RESEARCH

 

A capability approach analysis of student perspectives of a medical consultation quality-improvement process

 

 

J M Louw^I; T S Marcus^II; J F M Hugo^III

^IMB ChB, DTM&H, MMed (FamMed), PhD (FamMed); Department of Family Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa
^IIBSc (Econ), MSc, PhD; Department of Family Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa
^IIIMB ChB, MFamMed;.Department of Family Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND. Research shows that person-centredness declines during medical education. This study examines the underlying assumptions and effects of clinical associate training interventions on person-centred practice.
OBJECTIVES. To understand student experiences of a medical consultation quality-improvement (QI) process in terms of a capability approach to learning and the effects of this process on their person-centredness.
METHODS. In a randomised controlled trial students from 8 clinical learning centres (CLCs) participated in a qualitative, medical consultation QI process. Qualitative data (focus group discussions and reflective reports) were analysed using a capability approach to the learning framework.
RESULTS. Learning was triggered by disruptions to students' abilities, knowledge, identity and relationships. Through facilitated review-read-reflect-re/action scaffolded by feedback and practical assessment tools they learnt new person-centred consultation skills. The QI process functioned as a learning cycle in which students reviewed disruptions, identified areas for improvement and developed improvement plans. Through it, awareness of themselves developed more deeply, their relationships with peers and patients grew and they improved their knowledge and consultation skills.
CONCLUSIONS. Students demonstrated learning through their understanding of the skills and competencies required for person-centred practice. The study found students to be at different points along the directed/self-directed learning continuum, with most of them developing abilities to learn independently, work in groups, give and receive feedback and apply learning across different contexts. Facilitation is particularly important, given the uneven development of the 'dimensions of a person' at an individual level. Lastly, the capability approach is useful as an analytical framework and as a way of 'doing learning'.

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Person-centred practice is an ethical imperative'^[1,2] and an essential competency that has value for patients, clinicians and the health service.'³ At its core is a holistic view of the patient as a person with a unique illness experience, as well as the creation of a therapeutic relationship between patient and clinician.^[1] Despite various interventions, research shows that person-centredness and its constituent elements decline during the training of medical students. ^[4-6] To understand this phenomenon, it is necessary to examine the underlying assumptions and effects of training interventions on person-centred practice. This, in turn, requires an understanding of learning and the learner.

Marcus^[7] refers to four dimensions of the learner as sources of human capacity and competency, i.e. physical and mental abilities, knowledge and beliefs, sense of self and identity and social relationships. When there is a disturbance to any, some or all of these dimensions, the person experiences uncertainty. This uncertainty becomes the trigger to several, preferably conscious, cognitive and metacognitive activities that lead to learning. These include reviewing the activities or events that triggered the disruption, finding new information and critically evaluating the new information against the disruption, while taking into account self and identity, relationships and competencies. All this is done to develop an appropriate plan of action. Through practice, learners improve or develop new competencies, and develop or deepen their understanding of themselves and others, thereby growing the ability to learn in a continuously iterative learning cycle.^[8] The capability approach (Fig. 1)^[7,9,10] enables learners to develop mastery and move towards self-directed learning over time. It needs to be made consciously visible, scaffolded and guided by mentors and teachers, for all individuals to learn how to use it.^[9]

 

 

In this article, we use the capability approach to assess Bachelor of Clinical Medical Practice (BCMP) students' learning of person-centred consultation skills during a quality-improvement (QI) process on the medical consultation. Students with the BCMP degree are qualified to practise as clinical associates in South Africa (SA).^[11] They spend most of their 3 years of training doing service learning in a decentralised learning platform at clinical learning centres (CLCs). Typically, these comprise a district-level public hospital and its surrounding clinics.^[12] A local family physician provides oversight and leadership for student learning in each CLC, where students have daily contact with patients and conduct consultations under the supervision of qualified health professionals.

 

Methods

As part of a mixed-methods study, a randomised controlled trial of a QI intervention to learn person-centred practice was conducted with second- and third-year BCMP students.^[13] We report on the qualitative data from student reflective reports and focus group (FG) interviews with intervention group students. Students learning at 8 of 19 CLCs selected for the intervention by clustered randomisation were trained to implement the QI process as follows:

• Form a team of 2 - 4 fellow students in the same year group to work together to improve consultation skills.

• Read and reflect on 2 articles describing the medical consultation.^[14,15]

• Study 4 consultation assessment tools: Kalamazoo Essential Elements Communication Checklist (adapted) (KEECC(A)), Consultation Peer Assessment Tool (adapted for students at the University of Pretoria), CARE Patient Feedback Measure and Patient Enablement Instrument.

• Measure current consultation practice by assessing each other's consultations with the tools provided. Consultations could be video recorded, audio recorded and/or observed in person. Give feedback to each other based on the tools, and reflect on patients' perceptions of their consultations as recorded in the tools. Do self-assessment using one or two of the tools.

• Plan and implement measures to improve their own consultations.

• Repeat the measurements of their consultation practice.

• Reflect on changes in their performance and submit a report on the QI process.

One CLC closed after randomisation, but before commencement of training for the intervention. The 3 affected students were moved individually to 3 other CLCs. Students at the remaining 10 CLCs served as controls.

Even though intervention group students were repeatedly encouraged to submit reports, only 9 reports were received. Data for this analysis (Fig. 2) were drawn from these 9 written reflection reports from 17 students in 4 CLCs and 10 focus group discussions (FGDs) that explored student experiences of the QI process on the medical consultation conducted between 19 October and 23 November 2015. All 62 students in the intervention group were invited (volunteer sampling) to participate in FGs when they were on campus for tests or examinations. Each FGD involved 2 - 12 participants, lasted 7 - 25 minutes and was conducted by the first author in English, audio recorded and transcribed. The 48 FG participants included students from 7 of the 8 CLCs trained for the QI process. No student from CLC 8 volunteered to participate in an FGD, and no student participated in more than one FGD. In all FGDs, participants were asked: 'How are you progressing with the quality improvement on the medical consultation?', and 4 supplementary questions: 'How useful did you find the feedback that you were giving to one another?', 'How useful did you find the feedback from patients?', 'How useful did you find reflecting and thinking about your own consultation?' and 'How useful were the evaluation tools or rubrics?'

 

 

Data were interpreted using a capability approach to learning as a framework. For the purposes of this analysis, the physical and mental abilities of the learner were interpreted specifically in terms of consultation skills rather than as general abilities. Scaffolding for learning consultation skills included academic readings explaining the processes of the medical consultation, as well as assessment tools detailing the behaviours evaluated in a consultation. Guidance of learning included a QI process and advocating for a learning environment that enabled learners to engage meaningfully in the process. It was also facilitated by peer feedback among students to stimulate reflection on their performance as related to assessment tools. Feedback was deemed effective when it related to a specific learning context and was directed towards the attainment of specific goals.^[16]

Data were analysed through repeated reading of the reports and transcribed texts, as well as repeated listening to the audio recordings to identify specific insights into learning the consultation skills required for person-centred practice and to relate these to the phases and elements of the capability approach to learning (Fig. 1). Quotations were coded and catalogued deductively in themes using the Atlas.ti (version 7.5) (Atlas.ti Scientific Software Development GmbH, Germany) computer program. Codes and themes were verified through discussions between the first and second authors, with involvement of the third author when there was no agreement.

Ethical approval

The study was granted ethical clearance by the Research Ethics Committees of the Mpumalanga Provincial Government and the Faculty of Health Sciences, University of Pretoria (ref. no. 128/2013).

 

Results

The average age of the 62 students in the intervention group was 23.3 years and 44% were female.

Describing their competencies prior to undertaking the QI process, students said that by their second year they had a better understanding of person-centred practice, which prepared them for this QI process (Table 1: quote 1:25). They ascribed their skill in involving patients as equals in decision-making to previous training in preparation for an objective structured clinical examination (OSCE) (Table 1: quote 1:28). Students reported gaps in their knowledge of pharmacology (Table 2: quote 18:16), special investigations and communication skills (Table 1: quote 21:4).

In one instance, a student continued to externalise responsibility for learning (Table 3: quote 5:15).

Students experienced several disruptions in the QI process that triggered learning, including: being observed by peers (Table 3: quote 2:57; Table 4: quote 2:59) and/or recorded (Table 3: quote 2:16), while conducting a consultation, watching (Table 3: quotes 2:25 and 2:27) and listening (Table 1: quote 3:5) to recordings of themselves, not knowing enough (Table 2: quote 18:16; Table 4: quote 19:5) and feeling as though patients regarded them as incompetent (Table 3: quote 6:11; Table 4: quote 19:5). Some were also disrupted by technical and logistical barriers during implementation of the QI process and in 2 CLCs by administrative prohibition of recording videos of consultations together.

Students responded to the disruptions by reviewing their consultations through self-evaluation, using the consultation scoring tools (Table 1: quote 8:2), discussing with peers who observed them (Table 1: quote 3:14), listening to audio recordings (Table 1: quote 3:5) or watching video recordings (Table 3: quote 2:27).

Patient information needs triggered students to read up on pharmacology and investigative studies so that they could manage and explain the information to patients (Table 2: quotes 18:8 and 18:16; Table 4: quote 19:5).

Students became self-aware as they observed themselves in video and audio recordings (Table 1: quote 2:23; Table 3: quotes 2:26 and 2:27), with some responding that starting video recording themselves earlier in the course would have made them more comfortable (Table 1: quote 2:17). They reflected on their mannerisms and how they appear to patients (Table 3: quote 2:25). They also reflected on the way they interact in the consultation, becoming aware of not allowing patients to elaborate and of being unable to formulate open-ended questions (Table 3: quote 2:62). By watching their recordings, some gained an understanding of what it means to reflect (Table 3: quote 2:26), while others recognised that they were biased in their self-evaluations (Table 3: quote 1:33).

Through joint reflection on their consultation skills, students developed action plans to find solutions to the disruptions they experienced, such as reading about the subject, discussing issues with one another and others and practising (Table 3: quote 15:2; Table 2: quote 19:7; Table 1: quotes 20:8 and 21:9). For some, their insight into the value of learning with peers extended to planning co-operative learning to grow their all-round competencies beyond the QI process (Table 2: quote 19:7).

There were two different approaches to the disruption caused by administrative prohibition of video recording their consultations. Some students observed one another's consultations, used the reading material and gave one another feedback during consultations to improve their skills (Table 1: quote 6:22). Other students stopped the QI process to avoid confrontation with hospital management (Table 3: quote 7:6).

Specific feedback given by peers helped them learn physical examination and other consultation skills, such as not repeating questions and time management (Table 1: quotes 3:14, 5:34 and 20:4). They saw the value of diversity of experience and knowledge that came by way of peer learning, even suggesting that partners be rotated to get other opinions (Table 1: quote 21:9).

Students did not find formal patient feedback helpful. They felt it did not contribute to their learning, because it was consistently positive and nonspecific.

Students reported that the readings and assessment tools to support their learning were helpful. They especially found that Hugo and Couper's^[15] juggling analogy helped them grasp key components of the consultation (Table 1: quote 8:12) and that the consultation assessment tools helped them identify areas for improvement during self-evaluation (Table 1: quote 8:2). Some found the English used in the Kalamazoo measuring tool difficult to follow and preferred the adapted consultation peer assessment tool.

In terms of new and strengthened person-centred practice, students expressed strong person-centred beliefs regarding the medical consultation. For example, they felt it was important to facilitate patients to tell their stories (Table 2: quote 2:54) and to focus more on the patient's ideas and feelings (Table 2: quote 2:49). They also believed that making a personal connection with the patient was therapeutic (Table 4: quote 6:26).

They reported learning valuable person-centred consultation skills, such as listening and building trust to discuss sensitive information (Table 1: quote 3:7); being fully focused on the patient to better explore their illness experience (Table 4: quote 6:5) and improve treatment adherence (Table 4: quote 6:7); eliciting patient expectations (Table 3: quote 6:8); adopting a holistic approach to find underlying causes of patients' worries and complaints (Table 1: quotes 6:9 and 3:6) and recognising the importance of negotiation to achieve compliance (Table 1: quote 6:6). Students considered consultation skills to be a foundation for clinical practice, suggesting that they be learnt prior to clinical skills in the earlier years of the programme.

 

Discussion

Students found the QI process a valuable opportunity to self-evaluate and identify practice areas needing improvement to gain the competencies expected of them as clinicians.

Our findings show that a self-directed QI process with evaluation tools, peer feedback and reflection on audio and video recordings led students to learning person-centred care. Disruptions triggered cognitive and metacognitive processes, which through scaffolding, enabled students to engage in a self-directed cycle of reading, reviewing, reflecting and acting or planning action, impacting on all their dimensions as learners.^[9]

Watching video recordings of themselves conducting a consultation disrupted students' identity and sense of self. It triggered them to reflect on who they are, how they appear to others, and what they know or do not know. Self-awareness created through auto-critique is a recognised essential component for self-directed learning.^[17,18]

As reported elsewhere, students found being recorded stressful,^[17,19] which may explain why many did not video record themselves. As proposed by these students and in other studies,^[19] this could be partly alleviated by introducing video recordings of consultations early in the course.

This study confirms the importance of motivation and self-efficacy for all learning, especially learning that centres on self-directed activities.^[8] The student groups who abandoned the QI process when they were unable or not permitted to video record their consultations failed to learn. Through their own agency, the groups who continued the QI process, either without video recording or by overcoming technical and logistical obstacles, were able to develop their critical thinking skills and gain valuable person-centred competencies.

video recording or by overcoming technical and logistical obstacles, were able to develop their critical thinking skills and gain valuable person-centred competencies.

As reported by Aper et al.,^[20]conducting consultations with real patients both inspired and challenged students. Being regarded by them as incompetent, not only disrupted students' relationships with patients but also their sense of self. This has been described elsewhere as part of the process of identity formation, where individuals form their identity by imagining how they appear to and are judged by others.^[21] The QI process made students aware of how their own and patients' lack of confidence in their knowledge and abilities prevented them from inspiring trust in patients. For some, the awareness triggered by this disruption motivated self-development, driving them to re-establish and build themselves as competent healthcare student apprentices. For others, it triggered a defensive reaction that obstructed learning, as it cut to the core of their sense of self, leading them to express reluctance to share decision-making power with patients. This response points to the critical need for facilitation of learning to be an on-going process so that students develop the necessary competencies and skills to help them to retain their sense of self-worth and give them the confidence to collaborate with patients without appearing incompetent.

Through the QI process, students built and developed relationships with one another as peers. In this study, the principles of good feedback to promote changed practice were followed, i.e. that it be given face to face, be part of a coaching process (QI), contain specifics with examples, be based on observation, comparison (between peers) and a clear standard, as well as supporting positive change.^[22] The use of evaluation tools with clearly explained criteria to guide peer feedback ensured that what was said guided practice, even though it came from peers on the same level. Students demonstrated the ability to discern useful and unhelpful feedback. As with medical students,^[17,23] this study found that clinical associate students preferred peer feedback for its clarity and details and did not report any drawbacks.^[24] As in other research, the cognitive and social congruence between peers put students at ease being observed while conducting medical consultations.^[25] They felt that peers helped them focus, perform better and learn more than when they did consultations in the presence of a lecturer or examiner.

Although trained how to give feedback, the study found that student feedback was constrained by limitations in their knowledge of content and their relationships with one another. Generally, they gave feedback that related to their understanding of the knowledge and abilities required for the tasks and processes of the consultation, but did not address the issues of identity and relationships that these brought to light. This points to the important role of mentor and lecturer facilitation of learning to ensure that students are guided towards the best available knowledge and provided with deeper levels of feedback.

Study limitations

This study was conducted in a decentralised workplace-based training platform for clinical associate students and the findings may therefore not be generalisable to other teaching models.

Not all students submitted QI reports. Students from one of the intervention CLCs did not participate in the FGDs. They, however, submitted a joint report congruent with the rest of the data, suggesting that the results are an accurate reflection of their experiences with the QI process.

Despite repeated engagement with local supervisory structures, their support for the study was insufficient and contributed to variable implementation across CLCs.

FGDs 9 and 10 were of very short duration, largely because these involved only 2 or 3 students who did not implement the intervention. Even though FGDs 7 and 8 had 4 participants each, they were also of short duration. Participants in FGD 7 did not implement the intervention, while data generated in FGD 8 were congruent with the rest of the data. These limitations were mitigated by the number of FGDs and extent of data generated by the FGDs.

The researcher's position as BCMP programme co-ordinator may have prevented students discussing negative attitudes toward the course or patients. Even though students did not report personal negative attitudes toward patients, they did critique the consultation skills of other clinicians, as well as the timing of the QI intervention. However, the researcher's experience as a clinician allowed students to freely share their clinical experiences, which he could understand and empathise with.^[26]

 

Conclusion

Students demonstrated the learning achieved in the QI process through their understanding of the skills and competencies required for person-centred practice.

Using a capability approach to understand the triggers and processes of learning person-centred care, the study revealed that students are at different points along the directed/self-directed learning continuum. While some had yet to internalise their responsibility for learning, most were developing their abilities to learn independently, to work in groups, to give and receive feedback and to apply what they have learnt across different contexts. Given the uneven development of the 'dimensions of a person' at an individual level, facilitation of learning is particularly important to help students translate disruptions into learning. Similarly, the cycle of reviewing, reading, reflecting and acting benefits all students when it is scaffolded through reading and evaluation instruments, as well as by creating deliberate opportunities for feedback. In addition to being a way of 'doing' learning, the article also demonstrates the usefulness of the capability approach as a framework to analyse if and how learning happens.

Based on the quality of learning, it is recommended that a QI process on the medical consultation with video recording be included in the undergraduate curriculum of clinicians. Areas for future research include the effects of different tools to guide self-evaluation and peer feedback, the role and place of video recording in the learning cycle, the best methods and processes to support the learning of person-centred practice, and an exploration of the development of students' 'review' competencies over time.

Declaration. The research for this study was done in partial fulfilment of the requirements for JML's PhD (Family medicine) degree at the University of Pretoria.

Acknowledgements. Appreciation is expressed to the study participants, to Ms D Mhlari, Ms G Moodley, Mr K M Komana, Miss Z Sithole and Ms L I Mudau for transcribing the focus group recordings, and to Mrs N Smit for editing the manuscript. We thank Gerhard Cruywagen of Greenhouse Cartoons for designing Fig. 1.

Author contributions. JML: study conceptualisation, design, data collection and analysis; JML, TSM: interpretation framework; JML, TSM and JFMH: discussion and critical review.

Funding. None.

Conflicts of interest. None.

 

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Correspondence:
J M Louw
murray.louw@up.ac.za

Accepted 18 November 2019