Health budget cuts will be paid for by the most vulnerable.

No abstract available.

A national training course for clinical trainers in family medicine.

Quality vocational training is important to ensure that family physicians can strengthen the district health system. Competent clinical trainers and supervisors, with the necessary educational knowledge and skills, are required for this job. In 2014, a formal Train the Clinical Trainer (TCT) course was introduced in South Africa as a collaborative effort between the Royal College of General Practitioners (RCGP) and the South African Academy of Family Physicians (SAAFPs). To make the training relevant, the course was aligned with the National Unit Standards for Family Medicine, as these defined the learning outcomes for registrars. The aim of the TCT course was to equip workplace-based clinical trainers with an essential set of educational skills, which could be further developed through mentoring and support. Accredited trainers present the face-to-face course yearly to two family physicians from each of the nine departments of family medicine in South Africa. The TCT course is built around the educational principles of learner-centredness and andragogy. During these 5 days of training the roles and responsibilities of trainers and learners, the learning environment, alignment with the curriculum, assessment for and of learning, and leadership are covered. Recently online assessment, the e-portfolio and the use of entrustable professional activities were added to the course content. In the future we would like to accredit more clinical trainers through a process of workplace-based self-evaluation and 360-degree feedback from peers and students. Lastly, we want to expand the training course in the African region.Contribution: The Train the Clinical Trainer (TCT) course, established in 2014 through RCGP and SAAFP collaboration in South Africa, ensures family physicians have essential educational skills. Aligned with national standards, the course embraces learner-centered principles. Ongoing enhancements include online assessments and future plans involve accrediting more trainers through self-evaluation and expanding across the African region.

Developing entrustable professional activities for family medicine training in South Africa.

Workplace-based assessment (WPBA) is becoming part of high-stake assessments in specialist training. Entrustable professional activities (EPAs) are a recent addition to WPBA. This is the first South African publication on developing EPAs for postgraduate family medicine training. An EPA is a unit of practice, observable in the workplace, constituting several tasks with underlying knowledge, skills and professional behaviours. Entrustable professional activities allow for entrustable decisions regarding competence in a described work context. A national workgroup representing all nine postgraduate training programmes in South Africa has developed 19 EPAs. This new concept needs change management to understand the theory and practice of EPAs. Family medicine departments with large clinical workloads are small, necessitating navigating logistical issues to develop EPAs. It has unmasked existing workplace learning and assessment challenges.Contribution: This article contributes new thinking to developing EPAs for family medicine in an effort to understand more authentic WPBA nationally.

Oxygen as a drug and scarce commodity: Do we use it rationally?

BACKGROUND: Medical grade oxygen is classified as a drug and needs to be prescribed by a qualified healthcare professional. Oxygen therapy is prescribed to people who cannot maintain normal blood oxygen saturation while breathing atmospheric air. The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of the rational use of this scarce commodity. This study investigated oxygen therapy practices in adult ward patients. METHODS: A cross-sectional study design with an analytical component was used in the adults wards at a National District Hospital and the Pelonomi Academic Hospital in Bloemfontein. Data were collected from patient files, interviews and oxygen measurements of adult patients that received oxygen. RESULTS: One hundred and fifteen patients were included in the study, of whom 47.0% received oxygen without an oxygen prescription. Around 62.3% of the patients with prescriptions did not receive oxygen as prescribed. The prescriptions and oxygen administration for COVID-19 patients were better than for non-COVID-19 patients. A quarter of the patients possibly received oxygen therapy unnecessarily. CONCLUSION: Poor oxygen therapy practices were identified, including prescription errors, oxygen administration errors and oxygen wastage. A protocol should be developed and implemented for the prescription and administration of oxygen therapy. Training should occur to prevent oxygen wastage.Contribution: This study highlighted poor oxygen practices and prescriptions, as well as oxygen wastage in the absence of local oxygen therapy guidelines.

Induction of labour practices at Botshabelo District Hospital: Assessing the institutional guidelines.

Induction of labour (IOL) is defined as an artificial stimulation administered to initiate the delivery process before the onset of spontaneous labour. Setting-adapted guidelines need to be developed to promote safe maternal and neonatal care in line with the needs of a specific institution. This study aimed to describe and assess the current IOL practices at Botshabelo District Hospital, focusing on incidence, indications, induction methods, complications, and outcomes. A retrospective-descriptive study included all relevant data from IOL cases over six months between July and December 2017. From 168 attempted inductions of labour, 153 files were retrieved. The majority of cases (69.7%) were for post-dates. Normal vaginal delivery (NVD) was achieved in most patients (69.3%), while one patient had an assisted delivery. Thus, 30.1% of inductions failed and required caesarean sections. The incidence, indications, methods of induction, complications, and outcomes of IOL in BDH are in line with international guidelines; however, including the sweeping of membranes at term and balloon catheters as methods could improve the current guidelines.

Position paper on undergraduate Palliative Medicine education for doctors in South Africa.

BACKGROUND:  Basic palliative care teaching should be included in training curricula for health care providers (HCPs) at all levels of the health service to ensure that the goal set by the South African (SA) National Policy Framework and Strategy for Palliative Care, to have an adequate number of appropriately trained HCPs in South Africa, is achieved. Furthermore, palliative learning objectives for nurses and doctors should be standardised. Many SA medical schools have integrated elements of Palliative Medicine (PM) teaching into undergraduate medical training programmes for doctors; however, the degree of integration varies widely, and consensus and standardisation of the content, structure and delivery of such PM training programmes are not yet a reality. AIM:  This joint position paper aims to describe the current state of undergraduate medical PM teaching in South Africa and define the PM competencies required for an SA generalist doctor. SETTING:  Palliative Medicine programme leads and teachers from eight medical schools in South Africa. METHODS:  A survey exploring the structure, organisation and content of the respective medical undergraduate PM programmes was distributed to PM programme leads and teachers. RESULTS:  Responses were received from seven medical schools. Through a process of iterative review, competencies were defined and further grouped according to suitability for the pre-clinical and clinical components of the curriculum. CONCLUSION:  Through mapping out these competencies in a spiralled medical curriculum, the authors hope to provide guidance to medical curriculum designers to effectively integrate PM teaching and learning into current curricula in line with the goals of the SA National Policy Framework and Strategy on Palliative Care (NPFSPC).

The completion of partograms: knowledge, attitudes and practices of midwives in a public health obstetric unit in Bloemfontein, South Africa.

INTRODUCTION: most maternal and 24.3% of infant deaths occur during childbirth. Interventions during childbirth may reduce maternal and neonatal deaths. The Guidelines for maternity care in South Africa (2015) stipulates that all observations during labour should be recorded on a partogram. The objective of this study was to assess the knowledge and attitudes of nursing personnel and to evaluate their practices of completing partograms at National District Hospital, South Africa. METHODS: a two-phase, quantitative, cross-sectional, descriptive study design was used. In phase 1, the knowledge and attitudes of midwives and nurses were evaluated. Midwives and nurses completed anonymous, self-administered questionnaires that assessed their knowledge and attitudes. In Phase 2, partogram practices were measured by assessing completed partograms using a data collection tick sheet. RESULTS: twelve of the 17 nursing personnel completed the questionnaires. More than 90% of participants answered basic partogram knowledge questions correctly, but only two thirds knew the criteria for obstructive labour and just more than half that for foetal distress. Participants displayed a positive attitude toward the use of partograms. Of the 171 randomly selected vaginal deliveries during the study period, only 57.1% delivered with a completed partogram. Most elements of foetal monitoring and progress of labour scored above 80%, however, for maternal monitoring scored poorly in 26.4% of cases. CONCLUSION: although 71.4% of partograms scored more than 75% for completion, the critical components that influence maternal and foetal death, like the identification of foetal distress, maternal wellbeing and progress of labour, were lacking.

Students' voices: assessment in undergraduate clinical medicine.

INTRODUCTION: the perception exists among students that not all clinical assessments in undergraduate medical programmes are of high quality. 'Student voice' is a term used to describe how students feel about and experience their education in a safe and controlled environment. This study aimed to investigate the opinions and experiences of medical students at the University of the Free State on the quality of assessment in the clinical phase of medicine. METHODS: a cross-sectional study design was used. Quantitative data were collected with space to clarify opinions and make recommendations. The study population consisted of the clinical medical students in 2019 who had completed at least one module and one end-of-year assessment. Self-administered, anonymous questionnaires were distributed to obtain opinions and experiences regarding assessment. Questions in the questionnaire derived from an assessment framework for clinical medicine to ensure construct and content validity. RESULTS: one hundred and ninety-two (192) students completed questionnaires (84.6% response rate). Less than half of the students were of the opinion that the assessments were fair, with lack of blueprinting and incorrect level of assessment major contributors to this opinion. Two thirds believed that the assessment was aligned with outcomes, however training was not aligned with the assessment. More than 90% of students reported on the lack of feedback after assessment. Valuable suggestions from the students included ways of assessing professionalism, timing of assessments and training of assessors. CONCLUSION: majority of students were of the opinion that there is room for improvement in the quality of assessment.

Quality assessment in undergraduate medical training: how to bridge the gap between what we do and what we should do.

INTRODUCTION: the outcome of the undergraduate medical training programme in South Africa is to produce competent medical doctors who can integrate knowledge, skills and attitudes relevant to the South African context. Training facilities have a responsibility to ensure that they perform this assessment of competence effectively and defend the results of high-stakes assessments. This study aimed to obtain qualitative data to suggest practical recommendations on best assessment practices to address the gaps between theoretical principles that inform assessment and current assessment practices. METHODS: a focus group interview was used to gather this data. The teaching and learning coordinators for five of the six modules that are offered in the clinical phase of the undergraduate medical programme participated in the focus group interview. The focus group interview proceeded as planned and took 95 minutes to complete. The responses were transcribed and recorded on a matrix. RESULTS: the lack of formal feedback to students was identified as an area of concern; feedback plays an important role to promote student learning and improve patient care. The role of teaching and learning coordinators as drivers of quality assessment were recognized and supported. All participants agreed on the outcome of the programme and the central role of the outcome in all assessments. CONCLUSION: the training of assessors and the implementation of workplace-based assessment and assessment portfolios were recommended and can also address feasibility challenges. Participants recommended decreasing summative assessments and only performing these for borderline students.

Assessment practices in undergraduate clinical medicine training: What do we do and how we can improve?

BACKGROUND: Assessment should form an integral part of curriculum design in higher education and should be robust enough to ensure clinical competence. AIM: This article reports on current assessment practices and makes recommendations to improve clinical assessment in the undergraduate medical programme at the University of the Free State. METHODS: A descriptive cross-sectional study design was used. Qualitative and quantitative data were gathered by means of open- and closed-ended questions in a self-administered questionnaire, which was completed by teaching and learning coordinators in 13 disciplines. RESULTS: All disciplines in the undergraduate medical programme are represented. They used different assessment methods to assess the competencies required of entry-level healthcare professionals. Workplace-based assessment was performed by 30.1% of disciplines, while multiple-choice questions (MCQs) (76.9%) and objective structured clinical examinations (OSCEs) (53.6%) were the main methods used during formative assessment. Not all assessors were well prepared for assessment, with 38.5% never having received any formal training on assessment. Few disciplines (15.4%) made use of post-assessment moderation as a standard practice, and few disciplines always gave feedback after assessments. CONCLUSION: The current assessment practices for clinical students in the undergraduate medical programme at the University of the Free State cover the spectrum that is necessary to assess all the different competencies required. Multiple-choice questions and OSCEs, which are valid and reliable assessment methods, are used frequently. Poor feedback and moderation practices should be addressed. More formative assessments, and less emphasis on summative assessment, should be considered. Workplace-based and continuous assessments may be good ways to assess clinical competence.

A framework to benchmark the quality of clinical assessment in a South African undergraduate medical programme.

BACKGROUND: The outcome of the undergraduate medical programme is to produce clinically competent health care providers relevant for the South African context. Educational institutions find it hard to ensure the quality of assessments where competency must be assessed. This study aimed to compile an assessment framework that can be used to benchmark current assessment practices in the clinical phase of the undergraduate medical programme where competency must be certified. METHODS: In this observational, descriptive study, qualitative data were gathered using the steps described by the World Health Organization for rapid reviews. Literature was searched, screened and selected before data were analysed and a framework was constructed. RESULTS: Twenty-five official documents were included in the study. The framework addressed the three components of quality assessment, namely, accreditation, assessment and quality assurance. Assessors should attend to the principles of assessment, namely, validity, reliability, fairness, feasibility, educational effect and acceptability, but realise that no assessment meets all these criteria. The first step to ensure quality assessment is to identify a clear outcome. Assessment should be planned and aligned with this outcome. CONCLUSION: It is clear that clinical assessment is multidimensional and that no assessment is perfect. Programme accreditation, assessment practices and psychometrics can assist to improve the quality of assessment but cannot judge clinical competence. Using experienced assessors with a variety of assessment methods on a continuous basis is the proposed way to assess clinical competence. An assessment framework can assist to improve assessment, but it cannot guarantee quality assessment.

The profile and clinical picture of children with undernutrition admitted to National District Hospital.

INTRODUCTION: undernutrition has a profound effect on growth, development and susceptibility to infectious disease. In Africa, it was found that undernutrition is an underlying factor in around 35% of the preventable deaths of children under the age of 5 years. The first 1000 days of life is most crucial for childhood development. Undernourished children in their first 1000 days of development experience a significant reduction in brain development which cannot be regained later in life. The aim was to describe the profile and clinical picture of admitted children with undernutrition, in order to identify areas for intervention. METHODS: a descriptive study design with an analytical component was used. Data for undernourished admitted children, ages 2-71 months, for the study period 2016-2017 at the study site were included in the study. Data were collected from patient files and summarised by frequencies and percentages. RESULTS: data were collected from 172 patient files, which is > 80% of all children eligible for inclusion. Most (88.0%) of the children had a weight for age < -2 SD and 18.6% had bilateral pitting oedema. More than 80% of the children were still in their first 1000 days of life, 42.8% were born with low birth weight and 24.2% were not breastfed. Head circumference was only recorded for 16.3%. Presenting symptoms were cough, fever and diarrhea - in line with those covered in the Integrated Management of Childhood Illness (IMCI). CONCLUSION: most children presented within the first 1000 days of life, making focussed interventions possible. Areas identified for intervention were babies with low birth weight and babies not breastfed. As most children presented with IMCI symptoms, nurses should also assess the nutritional status of these children in accordance with the guidelines. Lack of anthropometric measurements and poorly recorded feeding histories should be addressed.

Assessment practices in undergraduate clinical medicine training: what do we do and how we can improve?

Background: Assessment should form an integral part of curriculum design in higher education and should be robust enough to ensure clinical competence. Aim: This article reports on current assessment practices and makes recommendations to improve clinical assessment in the undergraduate medical programme at the University of the Free State. Methods: A descriptive cross-sectional study design was used. Qualitative and quantitative data were gathered by means of open- and closed-ended questions in a self-administered questionnaire, which was completed by teaching and learning coordinators in 13 disciplines. Results: All disciplines in the undergraduate medical programme are represented. They used different assessment methods to assess the competencies required of entry-level healthcare professionals. Workplace-based assessment was performed by 30.1% of disciplines, while multiple-choice questions (MCQs) (76.9%) and objective structured clinical examinations (OSCEs) (53.6%) were the main methods used during formative assessment. Not all assessors were well prepared for assessment, with 38.5% never having received any formal training on assessment. Few disciplines (15.4%) made use of post-assessment moderation as a standard practice, and few disciplines always gave feedback after assessments. Conclusion: The current assessment practices for clinical students in the undergraduate medical programme at the University of the Free State cover the spectrum that is necessary to assess all the different competencies required. Multiple-choice questions and OSCEs, which are valid and reliable assessment methods, are used frequently. Poor feedback and moderation practices should be addressed. More formative assessments, and less emphasis on summative assessment, should be considered. Workplace-based and continuous assessments may be good ways to assess clinical competence

Child sexual abuse: The significance of the history and testifying on non-confirmatory findings.

BACKGROUND: Despite numerous studies and publications, there is still a common expectation that a medical assessment can confirm or rule out child sexual abuse (CSA). The truth is that CSA can never be ruled out and can seldom be confirmed on clinical grounds. AIM: The objective of this article was to suggest which aspects to consider when the expert medical witness in a CSA case needs to explain why CSA can seldom be confirmed and can never be ruled out. The importance of a sound medical and medico-legal history was discussed because the history was generally the only positive 'finding' of the assessment of children who have possibly been abused. METHOD: Authoritative sources were used to support the explanation of reasons for an absence of corroborative clinical findings in CSA, as defined by the World Health Organization. The authors structured the individual sections by providing a background on which to base the testimony. They then summarised the clinical forensic significance of the information which should be offered in the courts and which should reflect on the court records, to be taken into account in the eventual decision, which will be made by the court. RESULTS: A guideline was provided for answering questions frequently posed to the expert witness in child abuse cases where there were no positive findings. CONCLUSION: A structure for the explanation of reasons for a normal clinical examination when evaluating children who may have been sexually abused may reduce the discomfort of medical witnesses and improve the quality of expert medical testimony.

A descriptive study of trends in the pictures drawn by primary school learners in South Africa.

BACKGROUND: Illness, lack of vocabulary and unwillingness to discuss emotional distress may contribute to poor communication with children. Drawings may play a crucial role in enhancing communication with this patient group. AIM: This study aimed to describe the pictures drawn by primary school learners in the children's palliative care programme in Bloemfontein, South Africa, and to evaluate whether drawings can be used to assess emotional wellbeing. METHODS: Drawings were assessed according to standardised human figure drawing guidelines and emotional indicator (EI) scales. Pictures were discussed with the child and compared with the clinical presence of depression or emotional discomfort. RESULTS: A total of 29 pictures drawn by 20 children were assessed. Of the 20 participants, 18 were boys, with a mean age of 10.2 years, and 12 children were assessed as having clinical depression. CONCLUSIONS: The presence of two or more EIs, small pictures or pictures in dark colours may indicate clinical depression. Health professionals are advised not to try to interpret the picture, but to use the picture to enhance communication. Let the child explain the picture, rather than relying only on the assessment tool.

Bereavement overload and its effects on, and related coping mechanisms of health care providers and ward administrators at National District Hospital in Bloemfontein, Free State.

BACKGROUND: Patient death is an event that all health care workers will face at some point. Beyond the family, the greatest emotional strain is on people who work directly with the patient and family. Bereavement overload occurs after multiple losses without time for normal grief in between. AIM: To investigate bereavement overload, its effects and related coping mechanisms of personnel working in adult medical wards. SETTING: Four adult medical wards at National District Hospital, Bloemfontein. METHODS: An analytical cross-sectional study design was performed with the aid of an intervieweradministered questionnaire. The target population included health care providers (13 doctors and 20 nurses), eight final-year medical students, and four administrative staff working in thefour adult medical wards at National District Hospital, during August to October 2016. RESULTS: Half (48.9%) of the 45 participants reported bereavement overload. None of the medical students reported bereavement overload compared to 60.0% of nurses, 75.0% of administrative staff and 53.9% of doctors. Nearly two-thirds (64.5%, n = 29) stated that they suffered from compassion fatigue. The majority of participants (62.2%) used only positive coping mechanisms. The use of negative coping mechanisms correlated directly with a longer duration in the medical field. CONCLUSION: With a 49% prevalence of bereavement overload, it is important that support systems are in place to prevent the effects of negative coping mechanisms. The desirable outcome is that health care providers, who suffer from bereavement overload, experience compassion satisfaction and become more dedicated to the patients' well-being without expense to themselves.

The prevalence of neonatal jaundice and risk factors in healthy term neonates at National District Hospital in Bloemfontein.

BACKGROUND:  Neonatal jaundice affects one in two infants globally. The jaundice is the result of an accumulation of bilirubin as foetal haemoglobin is metabolised by the immature liver. High serum levels of bilirubin result in lethargy, poor feeding and kernicterus of the infant. AIM:  The main aim of this article was to determine the prevalence of neonatal jaundice and secondly to explore its risk factors in healthy term neonates. SETTING:  Maternity ward, National District Hospital, Bloemfontein, South Africa. METHODS:  In this cross-sectional study, mothers and infants were conveniently sampled after delivery and before discharge. The mothers were interviewed and their case records were reviewed for risk factors for neonatal jaundice and the clinical appearance and bilirubin levels of the infants were measured with a non-invasive transcutaneous bilirubin meter. RESULTS:  A total of 96 mother-infant pairs were included in the study. The prevalence of neonatal jaundice was 55.2%; however, only 10% of black babies who were diagnosed with jaundice appeared clinically jaundiced. Normal vaginal delivery was the only risk factor associated with neonatal jaundice. Black race and maternal smoking were not protective against neonatal jaundice as in some other studies. CONCLUSION:  More than half (55.2%) of healthy term neonates developed neonatal jaundice. As it is difficult to clinically diagnose neonatal jaundice in darker pigmented babies, it is recommended that the bilirubin level of all babies should be checked with a non-invasive bilirubin meter before discharge from hospital or maternity unit as well as during the first clinic visit on day 3 after birth.

Outcomes of children with advanced HIV initiated on antiretroviral therapy in a South African hospice.

BACKGROUND: Little is known about the long-term outcome of antiretroviral therapy (ART) for children with advanced-stage HIV. AIM: To assess the outcome in children with advanced HIV initiated on ART. The predictors for survival, general wellbeing and the role of palliative care were assessed. METHODS: Patient files, retained patient records and personal follow-up were used for data collection. Data on baseline characteristics, ART treatment and progress were collected at baseline, 6, 12 and 48 months. Information regarding general wellbeing and school attendance and performance were collected. RESULTS: 37 children were started on ART. At 48 months there were 18 known survivors and 7 known to have died. Another 12 were transferred to another programme or lost to follow-up. There was no significant difference in baseline characteristics between groups. All eligible children attended school and all received medical care. The hospice programme offered holistic care and support. CONCLUSIONS: No baseline characteristic could predict the outcome of children with advanced HIV initiated on ART. A hospice support programme can contribute to positive outcomes even when ART is initiated in children with advanced disease.

Pediatric pain management in palliative care.

The management of pain in pediatric palliative care (PPC) is essential. Whilst the field of pain management has developed over the years, much of what is done in PPC is based on anecdotal evidence or adult studies. This review explores recent developments in pain management in PPC, in particular the WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Key issues discussed include the definition, assessment, pharmacological and integrative management of pain, availability of medications, education and research. Whilst advances have been made, including publication of the guidelines, significant gaps exist in terms of the evidence base, education and access to essential medications and both interdisciplinary and international collaboration are required to meet these gaps.