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4.3.4.1 Study population

This population concerned itself with the lecturers, site co-ordinators and facilitators who deliver the Rehabilitation programme through direct student contact. It also included those involved in the assessment of the students at the end of their clinical and theoretical modules and the sixth year OSCE. It included medical doctors and professional rehabilitation team members as well as persons with disabilities who considered themselves to be experts on disability and rehabilitation. Although one person may have had different roles in different modules, they were included in the most relevant one for the purposes of defining the population.

The lecturers involved in the programme at the beginning of 2011 shortly before data was collected were as follows; one lecturer providing didactic teaching at the beginning of the early phase rotation and 16 lecturers in the theory block. This population of lecturers included the RPC, the Head of the CRS (both included in the previous population), the researcher, two rehabilitation doctors who were included in that population and 12 others who were not included in any other population in this study. Of these 12 lecturers four were professional staff employed by other divisions at the FHS, US, six worked in public and private clinical rehabilitation practice, and two were persons with disabilities as experts in the field of disability and rehabilitation. These 12 were considered as the lecturer population.

During the mid and some of the late phase clinical rotations at the rural sites, Family Physicians co-ordinate the integrated learning programme of the three divisions. They impact on the Rehabilitation programme through direct teaching and role modelling. These MFam Med graduates are well supported by the Division of Family Medicine, seven of whom share joint appointments between WC DoH and US. Some of these physicians have received training in rehabilitation principles and have applied this knowledge not only to student training but also in their clinical practices.

At these sites members of the multidisciplinary team identify patients for the students and discuss the rehabilitation plan with them. According to the Family Medicine undergraduate

secretary eight rural sites (Ceres, Worcester, Robertson/Montague,

Bredasdorp/Swellendam, Caledon/Grabouw, Hermanus, Madwaleni and Malmesbury) were used on a rotational basis during 2010. The population of site-co-ordinators for the mid phase was thus these eight Family Physicians. On contacting these co-ordinators, six facilitators could be identified at these mid phase sites.

In the early phase rotations of 2010 seven social workers at WCRC and two therapists at Bishop Lavis facilitated patient case discussions. Late phase rotations in 2010 were facilitated by three staff contracted by the CRS, one being the RPC, one the researcher with only the remaining one being included in this population. Thus 16 individuals made up the population of facilitators.

At the end of each rotation and in the OSCE students are assessed by members already mentioned in this population.

This population of 36 individuals as summarised in table 4.1 below, included medical professionals and experts in the field of disability and rehabilitation. These individuals have had limited opportunity to influence the programme other than those involved in developing the interdisciplinary learning session. Over and above content and mode of delivery of the programme, the sample from this population was asked to provide insight into their recruitment, selection, training and development as a lecturer.

Table 4.1: Members of the population of lecturers, site co-ordinators, facilitators and assessors. (Those marked with an * are excluded due to inclusion in other populations, RP = Rehabilitation Professional)

Early phase Mid phase Late phase Theory block OSCE Total

Lecturers RPC* 0 0 4 academic RP

6 clinical RP

2 persons with disabilities Head CRS* RPC* Researcher* 0 12 Site co- ordinators 0 8 Family Physicians 0 0 0 8 Facilitators 7 WCRC Social workers 2 RP at Bishop Lavis 6 RP 1 RP RPC * Researcher * 0 0 16 Assessors RPC* Researcher* RPC* Researcher* Researcher* RPC * Researcher * 0 TOTAL 9 14 1 12 0 36

4.3.4.2 Study sample group

From this population 30 prospective participants were purposefully selected as they were telephonically available from the data bases of theory block lecturers, clinical site co- ordinators and facilitators and contracted staff of CRS. The remaining six were excluded on the basis of lack of contact details or unavailability at the time of conducting this study.

Critical representation in this sample was considered to be:

 Representation of all roles (lecturers, facilitators, site co-ordinators and assessors) and  Representation of each module (early, mid, late and theory modules)

Representation from all the rural sites was not considered to be critical and all but two (Malmesbury and Madwaleni) were represented in this study. Sen Gupta, Hays, Kelly and Buettner (2010) assessed the results of students attending different rural sites. They found no difference in the results of the different groups and suggested that despite slight differences in activities and exposures, different sites could offer equivalent learning experiences and outcomes.

All sample participants were contacted telephonically after which self administered questionnaires were distributed by e-mail. 19 of the 30 (response rate 63%) responded of which one response was unsuitable for analysis as will be explained later in this chapter. All modules and educational roles were represented the details of which are contained in appendices 16aandb. All respondents were GPs or rehabilitation professionals except one who was a carer of a person with a disability, a rehabilitation advocate and supplier of assistive devices.

Six of the eight WCRC Social Workers, who contributed largely to the early phase rotation, eagerly responded. The Family Physicians as site co-ordinators and other disciplines as site facilitators in the rural rotations were also very eager to participate in the evaluation of the Rehabilitation programme, however only 50% of them responded, despite follow up.

The respondents were involved with the programme for between zero and 13 years. One noted that they were not involved as they only provided patients for students. As discussed with respondents, this was considered to be the role of the facilitator and as the person had been in this position for two years, the data was amended accordingly. One respondent stated that they had been involved for 13 years which is longer than the time that the programme under review has been running. After contacting the individual this was adjusted to 11 years. The mean length of time involved with the programme for this sample using the adjusted data was five years. The clinical experience of this sample was 14 years with a range of 1-40 years.

4.3.5 Students (enrolled in the MBChB curriculum of the FHS, US) 4.3.5.1 Study population

The target group for the training programme is the enrolled MBChB students of US who receive rehabilitation training in four exposures over their third to sixth years. The 180 students per each academic year are divided into small groups which receive their exposures consecutively throughout the year as outlined in table 1.1 in chapter 1. The programmes are delivered in phases that do not necessarily coincide with academic years. Thus at any point in time some students may have received an exposure and other students from the same academic year may not have. There may be a difference of up to 18 months between two students in the same academic year receiving the same exposure.

Thus seven groups within this population were identified according to their exposure to the various phases, modules and activities as tabled below.

Table 4.2: Sequential exposure of US MBChB students to rehabilitation activities

Phase Early Mid Theory Late OSCE

Year of MBChB study 3rd 4th or 5th 5th 5th or 6th 6th

Group 1 No No No No No

Group 2 Yes No No No No

Group 3 Yes Yes No No No

Group 4 Yes No Yes No No

Group 5 Yes Yes Yes No No

Group 6 Yes Yes Yes Yes No

Group 7 Yes Yes Yes Yes Yes

Group 1

US students in their first and second MBChB year have not yet been exposed to the Rehabilitation programme, but have however received an introduction to the ICF as part of their professional orientation in first year. They receive their first exposure to the rehabilitation programme during their third year. For the purpose of this study the approximately 180 students in their third year who had not yet received their first Rehabilitation exposure were considered as population group 1. They could not comment on the delivery of the programme under review but it was anticipated that they had untainted views of what the programme should deliver and thus could contribute to the review of selected indicators.

Groups 2-6

In order to gain students’ opinions on the programme content, delivery and student evaluation methods, their input should be gained as soon as possible after exposure to each phase. As described in the introduction, feedback questionnaires pertaining to the delivery of the programme are completed at the end of each clinical rotation and the theoretical module and summarised by the respective Module Chairs and RPC. These Module Chairs and RPC were requested to consider this feedback which has been provided from groups 2-6 when they participated in this study. These population groups were thus not included in this study sample.

Group 7

The US Rehabilitation programme is outcome based and designed so that each phase builds on previous phases. Group 7 which includes all US MBChB students who have experienced all rehabilitation training opportunities, should be able to provide a cross sectional opinion on the collective outcome of the programme. Half of this group participate in the final rehabilitation exposure, an OSCE, in April and the other half in November of the final (sixth) year of study. As the data collection for this study was performed in March to September 2011, the 84 students that participated in the OSCE in April 2011 comprised this population.

This population group is divided into six groups each completing their combined five-week Rehabilitation, Family Medicine and Community Health clinical rotation at different dates prior to the OSCE. Within these groups they are divided further according to the sites that they attend (II Military, Kraaifontein, Stellenbosch, Macassar, Elsies River, Robertson, Worcester, Helderberg, Khayelitsha, Wellington, Paarl, Swellendam, and Madwaleni) with approximately four students per group.

4.3.5.2 Study sample group

Group 1

A purposeful sample was obtained by approaching the 37 students that started their early phase rotation on 5 April 2011. This was the first third year group to participate in the early phase rotation after the questionnaires were developed. Students that were repeating the third year were excluded from this sample. There were no such students identified on the class list. Self-administered questionnaires were handed personally to the 37 students in this group. No student refused to participate. One student had a health condition as detailed in appendix 16e.

The purpose of including this sample was to gain pre-exposure opinions to validate the indicators. This sample did generate new themes against the eight open ended categorical questions but these were repeated within the sample and were consistent with other sample groups. It was thus considered not necessary to approach a second group of third year students as it was not anticipated that additional information would be gained.

Group 7

Ideally a random sample of 70 students would have comprised this sample (Research Advisors website accessed 18/10/2010; Universal Accreditation board website accessed 18/10/2010) providing a 95% confidence level and 5% margin of error. The researcher considered the best way to make contact with 70 students would be to make direct contact at a whole class lecture, but as the whole of the sixth year is dedicated to clinical rotations, no such opportunity existed. An occasion where large groups (approximately 20) of students are gathered was immediately after the OSCE. As this would be the last exam in a week of daily exams this was considered inappropriate. It was deemed unfair for the students to complete a questionnaire just after they had completed a two hour OSCE, when they would be focussed on post exam freedom. It was presumed that information gained in this setting would be of doubtful quality with possible resentment of the researcher. Discussion with the combined Module Chair concluded that it would not be possible to call a meeting of the sixth year student population identified. If an arrangement was made to meet directly with the small groups, 18 such contacts would have to be organised to reach 70 students. This was considered to be impractical, financially and time-wise not viable.

Discussion with the sixth year class representative led to the option of e-mailing all students in the population. Such methodology could be expected to have poor response rates (Baruch & Holtum, 2008) so the researcher considered contacting the students telephonically before sending out the questionnaires to improve response rates (Fincham, 2008). After attempting this method with the first seven students on the list, the telephone numbers proved not reliable and it was considered not to be financially or time-wise possible to contact the whole population of students. A questionnaire was thus e-mailed to all students in this population. An 83% response rate would provide a sample of 70.

Poorer than anticipated, only three of the 84 students responded. Finally a purposeful sample was selected. From the lists of the six groups of students one student from each group, each from a different site was contacted as available according to the phone numbers on the list. From the researcher’s experience students belonging to the same group may share opinions and in this way bias from just involving one or two groups or one or two sites was reduced. The researcher co-incidentally had contact with one further student and thus seven were directly invited to participate. Of these seven, four responded. The seven students contacted were also requested to ask fellow students who

had completed the OSCE to complete the questionnaire, gaining an additional four respondents.

This sample of 11 was not acceptable but could not be improved upon within this study. Five of the six student groups were represented. Seven of the 13 possible sites were represented with II Military being represented thrice, Kraaifontein and Stellenbosch being represented twice each. Groups from Macassar, Elsies River, Robertson and Worcester were represented once each.

4.3.6 General practitioners (of the Western Cape, SA)