Figure 7.2: CanMEDS roles framework for physician competencies (Frank et al., 2014)
7.2.4 Current competencies and standards in South Africa
South Africa has three main professional registration bodies for HCPs – the HPCSA, SANC and SAPC. In 2014 the Medical and Dental Professions Board published an updated version of the Core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in South Africa (HPCSA, 2014). This document, originally published in 2012, represents an adapted and contextualised version of the CanMEDS 2005 framework that was agreed upon between the Medical and Dental Professions Board and the training institutions (Van Heerden, 2013). graduates from these programmes are expected to fulfil seven distinct roles. The HCP role is identified as the central role interlinked with that of professional, communicator, collaborator, leader and manager, health advocate and scholar. The medical expert role (espoused by CanMEDS) was replaced by HCP to encourage its adoption outside of medicine. Furthermore, this competency framework includes leadership and management competencies, which are considered essential for change management and for organisational efficiency and effectiveness. For each role key competencies are identified along with enabling competencies, referring to the means to achieve key competencies that involve others and a range of actions, decisions and values. Throughout
Professional Communicator
Scholar Collaborator
Health
advocate Leader
Medical
the document there is a recurring emphasis on patient-centred care; ethics;
commitment to primary healthcare including prevention; holistic care; patient, family and community decision-making; the need to understand and respect cultural, religious and ethnic diversity; and, the need for professional teamwork.
For graduates from nursing programmes, the SANC has developed a Bachelor’s Degree in Nursing and Midwifery Qualification Framework (SANC, undated), which provides detailed exit-level outcomes and their associated assessment criteria.
In addition to the expected technical knowledge and skills, other competencies include sound ethical and legal practice; managing multi-disciplinary teams and health facilities; conducting research; information management; personal and professional development; and, providing care that is responsive to the individual’s needs. Problem-solving, teamwork and communication are also emphasised.
The HPCSA document on training standards for physiotherapists (HPCSA, undated draft) outlines only technical skills required. However, the South African Society of Physiotherapy details in their Standards of Physiotherapy Practice (2012: 4) document the “performance and conditions that it expects physiotherapists to aspire to in order to provide high-quality physiotherapy professional services to society”.
These standards include: administration and practice management, communica- tion, community responsibility, cultural competence, documentation, education, ethical behaviour, informed consent, legal, patient/client management, personal/
professional development, quality assurance, research and support personnel.
The South African Qualification Authority standards document for occupational therapists (OT) outlines exit-level assessment criteria, which recognise the changing role of the professional and include the need to understand the historical, cultural, societal context; applying primary healthcare and health-promotion principles;
scientific knowledge, ethics and research, a people-centred approach; critical awareness of the “person-occupation-environment relationship”; effective OT practice in a range of contexts; critical thinking and problem-solving; teamwork;
and, mediation and human rights advocacy.
In their vision, mission and values for the pharmacy profession in South Africa (www.
sacp.org.za), the SACP outlines key themes that include leadership, providing high- quality accessible services, responsiveness including collaboration and innovation, and patient-centric services based on health outcomes. It also proposes values for the profession namely caring, leadership, collaboration, excellence and prof- essionalism. It seems likely that these would also form part of the competencies of pharmacists registered with the Council.
7.2.5 Conceptualising core competencies
During a mapping and matching exercise it becomes clear that the professions of medicine, dentistry, clinical associates, nursing, pharmacy, physiotherapy and occupational therapy have overlapping core competencies. Figure 7.3 illustrates the main competency themes and their related sub-themes from the professional regulatory bodies of these professions. Competencies in each of these themes and sub-themes are underpinned and informed by certain principles, values and contexts for HCP practice. In conceptualising a common set of competencies
for 21st century HCPs it is important that such competencies are aligned with the critical cross-field outcomes of SAQA.
Figure 7.3: Conceptual framework of overlapping competencies of health professionals in South Africa
7.3 Pedagogical approaches for achieving competencies
Questions about the best ways to achieve or learn the desired competencies address the issue of pedagogy in a competency-based curriculum. Pedagogy is the science and art of teaching and pedagogical approaches refer to the
Collaborative practice
Health advocacy
Healthcare practice
Information and communication
Management and leadership
Professionalism
Research and scholarship
Teamwork (interprofessional; multicultural) Team negotiation and conict resolution skills Team problem-solving
Accountability to team members and society Critical awareness; responsiveness (to health needs) Positive inuence
Mediation; cultural competence Human rights advocacy
Profesional care and caring Clinical reasoning; critical thinking
Interpersonal relationships (patient/client; family; others) Clinical and procedural skills
information management including technology Faciliative communication
Communication skills (verbal; written; other); listening skills Teaching of patients, groups, communities, students, others Organisation and provision of healthcare services and treatment Administration and management of healthcare delivery;
practice management
Leading and managing change
Excellent, accessible services; quality assurance High personal and professional standards Profession-led self-regulation; self-care Continuous professional development Life long learning
High personal and professional standards Profession-led self-regulation; self-care Continuous professional development Lifelong learning
Competency Themes Competency Sub-themes
Legal framework; ethical principles; human rights principles and specic contexts (global, regional, socio-political, health systems, clinical practice, primary healthcare)
overall perspectives used to plan and implement one or several teaching-learning strategies. According to Horsfall et al. (2012) contemporary pedagogies emerged from critiques of assumptions about teaching, learning and people, and new forms of knowing and knowledge. Contemporary theories around adult learning (andragogy), popularly applied in HPE, are also being challenged causing teachers to think differently about the way they teach and the way their students learn.
Speaking to the andragogic principle of intrinsic motivation, Larson (2012) mentions, for example, that adult students, who find themselves in a learning programme that they have not chosen or are not interested in, will not be motivated to learn.
Similarly, the (adult) student’s prior experience, presumed to be a rich source of learning can be a barrier to learning if such experiences are sparse, negative or limiting. The latter thus challenges how we optimise students’ abilities and prior learning, not just their knowledge, in a CBE approach (Frenk et al., 2010).
Contemporary pedagogical approaches for producing HCPs for the 21st century must take into account student conditions and characteristics, the social context and the educational philosophy or values statement of the institution. Focusing on the latter, it means that the vision and mission of the institution responsible for educating HCPs determines the type of graduate (competencies) and the pedagogical approach to deliver learning programmes for the development of core competencies. It is clear from the literature that educational systems and institutions that embrace societal change and foster progressive, adaptive approaches to HPE are best placed to produce HCPs for the 21st century Frenk et al., 2010; Hay and Marais, 2011; Van Heerden, 2013; WHO, 2013). Adaptive curricula, according to Hay and Marais (2011:230) that continually evolve in response to socio-economic, political and professional imperatives ensure ongoing institutional transformation. The transformative power of a university curriculum, they say, is evident when students’ knowledge and experience help restructure conventions within the institution and also become a vehicle for changing societies for the better over time.
7.3.1 Transformative pedagogy
Within the known descriptions of pedagogy, transformative teaching and learning processes induce meaningful change that steers the person or the institution into new directions – the common denominator being an improved quality of life for all people. Transformative pedagogy combines the elements of constructivist and critical pedagogy (Ukpokodu, 2010) that empowers students to examine critically their beliefs, values, and knowledge – the student is thus at the centre of the teaching-learning encounter. In Chapter 8, mention is made of developing faculty members as leaders who, according to Frenk et al. (2010) will act as “enlightened change agents”. The learning environment that optimises transformative pedagogy is characterised as democratic, emancipatory and empowering, during which students and teachers engage as co-learners, valuing each other’s contributions and constructions of knowledge. Students are active participants in the process of learning, which helps them find self-expression and their own power to affect social change. At the level of teaching and learning, Horsfall et al. (2012) outline some of the contemporary pedagogies, which include involving learners as active participants (student-centred learning), promoting dialogue, focusing on the
relationship between teacher and learners, and noting the importance of values, emotions, cultural background and ethics. Longitudinal electronic portfolios and portfolio coaches are becoming a prominent feature of competency-based learning as demonstrated by Hall et al. (2012). The roles of contemporary educators include facilitation, trust development, role modelling, constructive communication and interaction, reflective practice and active engagement.
Active engagement in the learning process to see the world in a new way has its origins in the work of John Dewey (Dewey, 1933) and is the crux of transformative pedagogy. From the viewpoint of learning, Mezirow (2000) defines transformative learning as a process of changing our familiar frames of reference, making them more inclusive, open (to change), reflective and discerning so that they may shape beliefs, attitudes and views that will be more authentic and justified to guide our actions and behaviours (Ukpokodu, 2010). In the pecking order of curriculum orientations (transmission, transaction and transformation), a transformative ap- proach requires total integration between the learner (L) and the curriculum (C) (Fig. 7.4), with a view to giving meaning and relevance to the learning encounter, characterised by humanism and social adaptation – the aim, to transfer learning into social action outside of the classroom (Carl 2014). In alignment with the work of Carl (2014) is the view of Frenk et al. (2010: 1924) of transformative learning as
“the highest of three successive levels, moving from informative to formative to transformative learning”, which is mentioned in Chapter 1.
Figure 7.4: Curriculum orientations: from traditional to transformational
As no single pedagogical approach is the answer to transformative learning, meaningful combinations may be preferred which take into account varying student characteristics and experiences, and different learning contexts. A study conducted in an Irish nursing school (Murphy et al., 2011) considered combining two pedagogical approaches – problem-based learning (PBL) and simulation.
These approaches were combined, according to the authors, to enable students to generate meaningful knowledge related to a particular patient problem within a community context (in a PBL tutorial group) and then demonstrate in a controlled-simulated setting how they would manage that problem. In so doing,
Transmission Transaction Transformation
Traditional Transformational
C = Curriculum L = Learner