Nurse graduates' experiences and support needs: A qualitative systematic review of South Africa's community service programme.

BACKGROUND: The student-to-nurse graduate transition is a pivotal phase in the professional development of nurses. In South Africa, this transition is part of a compulsory community service programme, which requires newly graduated nurses to work in rural and/or underserved areas for a period of 1 year. OBJECTIVES: The aim of this study was to review nurse graduates' experiences and support needs during their transition in the compulsory community service programme. METHODS: A qualitative systematic review of experiences was conducted. Qualitative research studies that addressed nurses' experience in South Africa (2008-2017) were identified in Cochrane, Joanna Briggs Institute (JBI), Academic Search Complete, CINAHL, PubMed, SABINET, Science Direct, SCOPUS and Google Scholar databases. The systematic review methods included searching, sifting, abstracting and quality assessment of relevant qualitative studies by two reviewers and cross-checking by a third reviewer. Two reviewers independently performed blinded data extraction and quality assessment using the confidence in qualitative synthesis findings (ConQual) approach. RESULTS: A total of 1257 studies were identified of which 12 met the inclusion criteria. Seven of the 12 studies were published articles and six were theses. The quality of the studies was found to be of high standard based on the ConQual rating. Four main themes emerged from the analysis: (1) rich developmental experiences through practice exposure, (2) difficulties in reconciling theory and practice, (3) contextual challenges in the workplace and (4) need for professional support structures, educational measures and public guidelines. CONCLUSION: Although positive experiences were reported, various challenges emerged, indicating the need for more systematic support mechanisms during transition.

"I felt a sense of belonging somewhere". Supporting graduates' job transitions with WhatsApp groups.

BACKGROUND: Nurse graduates' transition into the world of work is a very challenging phase of professional development. This research examined the affordances of using moderated WhatsApp groups to support nurse graduates in this phase. APPROACH AND METHODS: Study participants, newly graduated nurses (n = 72) from South Africa, were assigned to two WhatsApp groups. The groups were facilitated by moderators during the 12-week intervention. The intervention was based on a curriculum that incorporated topics related to professional immersion that emerged from a priori needs assessment. Twelve individual interviews were carried out and analysed together with the written conversations from the WhatsApp chats using content analysis as part of an interpretive paradigm. RESULTS: Three central affordances emerged in the analysis: (1) Instructional: joint learning and cooperative problem solving in-situ; (2) Social: co-constructing proximity and providing motivational and socio-emotional support; (3) Professional: scaffolding job immersion in becoming and being a nurse. Through re-connecting relatable social ties (former students) and tapping into a medium that afforded intimacy, immediacy and high levels of ownership, the intervention offered spatially, socio-culturally and often emotionally 'dislocated' graduates a provisional space to belong to. CONCLUSIONS: The feasibility and dynamics of supporting graduates in marginalised and remote areas with a facilitated, peer-mediated and WhatsApp-based transition support group are shown; practical recommendations and challenges are discussed.

One Message, Many Voices: Mobile Audio Counselling in Health Education.

Health workers' use of counselling information on their mobile phones for health education is a central but little understood phenomenon in numerous mobile health (mHealth) projects in Sub-Saharan Africa. Drawing on empirical data from an interpretive case study in the setting of the Millennium Villages Project in rural Malawi, this research investigates the ways in which community health workers (CHWs) perceive that audio-counselling messages support their health education practice. Three main themes emerged from the analysis: phone-aided audio counselling (1) legitimises the CHWs' use of mobile phones during household visits; (2) helps CHWs to deliver a comprehensive counselling message; (3) supports CHWs in persuading communities to change their health practices. The findings show the complexity and interplay of the multi-faceted, sociocultural, political, and socioemotional meanings associated with audio-counselling use. Practical implications and the demand for further research are discussed.

Instant messaging and nursing students' clinical learning experience.

BACKGROUND: Although learning in clinical settings is a key element of nursing education, for many learners these are challenging developmental contexts often marked by isolation and a lack of belongingness. Despite the massive appropriation of mobile instant messaging (MIM) platforms and the connective properties attendant to them, very little is known about their role in and impact on nursing students' clinical learning experiences. APPROACH AND METHODS: To address this gap, the study, which was part of a multinational research project on the use of mobile social media in health professions education in developing countries, examined the use of the instant messaging platform WhatsApp by nursing students during placements and potential associations with socio-professional indicators. The survey involved a total number of 196 nursing students from 5 schools in Oyo State, Nigeria. RESULTS: The findings suggest that students used WhatsApp relatively frequently and they perceived that this platform strongly enhanced their communication with other students and nurses. WhatsApp use during placements was positively associated with students' maintained social capital with peer students, the development of a professional identity, placement satisfaction and with reduced feelings of isolation from professional communities. The determinants that influenced WhatsApp use during placements were perceived usefulness and perceived ease of use. No associations were found between WhatsApp use during placement and age, attitude, subjective norms and placement duration. CONCLUSION: This study is one of the first of its kind that points to the relevance of mobile instant messaging as part of nursing students' (inter)personal learning environments in clinical settings and, particularly, in the development setting under investigation. Further research is needed to corroborate these findings, to enhance the understanding of the impact mechanisms, and to evaluate a more systematic use of MIM in clinical learning contexts.

Mobile Instant Messaging (MIM) to support teaching practice: Insights from a nurse tutor program in Nigeria.

Aim: To determine the feasibility of using the Mobile Instant Messaging (MIM) platform, WhatsApp, to provide supervision and support for student nurse tutors during a teaching practice placement in Nigeria. Methods: A descriptive qualitative method was used to design and evaluate a six-week WhatsApp group discussion intervention among 19 student nurse tutors. Two pre-intervention focus group sessions (n=9 and n=10) and a workshop were conducted to assess the students' content needs and media usage, and to develop a short online supervisory curriculum. To evaluate the intervention, two focus group sessions (n=9 and n=9) were carried out, transcribed verbatim, and analysed together with the actual WhatsApp conversations using thematic content analysis. Findings: The participants found the WhatsApp-enabled learning space valuable, in particular for the transfer and application of knowledge in their day-to-day teaching practice and, more generally, for their professional development. There were rich and multifaceted indicators of learning and professional development in evidence which were mostly triggered by specific facilitation techniques. The four themes from the WhatsApp conversations are: (1) sharing and discussing "tricks of the trade"; (2) providing direction and triggering reflective (teaching) practice; (3) sparking professional discussions and announcing professional development opportunities; and (4) maintaining a continuous moderating and teaching "presence". Conclusion: Despite some technical challenges centred mainly on the accessibility of the MIM space, the study identified indicators of good supervision practice and the results point to the feasibility and value of MIM to enhance supervision during teaching practice.

Mobile instant messaging for rural community health workers: a case from Malawi.

BACKGROUND: Mobile instant messaging (MIM) tools, such as WhatsApp, have transformed global communication practice. In the field of global health, MIM is an increasingly used, but little understood, phenomenon. OBJECTIVES: It remains unclear how MIM can be used by rural community health workers (CHWs) and their facilitators, and what are the associated benefits and constraints. To address this gap, WhatsApp groups were implemented and researched in a rural setting in Malawi. METHODS: The multi-site case study research triangulated interviews and focus groups of CHWs and facilitators with the thematic qualitative analysis of the actual conversations on WhatsApp. A survey with open questions and the quantitative analysis of WhatsApp conversations were used as supplementary triangulation sources. RESULTS: The use of MIM was differentiated according to instrumental (e.g. mobilising health resources) and participatory purposes (e.g. the enactment of emphatic ties). The identified benefits were centred on the enhanced ease and quality of communication of a geographically distributed health workforce, and the heightened connectedness of a professionally isolated health workforce. Alongside minor technical and connectivity issues, the main challenge for the CHWs was to negotiate divergent expectations regarding the social versus the instrumental use of the space. CONCLUSIONS: Despite some challenges and constraints, the implementation of WhatsApp was received positively by the CHWs and it was found to be a useful tool to support distributed rural health work.

Using mobile phones and social media to facilitate education and support for rural-based midwives in South Africa.

BACKGROUND: Empirical studies show the value of mobile phones as effective educational tools to support learning in the nursing profession, predominantly in high income countries. PROBLEM STATEMENT: The rapidly increasing prevalence of mobile phone technology in Africa nourishes hopes that these tools could be equally effective in lowly resourced contexts, specifically in efforts to achieve the health-related Millennium Development goals. The purpose of this study was to investigate the perception and use of mobile phones as educational and professional tools by nurses in lowly resourced settings. METHODOLOGY: A quantitative survey using self-administered questionnaires was conducted of rural advanced midwives. RESULTS: Fifty-six nurses (49.6%) from the 113 rural-based midwives attending an advanced midwifery training programme at the University of KwaZulu-Natal, South Africa, filled in a questionnaire. The results showed that, whilst nurses regarded their technology competences as low and although they received very little official support from their educational and professional institutions, the majority frequently used mobile functions and applications to support their work and learning processes. They perceived mobile devices with their voice, text, and email functions as important tools for the educational and professional activities of searching for information and engaging with facilitators and peers from work and study contexts. To a lesser extent, the use of social networks, such as WhatsApp and Facebook, were also reported. CONCLUSION AND RECOMMENDATION: It is concluded that educational institutions should support the appropriate use of mobile phones more systematically; particularly in relation to the development of mobile network literacy skills.

Informal mobile learning in nurse education and practice in remote areas--a case study from rural South Africa.

BACKGROUND: With the proliferation of portable digital technology, mobile learning is becoming increasingly popular in nursing education and practice. Most of the research in this field has been concentrated on small-scale projects in high income countries. Very little is known about the ways in which nurses and midwives use mobile technology in remote and resource poor areas in informal learning contexts in low and middle income countries. OBJECTIVES: To address this gap, this study investigates whether nurses use mobile phones as effective educational tools in marginalized and remote areas, and if so, how and why. SETTING AND METHODS: In rural South Africa, 16 nurses who attended an advanced midwifery education program, facilitators and clinical managers were interviewed about their use of digital mobile technology for learning. Techniques of qualitative content analysis were used to examine the data. RESULTS: Several rich "organically-grown", learning practices were identified: mobile phone usage facilitated (1) authentic problem solving; (2) reflective practice; (3) emotional support and belongingness; (4) the realization of unpredictable teaching situations; and (5) life-long learning. CONCLUSIONS: It is concluded that mobile phones, and the convergence of mobile phones and social media, in particular, change learning environments. In addition, these tools are suitable to connect learners and learning distributed in marginalized areas. Finally, a few suggestions are made about how these insights from informal settings can inform the development of more systematic mobile learning formats.

Smartphones as multimodal communication devices to facilitate clinical knowledge processes: randomized controlled trial.

BACKGROUND: Despite the widespread use and advancements of mobile technology that facilitate rich communication modes, there is little evidence demonstrating the value of smartphones for effective interclinician communication and knowledge processes. OBJECTIVE: The objective of this study was to determine the effects of different synchronous smartphone-based modes of communication, such as (1) speech only, (2) speech and images, and (3) speech, images, and image annotation (guided noticing) on the recall and transfer of visually and verbally represented medical knowledge. METHODS: The experiment was conducted from November 2011 to May 2012 at the University Hospital Basel (Switzerland) with 42 medical students in a master's program. All participants analyzed a standardized case (a patient with a subcapital fracture of the fifth metacarpal bone) based on a radiological image, photographs of the hand, and textual descriptions, and were asked to consult a remote surgical specialist via a smartphone. Participants were randomly assigned to 3 experimental conditions/groups. In group 1, the specialist provided verbal explanations (speech only). In group 2, the specialist provided verbal explanations and displayed the radiological image and the photographs to the participants (speech and images). In group 3, the specialist provided verbal explanations, displayed the radiological image and the photographs, and annotated the radiological image by drawing structures/angle elements (speech, images, and image annotation). To assess knowledge recall, participants were asked to write brief summaries of the case (verbally represented knowledge) after the consultation and to re-analyze the diagnostic images (visually represented knowledge). To assess knowledge transfer, participants analyzed a similar case without specialist support. RESULTS: Data analysis by ANOVA found that participants in groups 2 and 3 (images used) evaluated the support provided by the specialist as significantly more positive than group 1, the speech-only group (group 1: mean 4.08, SD 0.90; group 2: mean 4.73, SD 0.59; group 3: mean 4.93, SD 0.25; F2,39=6.76, P=.003; partial η(2)=0.26, 1-ß=.90). However, significant positive effects on the recall and transfer of visually represented medical knowledge were only observed when the smartphone-based communication involved the combination of speech, images, and image annotation (group 3). There were no significant positive effects on the recall and transfer of visually represented knowledge between group 1 (speech only) and group 2 (speech and images). No significant differences were observed between the groups regarding verbally represented medical knowledge. CONCLUSIONS: The results show (1) the value of annotation functions for digital and mobile technology for interclinician communication and medical informatics, and (2) the use of guided noticing (the integration of speech, images, and image annotation) leads to significantly improved knowledge gains for visually represented knowledge. This is particularly valuable in situations involving complex visual subject matters, typical in clinical practice.

Reframing clinical workplace learning using the theory of distributed cognition.

In medicine, knowledge is embodied and socially, temporally, spatially, and culturally distributed between actors and their environment. In addition, clinicians increasingly are using technology in their daily work to gain and share knowledge. Despite these characteristics, surprisingly few studies have incorporated the theory of distributed cognition (DCog), which emphasizes how cognition is distributed in a wider system in the form of multimodal representations (e.g., clinical images, speech, gazes, and gestures) between social actors (e.g., doctors and patients) in the physical environment (e.g., with technological instruments and computers). In this article, the authors provide an example of an interaction between medical actors. Using that example, they then introduce the important concepts of the DCog theory, identifying five characteristics of clinical representations-that they are interwoven, co-constructed, redundantly accessed, intersubjectively shared, and substantiated-and discuss their value for learning. By contrasting these DCog perspectives with studies from the field of medical education, the authors argue that researchers should focus future medical education scholarship on the ways in which medical actors use and connect speech, bodily movements (e.g., gestures), and the visual and haptic structures of their own bodies and of artifacts, such as technological instruments and computers, to construct complex, multimodal representations. They also argue that future scholarship should "zoom in" on detailed, moment-by-moment analysis and, at the same time, "zoom out" following the distribution of cognition through an overall system to develop a more integrated view of clinical workplace learning.

Contextual dynamics in clinical workplaces: learning from doctor-doctor consultations.

CONTEXT: Some studies have explored the role of learning context in clerkships and in clinical teams. Very little is known, however, about the relationship between context and competence development in more loosely framed, day-to-day practices such as doctor-doctor consultations, although such interactions are frequent and typical in clinical work. METHODS: To address this gap in the literature, a study was conducted using semi-structured interviews in four different hospitals and participant observation at one site. Inductive content analysis was used to develop a framework. Special reference was made to the principles of situated cognition. RESULTS: The framework illustrates how different situational, personal and organisational factors interact in every learning situation. The interplay manifests in three different roles that doctors assume in highly dynamic ways: doctors learn as 'actors' (being responsible), as 'participants' (being involved) and as 'students' (being taught); contextual influences also impact on the quality of learning within these roles. CONCLUSIONS: The findings add to the current literature on clinical workplace learning and to the conceptualisation of context in the field of education. The practical contribution of the research lies in disentangling the complex dynamics of learning in clinical environments and in helping doctors and medical educators to increase their responsiveness to contextual factors.

Mobile learning in resource-constrained environments: a case study of medical education.

BACKGROUND: The achievement of the millennium development goals may be facilitated by the use of information and communication technology in medical and health education. AIMS: This study intended to explore the use and impact of educational technology in medical education in resource-constrained environments. METHODS: A multiple case study was conducted in two Nepalese teaching hospitals. The data were analysed using activity theory as an analytical basis. RESULTS: There was little evidence for formal e-learning, but the findings indicate that students and residents adopted mobile technologies, such as mobile phones and small laptops, as cultural tools for surprisingly rich 'informal' learning in a very short time. These tools allowed learners to enhance (a) situated learning, by immediately connecting virtual information sources to their situated experiences; (b) cross-contextual learning by documenting situated experiences in the form of images and videos and re-using the material for later reflection and discussion and (c) engagement with educational content in social network communities. CONCLUSION: By placing the students and residents at the centre of the new learning activities, this development has begun to affect the overall educational system. Leveraging these tools is closely linked to the development of broad media literacy, including awareness of ethical and privacy issues.

Learning through inter- and intradisciplinary problem solving: using cognitive apprenticeship to analyse doctor-to-doctor consultation.

Today's healthcare can be characterised by the increasing importance of specialisation that requires cooperation across disciplines and specialities. In view of the number of educational programmes for interdisciplinary cooperation, surprisingly little is known on how learning arises from interdisciplinary work. In order to analyse the learning and teaching practices of interdisciplinary cooperation, a multiple case study research focused on how consults, i.e., doctor-to-doctor consultations between medical doctors from different disciplines were carried out: semi-structured interviews with doctors of all levels of seniority from two hospital sites in Switzerland were conducted. Starting with a priori constructs based on the 'methods' underpinning cognitive apprenticeship (CA), the transcribed interviews were analysed according to the principles of qualitative content analysis. The research contributes to three debates: (1) socio-cognitive and situated learning, (2) intra- and interdisciplinary learning in clinical settings, and (3), more generally, to cooperation and problem solving. Patient cases, which necessitate the cooperation of doctors in consults across boundaries of clinical specialisms, trigger intra- as well as interdisciplinary learning and offer numerous and varied opportunities for learning by requesting doctors as well as for on-call doctors, in particular those in residence. The relevance of consults for learning can also be verified from the perspective of CA which is commonly used by experts, albeit in varying forms, degrees of frequency and quality, and valued by learners. Through data analysis a model for collaborative problem-solving and help-seeking was developed which shows the interplay of pedagogical 'methods' of CA in informal clinical learning contexts.