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Teaching Clinical Skills in Developing Countries: Are Clinical

Skills Centres the Answer?

Article  in  Education for Health · December 2003

DOI: 10.1080/13576280310001607433 · Source: PubMed

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Education for Health, Vol. 16, No. 3, November 2003, 298 – 306

CAREER ISSUES FOR LEARNERS

Teaching Clinical Skills in Developing Countries:

Are Clinical Skills Centres the Answer?

PATSY STARK1 & F. FORTUNE2

1
Department of Medical Education, University of Sheffield, UK and
2
Department of Clinical and Diagnostic Oral Services, St. Bartholomew’s
and the Royal London Dental School, London, UK

ABSTRACT Context: There is growing international interest in teaching clinical skills

in a variety of contexts, one of which is Clinical Skills Centres. The drivers for change
making Skills Centres an important adjunct to ward and ambulatory teaching come both
from within and outside medical education. Educationally, self-directed learning is
becoming the accepted norm, encouraging students to seek and maximize learning
opportunities. There are global changes in healthcare practice, increased consumerism
and increasing student numbers. In some countries, professional recommendations
influence what is taught. Increasingly, core skills curricula and outcome objectives are
being defined. This explicit definition encourages assessment of the core skills. In turn, all
students require equal opportunities to learn how to practise the skills safely and
competently. The moves towards interprofessional education make joint learning in a
‘‘neutral’’ setting, like a Clinical Skills Centre, appear particularly attractive.
Objective: To discuss the potential role of Clinical Skills Centres in skills training in
developing countries and to consider alternative options.
Discussion: Many developing countries seek to establish Clinical Skills Centres to ensure
effective and reliable skills teaching. However, the model may not be appropriate,
because fully equipped Clinical Skills Centres are expensive to set up, staff, and run. They
are not the only way to achieve high quality clinical teaching. Suggested options are based
on the philosophy and teaching methods successfully developed in Clinical Skills Centres
that may fulfil the local needs to achieve low cost and high quality clinical teaching which
is reflective of the local health needs and cultural expectations.

KEYWORDS Clinical Skills Centres, developing countries, teaching and learning

strategies, interprofessional education.

Author for correspondence: Dr Patsy Stark, RGN RM ILTM BA (Hons) PhD, Senior Fellow in
Medical Education, University of Sheffield, Department of Medical Education, Coleridge House,
Northern General Hospital, Sheffield S5 7AU, UK. Tel : 44(0) 114 2715939. Fax: 44 (0)
114 2424896. E-mail: [email protected]

Education for Health ISSN 1357–6283 print/ISSN 1469–5804 online # 2003 Taylor & Francis Ltd
http://www.tandf.co.uk/journals
DOI: 10.1080/13576280310001607433
 Clinical Skills Centres in the developing world 299

Introduction

There is growing international interest in teaching clinical skills away from the
hospital bedside. There have been two main reasons for this. The first is in
response to educational developments:

. The use of problem-based learning.

. The explicit definition of core curricula and outcomes objectives (Harden
et al., 1999; General Medical Council 1993, 2002).
. The adoption of adult educational principles of self-directed and
experiential learning (Rogers, 1983; Kolb, 1984; Schon, 1991).

Especially in the developed world, the second reason is the result of external
drivers.

. Clearer professional recommendations (General Medical Council, 1997,

2002).
. A rise in patient consumerism where patients are less tolerant of
exposure to novices (Secretary of State for Health, 1991).
. Increases in student numbers (Bligh, 2001).
. The specialization of clinical attachments/clerkships.

These influences are further complicated by changes in healthcare practice, the

move from hospital to community and primary care and the faster throughput
of patients in hospital (Towle, 1998). It is essential that all students acquire a
range of prescribed clinical skills. To meet this training requirement, it may be
necessary to look beyond traditional teaching settings to provide opportunities.
Clinical Skills Centres are one of the ways clinical skills teaching may be
provided. These are usually perceived as a space containing resources for
teaching practical clinical skills. Centres vary in the accommodation provided
and the resources available from one room with one manikin to purpose-built
structures with a vast assortment of equipment (Dent, 2001). Most commonly
they contain various manikins e.g. arms for venous access practice, resuscitation
dolls, heads with slides for retinal fundoscopy and pelvic models for speculum
and bi-manual examination. Some Centres also house a video or CD-Rom
collection and other computer based learning materials.
Because of the multiplicity of motivations, there is growing interest in the
development of Clinical Skill Centres in many countries for a variety of
reasons. In developing countries these are more commonly associated with
curriculum changes rather than socio-political and organizational influences.
However, there are at least two examples where the perceived need for a
Clinical Skills Centre is due to non-curricular issues. Because of the prevalence
of HIV and AIDS in sub-Saharan Africa, students need a high degree of
psychomotor proficiency in venous access techniques for their personal safety
300 P. Stark & F. Fortune

before they perform the skill on patients. In countries where religious beliefs
make it especially difficult for male and female students to be taught together,
clinical skills sessions conducted using manikins, not patients, may offer support
for students and provide opportunities to explore physical examination and
other skills (Das Townsend & Hasan, 1998).
Interest has been stimulated by the World Federation for Medical
Education (2001). However, there has been little discussion about the
expenditure of setting up Clinical Skills Centres, which in addition to the
initial capital and purchase costs, require other overhead expenditure and on
going costs of personnel and equipment.
Although all UK centres are based on the Maastricht model, (Bouhuijs
et al., 1978), each medical school has developed its centre to reflect its own
educational methodology (Bligh, 1995; Bullimore & Stark, 1996; Du Boulay
& Medway, 1999; Bradley & Bligh, 1999; Dent, 2001). In general,
instruction is aimed at preparing students for their clinical attachments
and to fill any gaps in clinical experience. They ensure that all students
have the same opportunity to learn core skills defined within the outcome
objectives of the curriculum. This results in benefits to all groups: the
patients, students and universities. Patients are protected from complete
novices. Students gain a degree of confidence and competence so that each
encounter with the patients is maximized. The university can assess the
defined core skills in the knowledge that all the students have had similar
learning opportunities.
The international move toward multiprofessional/interprofessional learning
offers the challenge of developing teaching and learning methodologies which
are effective and relevant for all the health professionals involved (Bajaj, 1994;
Boelen, 2001). Teaching in a Clinical Skills Centre may fulfil some of the need
by encouraging students from different professional backgrounds to share
relevant and common learning and to enable them to learn about one another
in a context that is not profession specific (Dent, 2001).
One of the authors (PS) has been a consultant for several medical schools in
Asia and North Africa, and the other author (FF) has worked and taught in
Southern Africa. This paper offers a discussion based on their experiences
about the options available for clinical skills teaching.

Defining the Issues

Clinical Skills Centres appear to offer a panacea for clinical skills teaching, but
it is important to consider the cultural aspects of medical education which
‘‘should and must differ from country to country’’ (Henderson, 1989).
However, from our experience, medical education systems in some developing
countries try to adopt but not adapt western curricula and teaching and learning
methods and because of that may fail to meet the needs of individual healthcare
 Clinical Skills Centres in the developing world 301

systems and cultural norms (Bajaj, 1994). While healthcare institutions should
be at the forefront of leading improvements in health provision by using the
talents of their staff to contribute to health developments and to teach students
evidence based medicine, this must all be within the local context of attitudes,
values and ethical perspectives (Boelen, 1995).
Clinical Skills Centres have been successfully developed in European
countries (Bouhuijs et al., 1978; Bligh, 1995; Dent, 2001) and elsewhere (Hao et
al., 2002), but it is not always appropriate to transfer this model wholesale to
medical and healthcare schools in developing countries. The capital cost of
setting up a Clinical Skills Centre may be far in excess of local budgets. Even if
the problem is overcome by outside funding, several obstacles exist. These
include:

. The purchase of equipment and manikins requiring foreign currency.

. Long delivery times for replacement parts.
. Local availability of consumable supplies (cannulae, masks etc.).
. Culturally unacceptable equipment.

Once set up and equipped, the maintenance and running costs may prove
prohibitive in the long term. It is discouraging for staff, students and the
institution when a much heralded Clinical Skills Centre becomes disused
because funding or staffing has ceased or the equipment cannot be repaired or
maintained.
We consider that there are three options available to medical and
healthcare schools considering the establishment of a Clinical Skills Centre.

(1) Develop a Clinical Skills Centre which will provide a focus for teaching
and learning of all the defined core clinical skills for uni-professional or
multiprofessional groups. In this model students are both timetabled to
attend sessions and permitted self-directed access for practise. One of
the most valuable assets is the permanent staff. To ensure the greatest
and most effective usage, the Centre should be staffed during the
working day, and it may be appropriate to staff the Centre in the
evenings also. Specialist teachers are employed who may come from the
same professional group as the students or interprofessional teachers
may be utilized i.e. senior nurses for medical students (Bullimore &
Stark, 1996; Bradley & Bligh, 1999). Standardized teaching (i.e. all
teachers agree to teach in the same way, using the same resources) and
feedback policies are part of the teaching strategy. Clinical Skills
Centres can be a suitable venue for clinical competency assessments,
capitalizing on the physical resources and the educational expertise of
the staff. Because all students receive the same training based on the
core curriculum, the skills components of assessments can easily be
blueprinted.
302 P. Stark & F. Fortune

(2) Develop a modified resource where only key manikins, e.g. resuscita-
tion, are available and specialist trainers are brought in to deliver the
specific training. In this model self-directed practice is not readily
available. Core clinical skills teaching is then delivered in the clinical
environment rather than in the Clinical Skills Centre. To ensure
equitable training, standardized teaching and feedback methods based
on sound educational principles can still be instituted. Because of the
multiplicity of teachers in this model, student logbooks or records of
achievement monitor the acquisition of skills. Assessment is based on
the assumption that all the core skills have been taught/learnt in
practice, rather than the knowledge that all students have been taught in
the Clinical Skills Centre (option 1). Widespread staff development is
an essential part of this strategy to ensure compliance with the
educational philosophy and the outcome objectives of the curriculum.
Clearly, this is a more challenging model since the educators that devise
the programme and assessments may not have full control over the
teaching/learning opportunities.
(3) Develop a revised model that suits the individual institution and which
reflects the educational principles of teaching in a Clinical Skills Centre
(above) but which is delivered without the physical infrastructure on
the wards, clinics and in primary care settings. Like option 2, logbooks
or records of achievement are a method of monitoring student progress
by both the students themselves and the teachers to ensure the core
skills are learnt. Staff development and the control of the skills
programme have the same significance as option 2. This is the least
expensive of the options, but the adoption of good clinical teaching
methods and equivalence of learning opportunities can still provide
students with the core skills and reassure educators that all students
have acquired the defined skills.

Adapting the Model of Clinical Skills Centre Teaching to Local

Needs

A modified or revised model based on the philosophy and teaching methods

successfully developed in Clinical Skills Centres may be the most applicable to
meet local health and cultural needs, i.e. option 2 or 3 above. This will work
best when:

. The core curriculum or outcome objectives, including essential clinical

skills, have been defined (Harden et al., 1999). The skills programme can
be planned in advance and the delivery does not rely on opportunism
during clinical attachments. Modern educational and assessment methods
depend on good and comprehensive curriculum planning.
 Clinical Skills Centres in the developing world 303

. There is an acceptance within the institutional culture of the need for

specific skills training, conducted in a variety of settings. There can be
hostility or ambivalence to this type of teaching and learning. Therefore
staff development is crucial. There has to be ‘‘added value’’ and
demonstrable benefit to students, staff and patients.
. There is a philosophy of student-centred education. Clinical Skills
Centres enable students to learn in a safe and supportive environment
where observation and feedback are inherent in the educational strategy.
This has to become the accepted strategy for all clinical teachers.
. Time and space are set aside for clinical skills training, wherever it is
undertaken.
. There is a recognition that all clinical teaching requires preparation (Cox,
1993).
. Optimum use is made of standardized teaching methods.
. Teaching is culturally sensitive, ethically based and attitudinally sound.
. The faculty can be certain that all students have had the opportunity to
learn and practise a particular skill. This can then be rigorously tested in a
clinical competency examination, often in an OSCE (Objective Struc-
tured Clinical Examination) (Harden & Gleeson, 1979; Bouhuijs et al.,
1987; Bradley & Bligh, 1999).

The desire for medical and healthcare schools to establish a Clinical

Skills Centre suggests a commitment that clinical skills will be taught
rather than acquired by passive and opportunistic observation. This is the
first step in identifying the importance that clinical skills play in
undergraduate medical and healthcare education. Many students are
overwhelmed by the prospect of talking to and touching patients in the
early stages of their training (Moss & McManus, 1992; Das et al., 1998).
If they can gain confidence by working with a dedicated skills teacher or
a good professional role model, some of their apprehensions will be
dissipated. The role of observation and feedback is crucial in this type of
teaching.

Achieving Low Cost, High Quality Clinical Skills Training

Suggestions to improve clinical skills training without the expense of

developing a Clinical Skills Centre include:

. Create a medical education unit or harness the educational talents of a

group of staff. Empower them and give them time and resources to learn
the role. They can drive and monitor change.
. Review the educational aims of the curriculum and define the outcome
objectives (what skills and what skills level the students must have
304 P. Stark & F. Fortune

acquired by graduation) (Harden et al., 1999). Make the information

available to students and staff alike. This review may occur naturally
during curriculum changes, but there has to be consideration of local and
national health needs and statutory regulations to inform the decision-
making.
. Analyse the students’ present clinical experience and consider if there are
ways to enhance existing teaching and learning strategies.
. Identify when the skills will be taught during the course, where and by
whom.
. Ensure that all students have opportunities to learn the core skills during
the clinical attachments that are available.
. Consider the opportunities for student led or self-directed learning.
. Determine how the core skills will be assessed.
. Develop a remediation strategy for students who do not meet the
standards.
. Staff development (Towle, 1997).
. Disseminate the educational goals. For many members of the
faculty who were taught by the apprenticeship model, modern
educational practices might seem unnecessary. A series of staff
development workshops on clinical skills training, problem-based
learning and other current medical education methodologies is
essential.
. Train the teachers to teach in a standardized, systematic and organized
manner.
. Produce written and videotaped training materials to support the
teachers (Stillman et al., 1997).
. Demonstrate the value of skills training (with or without patients) using a
group of students as a pilot project.
. Involve students in curriculum change and programme evaluation.
. Review the literature and ask external medical educators to share their
experiences, e.g. examples of skills workshops, clinical competency
assessment strategy, how they integrate knowledge and attitudes into
skills training and what policies they have in place to ensure clinical
education is ethically sound.
. ‘‘Twin’’ with another medical school. Perhaps you can share what you
have. The countries with established Skills Centres offer expertise, whilst
the developing country provides opportunities for exchange students
during electives etc. (Parry & Parry, 1998).

However, it is important to realize that there are still costs to implementing

educational change whether or nor a Clinical Skills Centre is established. Those
expenses centre on staff development, the reduced clinical activity during
teaching sessions and administrative costs associated with monitoring evidence
of skills acquisition.
 Clinical Skills Centres in the developing world 305

Discussion

While clinical skills can effectively be taught and learned in a Clinical Skills
Centre, it is not the unique pathway to implementing effective clinical skills
training. Each medical or healthcare institution must develop a curriculum,
including clinical skills, that is representative of its cultural and economic
features and defines the teaching and learning methodologies that will best
deliver the outcome objectives. Many schools are moving to a problem-based
approach to education where a Skills Centre may appear to be a pre-requisite.
In the past, skills acquisition was often left to chance and unobserved by
teachers. What Clinical Skills Centres offer the educational community is a
model of teaching, which appears to offer benefit. However, learning and
practising a clinical skill can be successfully carried out in other suitable
contexts provided there are opportunities for observation and feedback.
Dedicated and structured clinical skills training is the important factor whether
it takes place in a Skills Centre, on the wards or in the community.

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