The experiences of diplomates of a postgraduate health science education programme: a qualitative study

Background: An increasing number of interventions have been reported over the last ten years in the area of faculty development. We define faculty development as a series of planned activities aimed at preparing individuals for their teaching role. The planned activities include short workshop sessions of 2-3 hours in length and a 3-day introductory course in teaching and assessment. In 2014 we commenced a postgraduate diploma in health science education in a Faculty of Health Sciences in South Africa. The purpose of this study was to obtain perceptions from the first group of participants about the programme. Methods: The qualitative paradigm was chosen for this study and two focus groups were conducted with a total of ten participants. The focus groups were audio-taped and transcribed verbatim and the transcripts were analysed using Tesch’s approach (Cresswell, 2014) for qualitative analysis. Results: Four themes were identified: a new language, being a student again, seeing students as adult learners and a whole new world. The first theme was characterised by feelings of anxiety and loss as they grappled with understanding the language of the discipline of pedagogy. Participants generally enjoyed being a student again and this resulted in some reflection on their own students and seeing things from the student’s perspective. The last theme describes the new world in which participants felt that they now planned teaching and learning with insight rather than from their previous knowledge base of learning by doing and observing. Conclusion: The findings of this study suggest that the postgraduate diploma is appreciated and that participants have learnt from their experiences. Ways must be found to support those who have completed the programme in taking their learning forward and implementing new knowledge. McInerney P, Mabizela S, Moch S MedEdPublish https://doi.org/10.15694/mep.2018.0000207.1 Page | 2


Introduction
Faculty development or staff development as it is also known has been the subject of considerable study over the last few years. In a 10-year update of their systematic review, Steinert et al (2016) report a substantial growth in the field of faculty development. Of the 111 interventions analysed in their review 19 (16%) were described as longitudinal programmes and comparing this with their review in 2006, this constituted an increase from 10% to 36%. Only seven studies had adopted a qualitative design.
The definition of faculty development which is most appropriate to our initiatives is a planned series of events which is aimed at preparing individuals for their roles as teachers, clinicians and researchers for the purpose of enabling the institution to meet its goals, vision and mission (adapted from Bland et al., 1990). In developing teachers for their role, Steinert (2010) describes a process of activities that progress across two intersecting dimensions: the individual to group activities and the informal to formal approaches, with mentorship at the core. In the environment of a university Faculty of Health Sciences, the emphasis on research and the demand to publish, the development of teaching skills and expertise is frequently neglected (McLean et al, 2008). Many have developed their skills by doing and observing, with little attention to reflection on the teaching experience (Bland et al., 1990). This places many of our teachers in the lower left hand quadrant of Steinert's (2010) model (individual and informal). Our faculty development model includes short workshops and a three-day introductory course that covers essentials such as theories of teaching and learning, methods of teaching and assessing cognitive knowledge, skills, decision-making, communication and attitudes. Uptake of these workshops and the short course is variable. Reasons why faculty attend these workshops and courses has not been formally studied but when introducing themselves at the start of each session, participants are asked to state why they have come and what they hope to get from the session. The reasons given often refer to the fact that they have never had formal education in how to teach and have just done it as they think best or the way they were taught. Other reasons are that the session will act as a yardstick against which to measure oneself and see what they might be doing correctly, but also that they will "pick up some tips".
Many participants in the three-day workshop had expressed an interest in learning more about the field of health science education and in 2014 we introduced a postgraduate diploma in health science education. The diploma consists of four modules, namely, theories of teaching and learning, methods of teaching in the health sciences, curriculum design and assessment in the health sciences. The diploma was offered on a part-time basis only in 2014. Fourteen students commenced in 2014 and 21 in 2015. In both years students were from a variety of health science disciplines, including medicine, physiology and anatomy, emergency medicine and dental radiography and had varying years of teaching experience, with a pre-requisite minimum two years' experience. Each module was preceded by a reading list which was sent to students six weeks before a contact week. Attendance at the contact week was compulsory and consisted of formal sessions, discussions and group work. Following the contact week, one assignment was submitted each week for three or four weeks followed by a final assignment four to six weeks later. The latter counted as a final written examination. Each assignment required the student to apply information learnt to his/her own teaching practices. At the end of 2015, 24 participants successfully completed the diploma. The formal programme of short workshops and the postgraduate diploma move teachers to the upper, right quadrant of Steinert's model (2010).
Given that this was the first group of participants to experience this diploma it was important to obtain their perceptions of the diploma.

Methods
A qualitative approach was chosen to explore diplomates' experiences of the programme. We explored three main areas: (i) the experiences of those who completed the programme in 2015; (ii) the perceived benefits of doing the course;(iii) changes that completing the course had made to teaching. Diplomates who completed the diploma at the end of 2015 were invited to participate in a focus group. The date and time chosen was one suitable to the majority of those who expressed a willingness to participate in the focus group. Given that several were unable to attend because of having to fit it into their schedules, there were six participants in the first focus group. For this reason another focus group was organised and a further four participants attended. The ten participants were representative of the disciplines named above. Ethics permission to undertake the study was obtained from the Committee for Human Research Ethics Committee (Clearance Certificate No M160404). Ethics clearance was subject to focus groups being facilitated by persons external to the programme. Compliance with this condition was adhered to. The focus groups were held in a neutral venue in the faculty. The discussions were audio-taped and transcribed verbatim. Data were analysed using Tesch's approach (Cresswell, 2014).

Results/Analysis
Four themes emerged from the focus group discussions. These were: a valuing of the module on theories of teaching and learning, which participants described as a new language; doing the course opened up a whole new world and seeing students as adult learners and being a student again. The numbers in brackets after quotes refer to the participant who made the statement, where F refers to first (1) or second (2) focus group and P the participant number.
A new language Being exposed to readings related to the theories of teaching and learning created a disturbance for the participants. Participants described feeling lost in the language of the discipline. One participant stated: I remember spending hours reading those articles and looking up every third word trying to figure out what the article was trying to tell us. (F2P7) This feeling caused some anxiety for a more senior participant who stated that: I thought I was above average in terms of being a student, and then once I received the reading materials, I felt quite lost in terms of the volume and new concepts. In listening to colleagues, a lot of them seemed quite educated in terms of the language being used. That scared me quite a bit. (F1P5) This participant described how these feelings were overcome when s/he read an article about nurses who had gone back to study as older students. The article described the phases these nurses had gone through in adjusting to their new situation and being students again. This article provided the participant with a sense of relief that what s/he was feeling was not unusual. Another source of help came from colleagues within the group. Chatting over teas and lunches, it became evident that s/he was not alone in feeling overwhelmed.
Another participant described initial feelings as: … being immersed in a whole new university of language, but within the first day or two, the contact sessions worked. Despite feelings of anxiety, this module was described as the most influential module (F1P4). For this participant this was when we started to understand the language of education and a lot of the principles.

Being a student again
This theme describes feelings of excitement and personal growth. For several there was enjoyment in being a student again and being part of a multidisciplinary learning group.
It was interesting being a student again, I enjoyed that. It kinda helped me relate in some ways to students, … it was interesting. (F1P2) Another participant noted that: I really enjoyed the experience of being in a multidisciplinary group and having opinions and perspectives … which became like a small community of practice. I enjoyed that. (F1P3) One participant felt that an important factor was that people were doing the course because they wanted to and not because they had to do it. The fact that it was a multidisciplinary group added to the enjoyment. This was expressed as follows: We were all very excited about doing the course, it was a new course. People who were doing it were so excited about the material and I think that did carry through, that no one sat out on things, or did not want to participate. The other big thing was … here we have got people from an incredibly broad range, not only in terms of experience, but in terms of where they are coming from, what they got access to at the moment, the kind of students that they got, and similarity. (F1P6) Participants spoke about being challenged in their comfort zones. One stated that: It was the first time that I was exposed to, (that) I am allowed to have an opinion, discuss the opinion with other students. It challenged my comfort zone. I am more used to knowing that this is the book I am studying, almost, uhm, am not used to thinking. Now I actually think. (F1P1) Being allowed to have an opinion and share it was endorsed by another participant, who said: I also experienced it. You are so used to this didactic approach. This is it, write it down. I really enjoyed the opportunity to be able to basically have arguments with people in a constructive manner and come to conclusions.(F1P2) Another time a participant's comfort zone was challenged was when a basic science teacher was allocated to a bedside teaching session to observe teaching.
Go(ing) to the clinical setting really was a big exposure because we find that we tend to live in our own silos within our area of specialisation and not interact with other departments. So that was almost like breaking a barrier. (F1P5) The fact that we do not all learn in the same way was a learning moment. S/he described this as follows: I think, one thing I learnt amongst the participants in the course even -people study differently. I never realised that. I thought everybody was like me -we prefer to have the book, go through it and understand all the theory before we are exposed to a patient, and then to examine the patient, and now I see some people like to sort of experience or experiment, before they actually learn all the theory. (F1P1) One participant reflected on the teaching styles in the course and noted: Being a student you start thinking that well, this isn't working for me, and why would it work for students in general either, unless we changed it to something else which was more relevant. (F2P7) Being a student again did come with its sacrifices as one participant, who did the course on a part-time basis noted: I found it taxing in terms of, uhm, in terms of the pre-reading, and for the assignments after the contact week. The contact week was fine, but the other work that we had to do, trying to juggle that with work and family commitments and all of that was hectic. (F1P4) A whole new world This theme describes the benefits that participants accrued from doing the course both for themselves and their students. There was also evidence that participants had shared lessons learned with colleagues who had not done the course. The negative aspects related to trying to persuade colleagues that some teaching and assessment methods needed consideration and change.
For participants as individuals there was a sense of empowerment. One participant spoke of the authority (F1P6) that having done the course afforded him, whilst another said:

I think it opened up a whole new world with regards to education, because all I knew previously was how I was taught, which was back then transparency based, frantically scribbling down the notes, that kind of continued then with powerpoint presentations for many years … it has opened up so many different doors and avenues that you can bring in. (F2P8)
Others spoke about the clearer understanding that they now had of the educational language, which enabled them to engage more fully in debates and discussions in meetings.
For some of the participants this course offered the first exposure to learning management systems and what the possibilities are if used to maximum effect.
They (course lecturers) enlightened us as to how much more one could do with the electronic resources. That was quite an eye-opener. (F1P5) The benefits to their students were described in similar terms. A participant who had done the course on a part-time basis said: First year was a complete mind shift. Everything before that I felt very responsible for what happened (in the classroom), but after the programme I realised that … the learning needs to belong to them (students) and they need to be responsible. …So my approach to the learner, my approach to teaching changed. I use different methods, we brought in different assessment tools. I think it made me a better teacher, and it meant my students get more out of the teaching.
Another participant described how s/he now uses Kolb's experiential learning theory in developing lessons:

I really enjoyed looking at the Kolb's cycle of learning. I then developed a method of creating my lessons around that to make sure that we have all the different steps … with quizzes and feedback and so forth. (F1P3)
Others commented on ensuring that they accommodate for different learning styles in their teaching and aligning assessment with teaching (F1P1). This same participant also commented I give them (students) time to reflect on how they learn and what they learn.
One participant described lessons learned in the course as a bit of a double-edged sword (F1P2). This participant had been asked to review examination papers and found several problems with the questions asked and in giving feedback to the examiner had been met with an unwillingness to change. This was not an isolated experience. Another participant stated that those who had done the course: … we are driving change and moving things in different directions, but to win over the people who haven't gone through that process, yes, it's a challenge … we are fighting the whole system. (F2P7) In the same light another noted: Even the students initially were quite resistant to the way we tried to involve them. (F2P8) A participant from a diagnostic discipline noted that s/he had used newly acquired knowledge to mentor colleagues (F1P2). This discipline has also made a decision to send at least one person to do the course every year. Another participant from a clinical department reported having organized a course for members of the department, but noted that I know what should be changed, but some of those changes aren't in my control. So changing things like standard setting is very difficult … because although I have experience with the perspective, my colleagues haven't. (F2P10)

Seeing students as adult learners
This theme was developed from insights that participants described of seeing students in a different light. Realising the individuality of students and that teachers are not the sole source of information contributed to the development of this theme.

Now I understand that students are not all the same (F1P1)
A participant spoke of the positive effect that changes in teaching had had on students: Just seeing the effects of just changing your mind-set as a teacher, that creates a completely different student. Get(ting) students involved, our students changed completely; they were different people. The students' outputs were completely different. (F2P7) One big thing that I have also picked up was the fact that I am not the sole source of education. The sole source of information for the students, and that, uhm, actually if a lecture theatre is half full, I shouldn't worry too much. What counts at the end is, how are they handing the assessments and whether they have grasped the knowledge they were supposed to have. (F1P5) The above statement was confirmed by another participant who expressed it as follows: I think the big change is also taking it from a lecturer centred approach to a student centred … it is actually about the people who are learning and not what I want to get across to them. (F2P7) The benefits of these changes were noted as: And now that they have found it comfortable, they approach you. They engage with you regarding the topics to cover, than previously when they were scared to ask a question. Whereas now they know it is an open floor. (F2P9)

Discussion
There were several points raised in the focus groups that surprised us. These were that the module on the theories of teaching and learning was found to be the most significant module, that participants appreciated the opportunity for multi-disciplinary learning, that they saw their own students through different eyes, learnt the value of studentcentred learning and that their own learning was challenged by being expected to have an opinion and express that opinion. The fact that difficulties have been experienced in trying to change ways of doing in both teaching and assessment is not altogether unexpected but needs attention.
Participants commented on the difficulty of having to learn a new language when reading for the module on theories of teaching and learning. In their evaluation of a programme for educators in the health sciences, Steinert and McLeod (2011, p.970) state that participants "often report(ed) that they are overwhelmed by the 'jargon' of pedagogy." Kneebone (2002) reflected on the challenges he faced when starting to read in the field of medical education. He notes the tension that exists between disciplines where the science of the discipline is accepted and not challenged and the disciplines which challenge their own paradigms as part of their being and development. He questions how much of medical decision-making is scientific given the reliance on personal experience and empathy, compassion and caring. He notes the positivistic worldview of medicine and how it limits thought processes. Further, the learning of medicine is dominated by facts, detail and isolated "nuggets of information" (Kneebone, 2002, p. 517). This type of learning can be applied to all who participated in our focus groups, irrespective of their disciplinary background. These participants would have studied their discipline in isolation from others, been subjected to large volumes of factual information and probably had little formal exposure to information from the humanities. They would have been used to recalling facts and making linkages between cause and effect in decisionmaking. The theories of teaching and learning expose them to a thinking that takes them beyond factual detail to one where they are required to challenge their beliefs and reflect on what is happening in the teaching and learning process. Duff (2010, p.170) states that "academic discourse is not just an entity but a social, cognitive, and rhetorical process and an accomplishment, a form of enculturation, social practice, positioning, representation, and stancetaking." This development of an identity has been described by Ennals et al (2016, p.440) as a "shared experience of floundering in a new world, and a troublesome transition from expert practitioner to novice academic." They go on to say that expert practitioners know the rules of the game, but novice academics are learning the rules and how the game is played. What many don't realise is that they are learning a new discourse -a secondary Discourse (Gee, 1989).
That participants found support in the peer group is not surprising as they would all have been exposed to the same prior teaching and learning experiences. The value expressed of the multi-disciplinary group however, brings another dimension to the peer support articulated. It would appear that it was reassuring to participants to note that others felt the same way, irrespective of their background, but another dimension of the multi-disciplinary group was the opportunity to learn from one another. The anxiety expressed by the participants of being a student again and in another discipline, has been noted by others (Case et al., 2010;Weurlander & Stenfors-Hayes, 2008) as has the opportunity to reflect on own teaching and to develop empathy for own students (Case et al., 2010). The opportunity to network and learn from others has been reported on by Herrmann et al. (2007) and Steinert (2010). Interestingly, the participants in Herrmann et al.'s study (2007) also commented that the amount of effort required in the programme exceeded expectations. Steinert (2010) describes the concepts of learning by doing and learning by observing. This was evident amongst our participants who spoke of teaching as they had been taught and how they had done things in the classroom that were now challenged. There was evidence that they were now learning by reflecting on experience. This changed behaviour has been reported on by Leslie et al. (2013) who conducted a systematic review of faculty development in medical education and found that changes in behaviour were the most commonly reported (21 of 22 studies) outcome of faculty development programmes.
The difficulty in getting colleagues to appreciate the need to change ways of teaching and assessing, demonstrates that participants have moved into a new community of practice. Quinn (2012) describes the discourses around staff development, one of which suggests that good researchers become very good teachers. This perception may explain the difficulties of our participants. Quinn (2012, p.73) goes on to note that in discourses where academic identity has developed from disciplinary endeavours, the staff development discourse may be viewed as a "competitive contradiction". Academic identity related to development in the teaching discourse may also be influenced by the institutional culture which undervalues teaching (Hafler et al., 2011). How much this has been a contributory factor in our study is difficult to tell, but perhaps is one worth exploring. Lave and Wenger (1991) state that five factors characterise a community of practice: a common goal; the existence and use of knowledge to achieve that goal; the nature and importance of relationships formed among community McInerney P, Mabizela S, Moch S MedEdPublish https://doi.org/10.15694/mep.2018.0000207.1 Page | 8 members; the relationships between the community and those outside it; and the relationship between the work of community and the value of the activity. The participants in these focus groups started to form a community of practice during the course of their studies -their common goal being to improve their teaching practices, they drew support from one another and on completion of the course found difficulty in relating to others in their disciplines who had not done the course. This suggests that participants had moved from an academic identity of professionals to educators .