusion into what the researcher considered to be a more appropriate framework for this study.

As the programme under review was part of a curriculum that needed to be accredited by the HPCSA and needed to conform to the NQF (website accessed 24/08/2007), the researcher was guided by US CTL to consider criteria for programme design as set out by the Higher Education Committee (HEQC) a statutory body of the Council of Higher Education (CHE) (HEQC, 2004). Although the HEQC criteria raised questions additional to those presented in Figure 1.1, these were covered by the WFME standards as demonstrated in appendix 6a. The HEQC criteria were limited to the academic environment and were not specific for a medical or undergraduate programme. When used to evaluate the post graduate programmes of the CRS, they were found to be inadequate for the purpose (Hugo, Mji & Gcaza, 2007). The criteria did however follow a logical sequence which assisted in the development of the methodology of this study as described in chapter 4.

Further models reviewed included the British GMC principles of good medical practice published as Tomorrow’s doctors in 1993, updated in 2003, (GMC website accessed 24/08/2007) and Principles of Good Medical Education and Training (GMC website accessed 24/08/2007), which were linked to the WFME standards. The SPICES and PRISMS (Bligh, Prideaux & Parsell, 2001) models, Karle’s editorial on 21st

century innovations and international trends in medical education (2004) and Harden’s Ten questions (Dent & Harden, 2005) provided overarching philosophies such as student

centeredness, outcome based, community and problem orientated learning which again were all contained within the WFME global standards for basic medical education.

Thus the concepts of this study originated from the researcher’s direct involvement, communication with stakeholders and resultant awareness of concerns regarding the MBChB Rehabilitation programme. The concerns raised were however only a part of many that could have influenced the programme. The WFME standards provided a valuable framework that enabled the researcher to consider all areas of influence on the programme so that it could be comprehensively and holistically evaluated. The literature is thus discussed according to the standards from which indicators were drawn. As the standards were intended for application to a curriculum as a whole rather than just to a programme, this framework was adapted and built on to develop a set of indicators specific to the evaluation of the US MBChB Rehabilitation programme.