'Watching a flower grow day after day’ – the value of workplace based projects in Kuwait

Objectives The purpose of this research was to explore the value of workplace based projects within a University of Dundee Educational Postgraduate Certiﬁcate/Diploma/Master Degree Programme in Kuwait: students' views and experiences. Methods A small scale exploratory case study was conducted. A qualitative approach using narrative analysis, online questionnaire and focus group interviews were carried out with participants all of whom are studying on the University of Dundee Postgraduate Certiﬁcate/Diploma/Master programme in Diabetes Care and Education in Kuwait. An inductive thematic analysis was performed which focused on examining topics within the data. Results The results imply that the positive implementation of workplace based learning, with implications for patient care by practitioners, with a corresponding satisfactory review from course tutors, is important from an educational and clinical perspective. Practitioners in this study valued the opportunity to both work and study in order to improve their performance by implementing their new found knowledge and so educate others and change practice. Conclusion Workplace based learning is important as it enhances the students’ knowledge and understanding due to their having to apply this within a practical setting.’ In turn this allows them the opportunity to reﬂect on that practical experience and so inform further learning. ’ The merit of workplace based learning in this study is emphasised as a key part of a Masters educational programme in Kuwait. of learning; service impact; support for learning and future changes.


Introduction
Over the last decade the culture of training doctors has changed from being opportunistic to structured, with planned cycles of activities blended with service. This in turn allows an evaluation of the performance and progress of the health professional from one level to the next. (Rethans et al., 2002). In the United Kingdom the Calman Report (Hunter & McLaren, 1993) and the General Medical Council Tomorrow's Doctors Outcomes 1993 (General Medical, 1993) were key policy documents which led to a radical transformation of both undergraduate and postgraduate training. Both reports support the integration of theoretical teaching with practical work along with continuing assessment and feedback to teachers and trainees. In contrast to the United Kingdom there does not appear to be any documented evidence in the Kuwait context to support a similar approach.
Workplace based assessment has been defined as the evaluation of a doctor's progress over time on their performance, in those areas of professional practice most appropriately tested in the workplace (Swanwick & Chana, 2005;Royal College of Physicians, 2014) . It should include a process of collection of evidence of performance over the different phases of training.
Due to the rising number of patients in Middle East and North Africa regions who are suffering from diabetes mellitus (International Diabetes Federation, 2017), along with the considerable therapeutic advances in diabetes care and the mounting complexity in health service delivery, practitioners need to continuously improve their proficiency and skills. Healthcare programmes must make sure practitioners are sufficiently equipped for modern day practice. The postgraduate Masters Diabetes Care, Education and Management program offered by the University of Dundee in affiliation with NHS Tayside, and the Dasman Diabetes Institute in Kuwait, provides the opportunity to utilise novel teaching and work integrated learning methods in order to meet the reality of the current workforce needs.
Throughout the Masters level programme, participants extend their subject knowledge and also strengthen their analytical, problem-solving and communication skills thereby increasing their professional effectiveness. (Muir et al., 2014). Learning is applied through workplace based study and project activity, relevant to healthcare and laboratory practitioners working in Kuwait, in both the public and private sectors. A variety of community and hospital based workplace based project ideas are encouraged. These include health promotion and service development projects which have a focus on the evaluation of existing programs and / or the establishment of new programs or procedures. They are a central component of an experiential learning cycle (Kolb, 1984) that includes a planning phase, an observation phase and a reflection phase on performance which is expressed in constructive feedback to the student. The experience essentially enables practitioners to contribute to a reformed health care delivery system whilst influencing the prevention, management and understanding of this significant and widespread disease in Kuwait.
The programme has a modular structure with a clear common framework. Participants choose an individual study pathway from four main areas: clinical provision, education, research and management. The modules enable students to choose the most appropriate topics for their stage of study and learning needs and also their own workplace environment. Modules are units of study of twelve weeks duration. All modules have two summative assessed assignments: Assignment One, a 2000 word report which links to a specific workplace based project based on the module subject topic which is conducted over six weeks; Assignment Two is a 1500 word reflective inquiry of the participant's professional learning as they undertake the project work for each module. The outcome of the project is a written report and reflection of the experience which is submitted to the University at the end of the Muir F, Equi S, Scott M, McConville K MedEdPublish https://doi.org/10.15694/mep.2018.0000124.1 Page | 3 placement and which may be used as the basis for the dissertation topic. The assessments are both formative and summative assessments, with feedback being an important component. It is essentially a learning opportunity which is undertaken frequently and regularly.
Workplace based learning is an important aspect of the course and underpins each module within the programme. It is a fundamental characteristic for the evaluation of the healthcare practitioner's progress over time and in their performance of professional practice, in the workplace. Participants are encouraged to consider their practice in relation to the specific and at times quite detailed themes explored in the modules. It is a desirable approach for a number of reasons: it allows the practitioner to focus upon a particular clinical area or skill, to gauge their own progression or it can help identify the underperforming practitioner so that remediation can be effected. For the educationalist it can highlight the failing student who may require support or who is unable to progress to the next stage of the programme (Eardley, Bussey, Woodthorpe, Munsch, & Beard, 2013) Whilst workplace based learning has been embraced in several countries including North America, Australia and United Kingdom, (Augustine et al., 2010;General Medical Council, 2011;Fortune & McKinstry, 2012) there would appear to be little research pertaining to its value within the postgraduate healthcare and laboratory practitioners' context (Kuwait).

Aim
The aim was to provide students with an opportunity to express their views and experiences of the value of workplace based projects within an Educational Master Degree Programme in Kuwait.

Design
Situated within the qualitative paradigm of research, through the collaboration of researchers and practitioners, an exploratory case study method was adopted to reflect the shared nature of the experiences of participants in one educational location.
Previous low levels of participation for data collection in research, in the Kuwait setting, required special effort for successful recruitment. Thus, to gain a range of experiences and to ensure triangulation, data was collected through an online questionnaire, focus group interviews and narrative analysis of reflective coursework. Triangulation involves using more than one method to gather data, such as interviews, observations, questionnaires, and documents to increase confidence in the interpretation (Denzin, 2006).
The online questionnaire, with open ended questions, was designed to give participants the freedom to respond and give their own opinions via free text responses. This enabled information that is unique to individuals to be gathered which has a greater depth of meaning to explore the participant's experience, values, beliefs, thoughts and feelings. Questionnaires consisted of seven key statements and multiple sub statements designed to ascertain the students' experiences of the programme. This included questions relating to: the implications of workplace based study/learning for practice, positive experiences and challenges; its effect on others learning, staff; impact on patient care and practice; value of the modules within the programme as preparation for practice; future development plans to implement change in practice; changes personally and professionally. Questionnaires were helpful in maintaining participants' privacy. The responses (n=15) were anonymised by a staff member thus confidentiality was maintained.
Two focus groups were carried out: group one n=three, group two n=two. The recommended number of people per group is usually six to ten although some researchers have used as few as four (MacIntosh, 1981;Kitzinger, 1995). Numbers of groups vary, some studies using only one meeting with each of several focus groups, others meeting the same group several times (Burgess, 1996). Due to the low number of participants recruited, each group was interviewed once and each interview lasted approximately sixty minutes. One of the well-defined features of focusgroup interviews is its group dynamic. Hence the type and range of data generated through the social interaction of the group are often deeper and richer than those obtained from one-to-one interviews. Group interactions between participants gave insight into attitudes, opinions, perceptions and people's shared understandings of everyday life.
An interview guide was used to provide a framework for the interview and maintain consistency of the questions asked as it is in the comparison and contrast that themes and patterns emerge. In analysis, we strove for theoretical saturation which is only possible with consistency of questioning (Kreuger & Casey, 2009) Participants were given a brief introduction to the purpose of the study and an explanation of what they were being asked to do. The participants were interviewed in a place convenient to them and for as long as required. This took on average approximately sixty minutes for each group.
A basic human way of making sense of the world is through narrative and the 'storied lives' we live (Riessman, 1993). It is constitutive of reality as well as of identity/subjectivity. Narrative analysis was carried out on student's reflective coursework (n=6). Data was collected and analysed until data saturation occurred. Saturation of data was evident when a range of ideas were heard, recurrent patterns and themes emerged and no new information gleaned.

Participants
The participants in this study were pharmacist, healthcare and laboratory practitioners on the programme. The total number of participants was twenty four; they had completed one to six modules. Many students have studied internationally and are familiar with western universities. The majority have a sound comprehension of the English language even though it is not their first language.
Participants were recruited through the participant year lists 2011-2014. The reason for choosing these individuals was that they were easily accessible. We are directly involved in the teaching of participants. Data was derived from a single case and not selected on a random basis. Data was collected from as many people who willing to participate and necessary to gain the information required (Kvale, 1996).

Ethics procedure
Dundee University Ethics Committee confirmed that the project was carried out according to the ethical standards upheld by the University of Dundee (reference number -UREC 14050). Ethical considerations, as defined in the British Educational Research Association Guidelines (British Educational Research Association, 2011) applied all through the research.
Anonymity and confidentiality assurances were given so that the rights of the individuals were not compromised. Participants were given introductory information, via email and within the online questionnaire site, with the details of the study, why the study was being carried out and the format of the questionnaire. All participants provided consent at the beginning of the study period and were advised that they could remove themselves from the study at any time without any bias to them. This provided a degree of proof that the participant was aware of the nature of the study and they had given informed consent.
One particular ethical issue considered in the focus groups was the handling of sensitive material and confidentiality as there was more than one participant in the group. Participants were encouraged to keep confidential what they heard during the meeting and we assured anonymity of the data from the group. From the outset the facilitator clarified that each participant's contribution would be shared with the others in the group and the facilitator.
A pilot study was conducted with two members of staff who would not be participating in the main study.

Analysis
The questionnaire online data was downloaded, as a spreadsheet, and codes added to each respondent's questionnaire, in turn. A second researcher, a member of academic staff, checked the data for accuracy.
All data was analysed using an critical process which involves a number of interrelated stages to classify and arrange data according to key themes, concepts and evolving categories as they relate to the research question. Internal validity was assessed in various ways including reflexivity, triangulation and peer judgment (Cohen, Morrison, & Manion, 2011). Triangulation and data validation was informed by the level of consensus of the groups producing convergence among the different sources of information to form the themes in the study.
To further confirm the validity of data interpretation a peer debriefing method was implemented whereby data was secondarily analysed by an impartial source. Resulting analyses were compared to ensure concurring themes and decrease the likelihood of researcher bias.

Results
The results from the three data sets have been combined. The main themes identified in the analysis are as follows: understanding of workplace based learning; influencing the professional practice of others through workplace based projects; multi professional teamwork; improved Patient/Physician Relationship; challenges of workplace based learning in practice; positivity towards the workplace based projects; applying theory to practice; motivation for study; benefits of learning; service impact; support for learning and future changes.

Understanding of workplace based learning
Students indicated that their understanding of workplace based learning included: studying and working at the same time; the 'real' workplace; improving performance; enhance the quality for patient care and improve practice; implementation of knowledge.
"There are some ways and theories…to maximize the learning outcomes from the event and help improve work quality" Student 5: Reflective coursework.
"I understand that work places study is… [when] I study and I work at the same time…improving the outcome of my patient and by improving myself own knowledge and have reflect, and how to reflect." Student 1: Focus Group 2. "I think the purpose of [workplace based study] is to enhance quality of our job toward our patients at our own work place" Student 5: Questionnaire.

Influencing the professional practice of others through workplace based projects
Some students thought that the modules and their involvement in workplace based projects influenced the professional practice of others; they were involved in educating their colleagues; opportunities to facilitate others learning. One student noted specific changes that were made to the way his colleagues interacted with patients: "In this project the team started…to develop new insights that develop the service provided in the clinic" Student 3: Reflective coursework.
"The Quality Improvement was very nice for me because I used concept of quality improvement to change…I use Plan, Do ,Study, Act [a model for improvement and testing change] to improve things, to try new ways…" Student 3: Focus Group 1.

Multi professional teamwork
Students appreciated the value of the team's roles and suggested changes that could be made with colleagues for ways of working in the future, through education: "Since this project is a team work, nurses need to be involved and all on board. Team members need continuous motivation and supervision and the whole project objectives need to be reemphasized to them. I feel I have to appreciate self-motivated nurses and to keep promoting and encouraging other nurses" Student 4: Reflective coursework.
Similarly participants discovered a role in educating colleagues by transferring and sharing knowledge to change practice; they identified an improvement in their working relationships and communication with colleagues: a change in their perception of the workplace whilst making changes to their usual working routine through the application of their new knowledge and skills.
"This project is a great chance to apply what I learned…in my clinic and to implement a change with my colleagues and encourage the team work." Student 1: Reflective coursework.
"I transferred the knowledge I get from the programme… to all my colleagues the pharmacists, and this will translate I hope, into improved patient care" Student 3: Focus Group 1.
"… these projects allowed them [the students] to experience new ways of learning that they were not used to before…" Student 6: Questionnaire.

Improved Patient/Physician Relationship
A significant theme, which students referred to, included an improved patient/physician relationship; patients as partners; educating patients which resulted in patients taking more responsibility for the management of their diabetes: "I decided to start my project putting my patients in the heart of my interest. Patients benefited by becoming partners rather than dependents" Student 4: Reflective coursework. "I learn that if you have good knowledge you can treat a patient well and you can understand them more" Student 1: Focus Group 2.
"Concentrating on the good communication and patient awareness about the facts of his illness and good family learning to share in the programmed health care" Student 1: Questionnaire.

Challenges of workplace based learning in practice
The majority of students identified challenges which they faced when trying to implement change during their workbased projects. These included staffing constraints, lack of facilities, equipment and resources; lack of staff education, staff reluctance to change and lack of enthusiasm for change; culture and language, and the political climate.
"I realized that, developing a culture of reflective practice in the workplace does not occur spontaneously or overnight" Student 3: Reflective coursework.
"Sometimes there is resistant from like higher management, that maybe if you have like a new vision, or a new thought" Student 2: Focus Group 1. "Sometimes it is not possible to implement a workplace project effectively due to lack of facilities and equipment" Student 5: Questionnaire.

Positivity towards the work based projects
Students spoke about the positivity, enthusiasm and encouragement they had received, from colleagues in the workplace, whilst carrying out their projects: "The head of the…clinic was so excited… She said "I hope you can continue and I will support you -we really need to change". This word was like charging my energy and passion to work and implement my change waiting for a great outcome" Student 1: Reflective coursework. "I was amazed by the results achieved by the nurses. I asked one of the nurses one day about her learning while…educating them [patients] about SMBG [she said] I found out that by communicating with patients, they feel that we care for them and we are like their partners in treating their ailments. I feel glad that in simple ways I helped patients in managing their diabetes). That really was a wonderful moment" Student 4: Reflective coursework.
"So many of my colleagues were really supportive, they help me" Student 3: Focus Group 1.

Applying theory to practice
Students discussed how they applied what they had learned from the modules to their workplace: "the work based projects that I did for each module… now [I have] finished the project for the embassy…an educational intervention that I spread to all my colleagues, the pharmacists across Kuwait, so that was supporting the learning of others" Student 3: Reflective coursework.
"…take all the values from all these modules and to implement in my staff, and even though I come to the end of each module, I use my colleagues, the whole assignment, for the whole staff so at least they will Muir F, Equi S, Scott M, McConville K MedEdPublish https://doi.org/10.15694/mep.2018.0000124.1 Page | 8 benefit from the idea. It was really great" Student 2: Focus Group 1.
"I wanted to educate the staffs on diabetes and exercise but I didn't know how to start. Starting with "Facilitation"[module] and continuing with "Training the Trainers"[module]… allowed me to pass the knowledge in a very effective way" Student 13: Questionnaire.

Motivation for Study
Many students discussed their motivation to study this Masters course. This included the blended learning offered by the programme; the desire to teach others; the desire to learn something new and for lifelong learning: the hope of improving care for their patients: "The most important thing to me when I took this course… is to support my lifelong learning as a pharmacist" Student 2: Reflective coursework.
"It's like I want to study… it's like improving myself as well as my staff and the whole organization" Student 2: Focus Group 1.
"I am interested to make improvement in my workplace" Student 12: Questionnaire.

Benefits of learning
Students alluded to several positive experiences of workplace based projects: how the process of learning benefited them as individuals; change in self-perception: value of the module content and its value for practice: "I enjoyed acquiring learning during working in the project; it was like watching a flower growing day after day" Student 4: Reflective coursework.
"… the modules…all these assignment…push all of us, to do the change" Student 2: Focus Group 2.
"I feel more responsible on changing things. Previously, I just accepted the defects and cope with it" Student 3: Questionnaire.
Some students experienced difficulties with this new found learning and the challenges encountered with various aspects of the course and the modules: confusion with theoretical concepts for example the concept of professionalism and leadership; "Everything in this course was different and sometimes harder… before starting the course I had preparatory/introductory tasks. Solving those tasks was not as easy as expected. At the beginning, I was not able to solve all tasks. Some were easy, others were hard" Student 5: Reflective coursework.
"How to reflect what you learn by video consultation, which is the most challenging because it's hard to do this is the first time to record, I record myself how to consult other people" Student 2: Focus Group 3.

Service impact
A few students discussed the possibility of using their newly acquired knowledge to improve medical care and improve patient care. Only one student had not witnessed any change in patient care.
"the work based projects that I did for each module… now [I have] finished the project for the Muir F, Equi S, Scott M, McConville K MedEdPublish https://doi.org/10.15694/mep.2018.0000124.1 Page | 9 embassy…an educational intervention that I spread to all my colleagues, the pharmacists across Kuwait, so that was supporting the learning of others" Student 3:Reflective coursework.
"All the skill that we are learning it's improving the whole place and for sure this will have a good impact on the service that we are providing for the patients" Student 2: Focus Group 1.
"Global thinking of the patient, not only from the clinical point of view but also from the social and psychological aspects [are potential changes]" Student 15: Questionnaire.

Support for learning
Students discussed how the support from the course teachers and their peers influenced and benefitted their learning; the online discussion forum was also highlighted: "With more explanation and examples from our tutors it was easier" Student 1: Reflective coursework.
"…the online forum posts… were of great value for me in raising my understanding and awareness of the vague points of my project" Student 3: Reflective coursework.
"In general teachers were very supportive and always give constructive feedback" Student 4: Questionnaire.

Future Changes
A few students suggested areas where teaching support could be developed: "Increase the face to face days. And increase the online activities [are potential improvements]" Student 2: Focus Group 2.
"I loved to sit and listen…extend more time on this and to have an easy access to the online library" Student 1: Questionnaire.
"[Teaching support] must be more informative and goal directed" Student 2: Questionnaire.

Discussion
Literature supports the value of workplace based study as a rich source for learning (Grieveson, Kirton, Palmer, & Balmer, 2011;Poell & VanWoerkom, 2011;Fortune & McKinstry, 2012) . Students in this study valued the opportunity to work and study, to improve their performance whilst implementing their new found knowledge to educate others and to change practice. Students' placed value on this learning to enhance the quality of the work, for them and their co-workers, while improving care for the patients with whom they worked. Learning whilst working can lead to enhanced clinical practice, better patient/physician relationship and the service offered to patients (Fortune & McKinstry, 2012). Students maximised the opportunities to work collaboratively and towards a positive learning outcome.
Previous research suggests that challenges may be encountered when implementing a workplace based project (Kalsi, Kalsi, & Fisher, 2013). Students overcame challenges, such as, resistance by staff to change practice, a lack of facilities and equipment and time. Project placements enabled students to work through messy, ill-defined problems in realistic team-based environments (Fortune & McKinstry, 2012). Students maximised the opportunities to work collaboratively and towards a positive learning outcome.
While literature suggests that the current implementation of workplace based learning is at odds with its intended use, formative functions are overlooked in favour of the summative and a 'tick-box' exercise which negatively impacts upon training opportunities (Ali, 2013). Students' in this study valued the on-going support and constructive feedback from their teachers. Feedback in a training environment is essential to promoting positive and desirable development (Archer, 2010;Bruce, 2010;Bok et al., 2013). Assessment for workplace based learning requires meaningful feedback with each assessment (Bok et al., 2013).
The assessment has value in so much as formative assessments can prompt supervision, feedback and reflection (Mitchell, Bhat, Herbert, & Baker, 2011). Two students indicated the need for more informative and online activities, highlighting the significant role of workplace based learning as part of the professional's experiential learning (Grieveson et al., 2011) and the value of feedback to deepen students' learning (Al-Kadri, Al-Kadi, & Van Der Vleuten, 2013).
Participants on this Master's degree programme are required to be self-directed learners, demonstrate better thinking skills, and critically appraise evidence (Knowles, 1978;Brookfield, 1984). This was evident by the way in which participants questioned established work practice and this in turn enhanced depth to their learning (Ramsden, 1992). Project placements are likely to contribute to the development of skilful practice to a greater extent than traditional professional practice because of the self-directed, political and collaborative nature of the experience (Billett, 2009).
Workplace based learning has been adopted in areas across the globe (Augustine et al., 2010;Fortune & McKinstry, 2012;Atreja, 2013;Royal College of Physicians, 2014). Distinct from other studies this case study has informed workplace based learning for diabetes care education in Kuwait. Learning, as indicated by individuals, through formal activities provided on-going preparation and supports integrating theory with practice. The work further verifies that developing working partnerships has value and meaning for the future. This programme has encouraged healthcare practitioners in Kuwait to consider the theoretical knowledge that is required to support their practice. The qualitative research described has identified significant issues and concepts, in terms of the value of workplace based learning, to direct the participant's learning and so lead to improved clinical practice and patient care.

Conclusion
In contrast to previous work, this practical method has added meaning to workplace based learning in the current Kuwait setting through exploration of the students' experiences. The positive implementation of workplace based learning and satisfying return for practitioners, with implications for patient care, is important from both an educational and clinical perspective.
This small scale study explored the value of workplace based learning within an educational programme from a Kuwait perspective. Therefore the findings may not be generalizable. While data was triangulated the sources yielded a low response to participate in the study. The overall respondents for the focus groups and questionnaires were variable. Nonetheless, there was a degree of triangulation. The low response rate may be due to lethargy among students as they are asked to provide feedback during the programme continuously as part of curriculum development. The participation rate was compensated for by the detailed responses provided by the students.