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OBJECTIVES: The purpose of this educational intervention was to introduce, iteratively adapt, and implement a digital formative assessment tool in a surgical speciality. The study also evaluated the intervention's impact on perioperative teaching, learning, feedback, and surgical competency. DESIGN: A participatory action research model with a mixed methods approach. SETTING: This study was performed over 10 months in an institutional hospital in South Africa with a general surgery department. PARTICIPANTS: Twelve supervising surgical trainers/faculty and 12 surgical trainees/residents consented to participate in the intervention. RESULTS: The first 4 months of the intervention focused on relationship building, a multi-stakeholder contextual needs assessment and training sessions to support a shared mindset and shift in the teaching and learning culture. The final adapted perioperative competency-building tool comprised a 23-item assessment with four open-text answers (Table 1). Over the following 6-month period, 48 workplace-based competency-building perioperative evaluations were completed. Most trainees took less than 5 minutes to self-assess (67%) before most trainers (67%) took less than 5 minutes to give oral feedback to the trainee after the perioperative supervised learning encounter. On average, the digital tool took 6 minutes to complete during the bidirectional perioperative teaching and learning encounter with no negative impact on the operational flow. All trainers and trainees reported the training and implementation of the digital tool to be beneficial to teaching, learning, feedback, and the development of surgical competency. Analysis of the completed tools revealed several trainees showing evidence of progression in surgical competency for index procedures within the speciality. The focus groups and interviews also showed a change in the teaching and learning culture: more positively framed, frequent, structured, and specific feedback, improved accountability, and trainee-trainer perioperative readiness for teaching. Highlighted changes included the usefulness of trainee self-assessment before perioperative trainer feedback and the tool's value in improving competency to Kirkpatrick Level 4. CONCLUSION: Implementing an adapted digital Workplace-Based Assessment (WBA) tool using a participatory action research model has proven successful in enhancing the effectiveness of supervised perioperative teaching and learning encounters. This approach has improved teaching and feedback practices, facilitated the development of surgical competency, and ultimately impacted the overall culture to Kirkpatrick level 4. Importantly, it has positively influenced the trainee-trainer relationship dynamic. Based on these positive outcomes, we recommend using this effective method and our relationship-centred framework for implementing formative competency-building tools in future studies. By doing so, larger-scale and successful implementation of Competency-Based Medical Education (CBME) could be achieved in various contexts. This approach can potentially enhance teaching and learning encounters, promote competency development, and improve the overall educational experience for surgical trainees and trainers.

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High levels of stress and burnout, low help-seeking behaviour and unhealthy coping in healthcare professionals (HCPs), are a critical concern globally. Mindfulness-based interventions (MBIs) reduce stress, are a healthy coping mechanism and have become increasingly popular among HCPs, especially during the Covid-19 pandemic. Nevertheless, HCPs' busy schedules require the intervention to be accessible, pragmatic, and context specific. Key to this goal is approaching mindfulness from a multicultural perspective, especially in diverse settings such as Africa. This paper aims to provide practical tips to ensure that the MBI offered is effective with multicultural HCPs during intense stress. Four tips each discuss the curriculum, implementation, and sustainability, respectively. The tips are elucidated by practical examples of regulating stress in healthcare settings and to offer a guideline to help structure future MBIs to be culturally and context appropriate.

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BACKGROUND: Workplace-based assessments (WBAs) are part of a competency-based curriculum where training progression is dependent on the achievement of defined competencies in a real-world clinical environment. There is a significant literature gap on the impact of WBAs implemented in resource constrained countries and their contextual challenges. This study aimed to examine the use, impact, and educational context of WBAs in South African medical specialist training programs drawing on perspectives from both trainees and trainers to identify educational challenges and propose effective solutions. METHODS: A mixed methods national electronic survey was conducted with specialist medical trainees and supervising trainers from all eight specialist training institutions in South Africa involving 16 specialities. The survey responses were voluntary and anonymous. The survey was closed after seven months when data saturation was achieved. Descriptive statistical analysis was performed using SPSS Version 27 (SPSS Inc, 2012, Chicago, IL) for the quantitative analysis. The thematic coding framework for the qualitative analysis was facilitated by NVivo Version 12 software. RESULTS: There were 108 ethnically diverse supervising trainers and 248 specialist trainees' survey respondents. Across the 16 medical specialities, 45% of the respondents were using WBAs. Despite contextual resource and staff challenges, this study found that WBAs had a positive impact to Kirkpatrick level 2 in providing actionable feedback to improve competency. WBA users had a significantly higher rating for trainee supervision (p < 0.01), general quality of feedback on trainee competence (< 0.01) and the specialist training program (p = 0.03) compared to WBA non-users. They also had a higher rating for the assessment of the trainee as a professional (p < 0.01); scholar (p < 0.01); communicator (p < 0.01); collaborator (p = 0.001) and leader/manager (p < 0.001) based on the AfriMEDS competency framework. Racism, sexism and favouritism were challenges that negatively affected the training programs. CONCLUSION: Overall, this study reports that the use of WBAs had a substantially favourable impact on teaching, learning, feedback and supports a competency-based approach to specialist training programs. Addressing the contextual concerns that negatively impact training; training the trainees and trainers about their relationship, roles and responsibilities; and focusing on a trainee-centred, inclusive and empowering teaching approach will help further enhance its effectiveness.

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BACKGROUND: South Africa (SA) is on the brink of implementing workplace-based assessments (WBA) in all medical specialist training programmes in the country. Despite the fact that competency-based medical education (CBME) has been in place for about two decades, WBA offers new and interesting challenges. The literature indicates that WBA has resource, regulatory, educational and social complexities. Implementing WBA would therefore require a careful approach to this complex challenge. To date, insufficient exploration of WBA practices, experiences, perceptions, and aspirations in healthcare have been undertaken in South Africa or Africa. The aim of this study was to identify factors that could impact WBA implementation from the perspectives of medical specialist educators. The outcomes being reported are themes derived from reported potential barriers and enablers to WBA implementation in the SA context. METHODS: This paper reports on the qualitative data generated from a mixed methods study that employed a parallel convergent design, utilising a self-administered online questionnaire to collect data from participants. Data was analysed thematically and inductively. RESULTS: The themes that emerged were: Structural readiness for WBA; staff capacity to implement WBA; quality assurance; and the social dynamics of WBA. CONCLUSIONS: Participants demonstrated impressive levels of insight into their respective working environments, producing an extensive list of barriers and enablers. Despite significant structural and social barriers, this cohort perceives the impending implementation of WBA to be a positive development in registrar training in South Africa. We make recommendations for future research, and to the medical specialist educational leaders in SA.

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OBJECTIVE: To investigate the use and effectiveness of Workplace-based assessments (WBAs) and their impact on training, feedback, and perioperative teaching in surgical training programs. DESIGN: A mixed methods cross-sectional, national electronic survey was conducted with surgical trainees and consultant trainers. SETTINGS: The trainees and supervising faculty were from all 8 major surgical training universities across 11 surgical disciplines in South Africa. PARTICIPANTS: A total of 108 surgical trainees and 41 supervising consultant trainers from 11 surgical disciplines across 8 surgical training universities responded to the survey. RESULTS: The most significant educational gap identified by both the surgical trainees and trainers across all surgical disciplines was inadequate perioperative feedback. A third of the respondents were currently using workplace-based assessments. The WBA users (both trainees and trainers) had a higher rating for the general quality of surgical feedback than WBA nonusers (p = 0.02). WBA users also had a higher rating for the general quality of feedback given to trainees on their skills and competence (p = 0.04) and a higher rating for trainee supervision (p = 0.01) and the specialist training program overall (p = 0.01). The WBA users also had a higher rating for the assessment of competencies such as the trainee as an effective communicator (p < 0.01) and collaborator (p = 0.04). CONCLUSION: This study found that the use of WBAs enhances the quality and effectiveness of feedback in surgical training programs. We also found that the use of WBAs enhance perioperative teaching and learning and improves the assessment of relational competencies. This was also associated with high ratings for the quality of trainee supervision. Faculty and trainee development, strengthening the trainee-trainer relationship, and integrating iterative stakeholder feedback could help realize the full potential of WBAs to augment surgical training across disciplines.

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Background: Coronavirus disease 2019 (COVID-19) placed healthcare professionals (HCPs) at a higher risk for stress-related conditions. Implementing a brief online mindfulness-based intervention (MBI) was hypothesised to transform the HCPs' ability to cope with stress by enhancing their self-care. Aim: This study aimed to explore the impact of an online MBI on HCPs' self-care practices and determine if personality traits were a moderating variable. Setting: An online MBI was implemented for HCPs working in South Africa during the COVID-19 pandemic lockdowns. Methods: A quantitative study design included a pre-assessment and post-assessment component, which allowed paired comparison and regression analysis to confer correlations. Data were collected via two validated instruments: the Mindful Self-Care scale-2018 and the Big Five Personality test. Results: Forty-nine HCPs participated in the study. Significant improvements were found in all the major self-care subscales post-intervention (p < 0.05). No significant associations were found between the personality traits and self-care except for neuroticism, which appeared to be an essential moderating variable. Conclusion: An online MBI significantly impacted health professionals' ability to care for themselves, despite their personality styles. Contribution: The impact of an online MBI on HCPs' self-care during the most intense time of stress and with a cohort of people known to be the most vulnerable to stress, namely those with neuroticism to date, has not been commented on.

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BACKGROUND: Feedback is vital to improving trainee competencies in medical education. The challenges of the global COVID-19 pandemic related to social distancing to curb the spread of the virus ignited a rapid transition to online medical education. These changes highlight the need for digital feedback tools that enhance the efficacy and efficiency of feedback practices. This protocol is for a scoping review that aims to identify the different digital tools and applications in medical education as reported in the literature, as well as highlight gaps in the current literature and provide suggestions for future technological developments and research. METHODS AND ANALYSIS: A review of the relevant literature will be guided using the Joanna Briggs Institute methodological framework for scoping studies. Using the search strategy developed by the authors, an electronic search of the following databases will be conducted: PubMed/MEDLINE, EBSCOhost (academic search complete, CINAHL with full text) Scopus, Google Scholar, Union Catalogue of Theses and Dissertations (UCTD) via SABINET Online and World Cat Dissertations and Theses via OCLC. Studies will be identified by searching literature from January 2010 to date of review. Using a validated data extraction form developed for the scoping review, the review team will screen eligible studies and import them onto an electronic library created specifically for this purpose. Data collection for the review will be documented through a PRISMA-P flowchart, and the scoping review will use a basic descriptive content analysis to analyse and categorise the extracted data. All review steps will involve two or more reviewers. DISSEMINATION: The review will provide a comprehensive list of digital tools and applications used to enhance feedback in clinical training and inform future technological developments. The findings will be disseminated through medical education conferences and publications.

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Background: The disruptions of the coronavirus disease 2019 (COVID-19) pandemic have placed added stress on health care practitioners' (HCPs) mental health. Mindfulness-based interventions (MBIs) have been reported to increase the awareness of burnout and promote self-care practices that enhance mental well-being. Aim: To gain insight into the use of mindfulness through the lens of PhotoVoice on how HCPs reflected on their stressors and sense of self whilst working as frontline workers during the COVID-19 pandemic. Setting: This study was conducted online with HCPs working in South Africa during the first wave of COVID-19. Method: A four-week MBI intervention was implemented using Zoom. An exploratory qualitative analysis was conducted using a PhotoVoice methodology. Interpretative phenomenological analysis was used to generate themes. Fifty-five HCPs consented to participate in this study. Results: The major themes identified were operating on autopilot, feeling a sense of overwhelm because of COVID-19, using faith to cope and being able to attain a sense of self-compassion by the end of the intervention. Conclusions: Using visual representations, HCPs were able to share the development of their reperceived lived experiences of increased self-compassion as they navigated the dilemmas and disruptions of the pandemic. Contribution: A brief online MBI was impactful enough to show a reappraisal of the stressors of COVID-19, such that HCPs felt calmer, more competent and more compassionate. PhotoVoice methodology is recommended for future studies and mindfulness courses. It facilitates a deeper understanding of the practice of imbuing mindfulness and its impact on stressors and the self.

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BACKGROUND: Newly qualified medical practitioners in South Africa (SA) are part of the frontline health care workers who face Africa's most severe coronavirus disease 2019 (COVID-19) pandemic. The experiences of interns during the pandemic reflect SA's preparedness to respond in a crisis and inform strategies that could be adopted to balance training and service in resource-challenged contexts. AIM: To explore the strengths, weaknesses, opportunities and threats posed during the first wave of the COVID-19 pandemic as reflected on by interns within the clinical training platforms in SA. SETTING: Public hospitals in KwaZulu-Natal. METHODS: An online questionnaire consisting of eight open-ended questions based on the SWOT framework related to personal and professional perspectives to clinical training during the COVID-19 pandemic was developed using SurveyMonkey. All data were collected remotely via social media platforms. Data were thematically analysed. RESULTS: Forty-six interns reflected on personal and systemic challenges as the major threats and weaknesses in intern training during the COVID-19 pandemic. Extrapolating on strengths and opportunities, there were three overarching learnings interns reflected on. These related to being a medical professional, communities of practice and the development and enhancement of clinical and non-clinical competencies. Existing challenges in the environment exacerbated the threats posed by COVID-19 and innovative strategies related to improving support, feedback, broadening the intern curriculum and online training. CONCLUSION: Although the clinical environment where interns learn and work is often stressful and overpowered by high service burdens, there are unique opportunities to enhance self-directed learning and graduate competencies, even in the midst of the COVID-19 pandemic.

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PURPOSE: Self-directed learning (SDL) has been advocated for effective training of final-year health professions students. COVID-19 challenges conventional teaching, learning, and assessment in the clinical environment. This study aimed to identify and explore enablers and barriers to SDL among final-year health professions students training during the COVID-19 pandemic. METHODS: Adopting the SWOT (strengths, weaknesses, opportunities and threats) framework, this study explored the clinical learning and training experiences of final-year health professions students during the pandemic. A survey was conducted via online platforms. Data from 155 respondents were thematically analyzed. RESULTS: Personal attributes such as reflection, self-determination, motivation, resilience, and positive learning behaviors and skills were identified as SDL enablers. Collaborative learning networks and online learning platforms facilitate learning needs and goals. Fear and anxiety, untrusted learning sites, uncertainty about graduation, financial issues and challenges in the learning environments were the major themes related to barriers to SDL. CONCLUSION: The importance of SDL as a skill for uncertain times warrants further investigation in the training of future healthcare professionals. Inclusive planning and engagement with final-year health professions students to address identified stressors, as well as the creation of shared platforms where students are part of the decision-making processes for clinical learning and training are recommended. Responsive curricula that optimize unpredictable disruptions in clinical training are needed to equip students to diagnose their own learning needs and implement appropriate learning strategies.

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Background: Newly qualified medical practitioners in South Africa (SA) are part of the frontline health care workers who face Africa's most severe coronavirus disease 2019 (COVID-19) pandemic. The experiences of interns during the pandemic reflect SA's preparedness to respond in a crisis and inform strategies that could be adopted to balance training and service in resource-challenged contexts. Aim: To explore the strengths, weaknesses, opportunities and threats posed during the first wave of the COVID-19 pandemic as reflected on by interns within the clinical training platforms in SA. Setting: Public hospitals in KwaZulu-Natal. Methods: An online questionnaire consisting of eight open-ended questions based on the SWOT framework related to personal and professional perspectives to clinical training during the COVID-19 pandemic was developed using SurveyMonkey. All data were collected remotely via social media platforms. Data were thematically analyzed. Results: Forty-six interns reflected on personal and systemic challenges as the major threats and weaknesses in intern training during the COVID-19 pandemic. Extrapolating on strengths and opportunities, there were three overarching learnings interns reflected on. These related to being a medical professional, communities of practice and the development and enhancement of clinical and non-clinical competencies. Existing challenges in the environment exacerbated the threats posed by COVID-19 and innovative strategies related to improving support, feedback, broadening the intern curriculum and online training. Conclusion: Although the clinical environment where interns learn and work is often stressful and overpowered by high service burdens, there are unique opportunities to enhance self-directed learning and graduate competencies, even in the midst of the COVID-19 pandemic.

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BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, health professionals were pushed to the front line of a global health crisis unprepared and resource constrained, which affected their mental well-being. AIM: This study aimed to investigate the effectiveness of a brief online mindfulness-based intervention (MBI) on stress and burnout for health professionals training and working in South Africa during the COVID-19 crisis. SETTING: The context of the study is the overburdened, under-resourced health care system in South Africa during a global pandemic. METHODS: A mixed method framework was adopted for this study. The quantitative data was analysed using descriptive analysis and the participants' qualitative experiences were interpreted using interpretative phenomenological analysis. RESULTS: Forty-seven participants took part in this study. The study found a statistically significant (p < 0.05) reduction in stress levels and emotional exhaustion as well as an increase in mindful awareness and feelings of personal accomplishment after the intervention. The participants' shared experiences were analysed in two parts. The pre-intervention analysis presented with central themes of loss of control and a sense of powerlessness because of COVID-19. The post-intervention analysis comprised themes of a sense of acquired control and empowerment through increased mindfulness. CONCLUSIONS: The study found that a brief online MBI can be associated with reduced levels of stress and burnout as well as an increased sense of control and empowerment, felt both personally and professionally, during a global crisis. CONTRIBUTION: The impact of an online MBI for health care professionals amidst a pandemic has not been previously documented.

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BACKGROUND: In this research paper we report on the quality of feedback provided in the logbooks of pre-clinical undergraduate students based on a model of 'actionable feedback'. Feedback to clinical learners about their performance is crucial to their learning, which ultimately impacts on their development into competent clinicians. Due to students' concerns regarding the inconsistency and quality of feedback provided by clinicians, a structured feedback improvement strategy to move feedback forward was added to the clinical skills logbook. The instrument was also extended for peer assessment. This study aims to assess the quality of feedback using the deliberate practice framework. METHODS: A feedback scoring system was used to retrospectively assess the quality of tutor and peer logbook feedback provided to second and third year medical students to identify deliberate practice components i.e. task, performance gap and action plan. The sample consisted of 425 second year and 600 third year feedback responses over a year. RESULTS: All three deliberate practice components were observed in the majority of the written feedback for both classes. The frequency was higher in peer (83%, 89%) than tutor logbook assessments (51%, 67%) in both classes respectively. Average tutor and peer task, gap and action feedback scores ranged from 1.84-2.07 and 1.93-2.21 respectively. The overall quality of feedback provided by the tutor and peer was moderate and less specific (average score < or = 2). The absence of the three components was noted in only 1% of the feedback responses in both 2nd and 3rd year. CONCLUSION: This study found that adding in a feed-forward strategy to the logbooks increased the overall quality of tutor and peer feedback as the task, gap and action plans were described. Deliberate practice framework provides an objective assessment of tutor and peer feedback quality and can be used for faculty development and training. The findings from our study suggest that the ratings from the tool can also be used as guidelines to provide feedback providers with feedback on the quality of feedback they provided. This includes specifically describing a task, performance gap and providing a learning plan as feed-forward to enhance feedback given.

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Background. Clinical skills training in the clinical skills laboratory (CSL) environment forms an important part of the undergraduate medical curriculum. These skills are better demonstrated than described. A lack of direct observation and feedback given to medical students performing these skills has been reported. Without feedback; errors are uncorrected; good performance is not reinforced and clinical competence is minimally achieved. Objectives. To explore the perceptions of 3rd-year medical students and their clinical teachers about formative clinical assessment feedback in the CSL setting.Methods. Questionnaires with open- and closed-ended questions were administered to 3rd-year medical students and their clinical skills teachers. Quantitative data were statistically analysed while qualitative data were thematically analysed. Results. Five clinical teachers and 183 medical students participated. Average scores for the items varied between 1.87 and 5.00 (1: negative to 5: positive). The majority of students reported that feedback informed them of their competence level and learning needs; and motivated them to improve their skills and participation in patient-centred learning activities. Teachers believed that they provided sufficient and balanced feedback. Some students were concerned about the lack of standardised and structured assessment criteria and variation in teacher feedback. No statistical difference (p0.05) was found between the mean item ratings based on demographic and academic background. Conclusion. Most teachers and students were satisfied with the feedback given and received; respectively. Structured and balanced criterion-referenced feedback processes; together with feedback training workshops for staff and students; are recommended to enhance feedback practice quality in the CSL. Limited clinical staff in the CSL was noted as a concern

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Collaborative approaches such as Problem Based Learning (PBL) may provide the opportunity to bring together diverse students but their efficacy in practice and the complications that arise due to the mixed ethnicity needs further investigation. This study explores the key advantages and problems of heterogeneous PBL groups from the students' and teachers' opinions. Focus groups were conducted with a stratified sample of second year medical students and their PBL teachers. We found that students working in heterogeneous groupings interact with students with whom they don't normally interact with, learn a lot more from each other because of their differences in language and academic preparedness and become better prepared for their future professions in multicultural societies. On the other hand we found students segregating in the tutorials along racial lines and that status factors disempowered students and subsequently their productivity. Among the challenges was also that academic and language diversity hindered student learning. In light of these the recommendations were that teachers need special diversity training to deal with heterogeneous groups and the tensions that arise. Attention should be given to create 'the right mix' for group learning in diverse student populations. The findings demonstrate that collaborative heterogeneous learning has two sides that need to be balanced. On the positive end we have the 'ideology' behind mixing diverse students and on the negative the 'practice' behind mixing students. More research is needed to explore these variations and their efficacy in more detail.

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BACKGROUND: Tutorial group effectiveness is essential for the success of learning in problem-based learning (PBL). Less effective and dysfunctional groups compromise the quality of students learning in PBL. AIMS: This article aims to report on the reliability and validity of an instrument aimed at measuring tutorial group effectiveness in PBL. METHOD: The items within the instrument are clustered around motivational and cognitive factors based on Slavin's theoretical framework. A confirmatory factor analysis (CFA) was carried out to estimate the validity of the instrument. Furthermore, generalizability studies were conducted and alpha coefficients were computed to determine the reliability and homogeneity of each factor. RESULTS: The CFA indicated that a three-factor model comprising 19 items showed a good fit with the data. Alpha coefficients per factor were high. The findings of the generalizability studies indicated that at least 9-10 student responses are needed in order to obtain reliable data at the tutorial group level. CONCLUSION: The instrument validated in this study has the potential to provide faculty and students with diagnostic information and feedback about student behaviors that enhance and hinder tutorial group effectiveness.

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