Training of health professionals can be deliberately structured to enhance rural recruitment by exposing the trainees to the realities of rural life and practice through Community-Based Education and Service (COBES) programs. During this period, students spend a part of their training in the community they are likely to serve upon completion of their study. Student engage and empower local people in the community to address their health needs during their placements, at the same time they are learning from the people. During community –based education, students are constantly supervised by health facility staff and academic staff from the University to ensure that the intended objectives are achieved. The aim of the present study was to explore student perception on field attachment of supervision support from hospital staff and academic staff during their community-based education, and service (COBES) placement and to identify ways in which the student learning can be improved.

A qualitative, explorative study was conducted using open ended questionnaire during COBES placement of the University of Namibia third year undergraduate medical students for 2013 to 2015 in Namibia. Most of the students reported to be happy with the supervision from the hospital staff however, they expressed some challenges that affecting supervision negatively such as: academic staff spend very short time with them, shortage of staff at health facilities as the ratio of staff to patients is low which negatively affect their supervision and insufficient orientation of cite supervisors on the expectation during COBES placement.

1. Introduction:

Field attachment is a field –based practical training experience that prepares trainees for the tasks they are expected to perform on completion of their training. Currently field attachment in the University of Namibia, School of Medicine is known as “Community Based Education and Services (COBES). Field attachment in this context refer to any approved field based practical work carried out by staff and students for the purpose of teaching and / or research in places outside the University control but where the University is responsible for the safety of its staff, students and others exposed to their activities. During primary health care attachment a student should not be left alone, to work on their own but under the supervision of senior staff to supervise their activities and also to guide them. There are two distinct level of supervision: site level day to day-to- day supervision by the field supervisors and the academic supervisors from the School of Medicine. The academic supervisors should visit the site at least once for 2 to 5 days in four weeks of student attachment to primary health facilities. During the visit, the academic supervisor interacts with the students on field attachment, field supervisor and other relevant officials and also visit the attachment sites to acquaint themselves with the activities of the students.

Supervision is an intervention that is provided by a senior member of a profession to a junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the junior member(s), monitoring the quality of professional services offered to the clients she, he, or they see(s), and serving as a gatekeeper of those who are to enter the particular profession ( Barongo & Lukolo,2015 ). The field attachment, being part and parcel of the academic program, must be assessed, graded and the grades should contribute towards the award of a student.

There are unique competencies and skills involved in supervision that allow the supervisor to help the supervisee. In addition, supervisors incorporate various modes and interventions to facilitate supervisee development.

Dialogue can develop between supervisor and supervisee as a means to share personal styles and preferences for frameworks and interventions to be used in supervision. In the clinical setting, students who experience ‘enriched’ environments of care and learning can have their perceptions of transformed and are more likely to view it as a positive career choice. Positive environments are those where the student is welcome, where a nominated professional supports and challenges the student, where staff provide learning opportunities and are approachable, knowledgeable and skilled, and where working with clients in a holistic manner is valued. It may be coordinated and overseen by a person employed by the University or by a member of the health service (clinical educator, registered nurse or clinician (Crampton PES, 2013).

As part of the training endeavour, medical students need to be given opportunities to observe and actively participate in clinical interactions in order to acquire the knowledge, skills, behaviours, attitudes and judgment required for future practice. This occurs through a process of graduated responsibility, whereby students are expected to assume increased responsibility as they acquire greater competence. For this to occur safely, supervisors must assess the competencies of the students they are supervising on an ongoing basis.

During the educational process, also gains an understanding of the values of the profession, as well as their individual duties to the patient, collective duties to the public, and duties to themselves and colleagues (Chang LW, 2010). These are all essential components of medical professionalism. Students cultivate attitudes and behaviours about professionalism through observing their supervisors. Positive role-modeling is therefore of the utmost importance and supervisors are expected not only to demonstrate a model of compassionate and ethical care but also to interact with colleagues, patients, patients’ families, students, and other staff in a professional manner. An understanding of the responsibilities and expectations placed on supervisors is essential for ensuring patient safety in this complex environment. The University of Namibia, School of Medicine deploys third year Medical students to various regions primary health care facilities each year for a period of four weeks, to produce practically oriented graduates that meet the required medical profession related competences of the community of their future service. Through community medicine attachment, medical students are enabled to associate themselves with the health and medical needs of the communities, this association will enable the students feel their own gap on these health issues to address them, or to be able to manage them. This study was conducted to explore the experience of third year medical students on field placement supervision at Primary Health Care settings in Namibia.

2. Methods:

2.1 Study design:

This is a qualitative research design to explore the experience of third year medical students on field placement supervision at Primary Health Care settings in Namibia during the year of 2013, 2014 and 2015 field placement. Students were given a questionnaire to complete.

2.2 Study setting:

The study was conducted at Primary Health Care settings in all regions in Namibia between 2013 and 2015 during Primary health placement.

2.3 Study population and Sampling:

The population for this study consisted of 185 third year medical students, during 2013, 2014 and 2015 academic year at the University of Namibia, School of Medicine. Purposive sampling was used and all the students that were placed in the field and willing to participate, participated in the study.

Inclusion criteria

Participants should be third year undergraduate medical student the University of Namibia, in 2013 and 2015.

2.4 Ethical consideration:

The study respected the right of participants. Participation was voluntarily, those who did not want to participate were not forced to participate. The researched obtained informed consent from participants.

2.5 Data collection:

Data was collected using a self-administered open- ended questionnaire and this was only for third year medical students placed for field attachment at primary health facilities during 2013-2015 primary health care attachnent in Namibia.

2.6 Data analysis:

Data analysis was carried out manually following an iterative process, a valuable technique in qualitative research methods. The analysis involved identifying patterns of similar meaning within the data and labelling as codes. This was done to synthesize valuable and meaningful information. The codes were related to each other and clustered leading to the emergence of broader categories of data. These categories were used to come up with themes that were used as findings.

3. Results discussions:

Two main themes and sub-themes were generated from the findings. The quotes provides illustrative example of the theme and sub- themes that supplement the findings.

Themes Sub-themes
Field supervision adequacy during field placement
Supervision challenges during field placement and way forward

Summary of students’ experience on field supervision

3.1 Field supervision during field placement positive aspect and constraints:

3.1.1 Supervision from Hospital Staff:

This theme describes how adequacy is field supervision from the hospital staff. The majority of students highlighted some aspects to indicate that supervision were sufficient from the hospital staff as highlighted by extracts from the participant responses:

“Adequate, we had to do always procedures under the supervision and present cases to doctors and get constructive comments”

“Hospital nurses and doctors gave us much supervision, letting us show up”

Another one said:

“Doctors and nurses always available for us”

One student had this to say:

“There was control strategies and very strict, to me it is effective, thus why we have a wide range of knowledge”

“Very adequate, we worked closely with doctors and nurses, nurses accompanied students during outreach, and we had a very capable and organized supervisors, good planners”

“Another student mentioned the following statement:

“Beyond expectation, it was beyond what I expected, we were touch a lot and took part in many activities. We were exposed to many things we did in class”

Many students were happy with the supervision from health care facilities staff, however they were also concerned about the shortage and workload of the staff that they cannot attend to students even they which to do so, the following statement is an evidence:

The following quotes support the statement:

“In some units supervision was not adequate because of staff shortage, doctors are so busy because of shortage, and sometimes there is no enough time to attend to us”

“Doctors are busy and very few, and too many patients, no time to give us attention even they want to do so, I just pity them”

Another student had this to say about shortage of doctors, that even they are willing to teach them, they are busy and few:

“Nurses and doctors are eager to teach”

Hospital staff shortage is a crucial in Namibia.

3.1.2 Academic Staff Supervision:

The study found out that students were not satisfy by academic supervision, they mentioned that academic supervisors spent too short time at sites.

The following quotes is an evidence to the statement:

“It could be better if academic supervisors spend a day or more days at hospital and also to enquire more information on our strengths and weaknesses”

Another student stated as follow:

“More visit from lecturing staff is needed, supervision from school came today, and I personal didn’t get to talk to them as we went for outreach”

The student had this to say:

“I don’t remember seeing institutional supervisor, they did very few visit to check on us, but they motivated us and encouraged us”

However there is also a concern from the students that the time academic supervisors spend at hospitals is too short, they need to be at the same hospital at least for three to four days. The following quotes serve as an evidence:

“Academic supervisors to spend more time working with field supervisors to best evaluate the students”

“Academic staff to spend more time at health facilities”

“Short time spending with students”

“Once academic supervisors come over, they seem to have limited time, they spend few hours with us, sometimes in hurry”

This is also go along with field attachment time, students expressed that four weeks for field attachment is too short, to be extended to six weeks. Below is the quote:

“Our time is too short to catch up what we are learning, I wish it can be six weeks”

Meanwhile some students felt that the supervision from academic staff was adequate by said:

“It was excellent, academic supervisors comes over,”

“Very adequate, academic supervisors checked us frequently for any problem”

“Very adequate, academic supervisors comes every week, inspected our accommodation on the first visit, asked about any challenges that we are facing”

When students are within the communities, a university –trained supervisor coordinates student activities together with the health facility staff, they facilitates learning and caries out students assessment. Assessment of students involves continuous progressive assessment of weekly activities entered in logbook, tutorial assessment and oral presentation of students’ activities. This supervisory role involves physical visits to health facilities to address any concerns and fear or challenges the students could be facing. Although this arrangement has been going on at School of Medicine, University of Namibia for quite some time, it is a concern for students that it is not adequate. Literature is replete with evidence suggesting that the quality of student supervision during field attachments is related to overall student satisfaction with the student placement ( Mubuuke, 2015 )

3.2 Supervision challenges during primary health field attachment and way forward:

The students in this study reported some challenges they experienced during field placement as follow: the need for clinical mentors, staff shortage, field placement time too short and poor health facilities staff orientation on student placement activities. The student felt that having field supervisors and clinical mentors spending as much time as possible with students will enhance proper evaluation of field attachment. This was clearly mentioned by most of students.

The students proposed some points to be taken into account to minimize the challenges

“We would want to have clinical mentors spending as much time as possible with the students at the respective facilities”

The other one said:

“Facilitators should spend more time at facilities”

“It is needed for COBES supervisors from school to be with students for a week”

“Supervisors should visit more frequently, by having supervisors on site evaluating how well the procedure in log books are done”

Students also feels that the health facilities have to be provided with guide on what students expected to do, such as evaluation, since evaluation is a crucial aspect of the supervision process, and one that is often the source of discomfort for both the supervisor and supervisee. the following quotes are typical:

“School should give guide to the health facilities, what students expected to do”

“Supervisors should also submit the evaluation for student performance”

‘Evaluation tool should be discussed with site supervisors”

“Log book self is sufficient for evaluation but the delegated field supervisors from hospitals should be properly informed, and oriented”

They also feels that evaluation should base on the activities performed during field attachment”

“Having more detailed logbooks with an evaluating system to score how students are progressing”

“Evaluation should be done during field attachment formally based on the clinical skills performed”

Students also feels that co-operation between the school and hospital staff is crucial to empower the process of supervision by said the following:

“It require co- operation between site supervisors and the academic supervisors”

The need for field attachment mentors is crucial to supervise students during field attachment, to ensure adequate evaluation for student performance and that students are well attended to, and well equipped with necessary skills during field attachment.

4. Conclusion:

This study has revealed that although students were happy and satisfied with field attachment

supervision, there are some concerns such as staff shortage, attachment time too short, short. Time that academic spend at health facilities and the need for proper orientation for health facilities staff to enhance the professional functioning of the supervisor and to assure quality of care.