Undergraduate acute care clinical competencies for managing acute care cases in adult patients within a South African in-hospital environment: A modified Delphi Study

Abstract

Introduction

With the increase of global population, there has been an increased demand for acute care services both locally and globally. In the absence of an acute care competency-based curriculum in South Africa, this study sought to identify the core competencies required by undergraduate medical students to safely manage adult patients within an acute care setting in a South African hospital environment.

Methodology

The modified Delphi study comprised of three rounds. The traditional Delphi method, which uses the same participants across various rounds, was modified by using different stakeholders across the three rounds. Emergency Medicine (EM) specialist trainees (registrars) generated competencies in round one, which were provided to a multi-disciplinary team with expertise in undergraduate curriculum development in round two, using a 5-point Likert scale for rating their agreement-disagreement. Round three entailed inviting the round one contributors to anonymously comment, via online survey, on the competencies generated in round two.

Results

A total of 34 EM registrars participated during round one and 7 curriculum development experts participated during round two. A total of 120 competencies were identified from the 3-round Delphi study; of these 103 (85.8%) were reached by “Strong Agreement”; 16 (13.3%) reached by “Agreement”; and 1 (0.8%) was undecided.

Discussion

The results of the modified Delphi study contributed to developing a comprehensive list of undergraduate acute care clinical competencies set in a South African context. The value of engaging with medical practitioners at the forefront of delivering acute care in a South African healthcare environment who are exposed on a daily basis to the healthcare needs of society, became evident. The findings of this study highlight and reinforce the importance of contextual relevance during the curriculum development process.

Conclusion

The modified Delphi method, based on three iterative rounds and feedback from experts, was effective in reaching consensus on the competencies required by undergraduate medical students to manage acute care adult patients safely within a South African hospital environment.

African relevance.

• •The effective management of Acute care clinical skills is needed in Africa to reduce morbidity and mortality rates.
• •There is a need for a set of undergraduate core competencies for the management of adult acute care clinical skills.
• •There is an urgent need to adequately prepare newly qualified medical doctors for practice, particularly within resourced constrained environments, such as Africa.

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Introduction

In order to be clinically competent and safely manage patients, health care professionals are required to be competent at performing a wide range of clinical skills. Preventable medical errors result in harm and thousands of deaths per year within healthcare facilities across the world [1]. The need for medical training facilities to review how they prepare students has become urgent [2]. Given the potential risk of harm and ethical implications, it is not acceptable for novice students to prematurely ‘practise’ their skills on patients within the clinical environment.

Acute care as a sub-specialty responds to life- threatening medical emergencies throughout the patient care pathway irrespective of the cause. This may include a range of clinical functions including pre-hospital care, EM, acute care surgery, inpatient stabilization and intensive care [1]. Acute care seeks to complete a health system paradigm through the integration with preventative and primary care. Acute care plays a crucial role in the prevention of death and disability, as primary care is often not ideally positioned, or often unable, to assume this role [1]. Additionally, acute care serves as a gateway to health care services for individuals who require urgent interventions.

Changing patient demographics both in South Africa and globally has required health care systems to revise and adapt their service delivery models. With the ever-increasing growth in population and life expectancy, there has been an increased need for acute care services to respond to the needs of these populations. Meeting this demand will require integration between emergency services and primary care coupled with public health measures to prevent illness [1].

South African medical training programs incorporate a two-year internship within undergraduate medical studies to bridge the gap between theoretical knowledge and the safe execution of clinical skills. This internship is intended to prepare students for their independent practice during the community service officer (CSO) year. However, concerns have been raised regarding the adequacy of supervision during the internship [3]. To safeguard patient safety, it is crucial to ensure that graduating medical students are fully competent before entering the clinical environment. To this end, the aim of this paper is to identify the competencies required by undergraduate medical students to safely manage adult patients in an acute care setting within a South African hospital environment through a modified Delphi study

Methods

The Delphi method is a consensus-building technique that involves iterative survey rounds with input from anonymous experts to refine judgements on the importance of specific issues using both qualitative and quantitative methods. It is widely used in curriculum development to identify competencies across fields such as nursing, physiotherapy, anaesthesia, and psychiatry [4].

This study applied a modified Delphi technique, similar to the ‘Acute Care Undergraduate Teaching (ACUTE) Initiative’ [5], involving different stakeholder groups in rounds 1 and 2 to improve response rates and build on prior research [[6], [7], [8]]. Round one focused on Emergency Medicine (EM) specialist trainees (described as registrars), selected for their direct experience in acute care during internships and community service, while round two included healthcare providers with over five years of experience in curriculum development. This approach aligns with the philosophy that curriculum development is multifaceted and influenced by various stakeholders.

EM registrars were identified as the most suitable stakeholders for round one, and healthcare providers with extensive experience in undergraduate curriculum development and acute care clinical skills were chosen for round two. The registrars were recruited through professional organizations and university departments across South Africa (University of Cape Town, Stellenbosch University, University of KwaZulu Natal, and University of the Witwatersrand). They were asked to provide input on the essential knowledge, skills, and attitudes (competencies) required for medical graduates to safely care for acutely ill patients. These responses were then synthesized by the research team into general categories like airway, breathing, and circulation, following the framework used in the ACUTE study [5].

The synthesised competencies from round one contributors’ were presented to the round two panel, via an online survey, to obtain their views of the appropriateness of the suggested competencies. To reflect the diversity of competencies typically encountered in the acute care setting, care was taken to ensure the round two panel were multi-professional.

Their responses were analysed using the level of agreement/disagreement on a 5-point Likert scale, which were further categorized as shown in Table 1.

Table 1.

Strength of Agree or Non-agreement.

Mean score (Likert score)	Strength of Agreement or Non-Agreement
1 – 1.7	Strong Agreement
1.8 - 2.5	Agreement
2.6 – 3.4	Undecided
3.5 – 4.2	Disagreement
4.3 – 5.0	Strong Disagreement

The purpose of Round three of the Delphi study was to give Round one contributors the opportunity to review and provide feedback on the competencies developed during Round two. Contributors could suggest modifications. After the 14-day period, no further contributions were submitted.

Results

Delphi study Round one

During Round one of the Delphi study; the survey had 37 respondents (EM registrars), out of a total population of 82 from (UCT, SU, UKZN, Wits) which equates to a response rate of 45 %.

Participants obtained their undergraduate medical degree from various universities (Fig. 1). Given that South Africa is a diverse country where the difference in patient demographics can be vastly different from one location to another, it was important that the respondents displayed this diversity. The study respondents (EM registrars) acquired their undergraduate medical degree from 6 of the 10 medical schools in South Africa that offer undergraduate medical training.

Fig. 1.

Institution of undergraduate medical degree of EM registrars in round one.

The study identified 120 core competencies, of these 103 (85.8%) reached “Strong Agreement”; 16 (13.3%) reached by “Agreement”; and 1 (0.8%) was undecided.

Table 2 depicts the number of corresponding contributions provided by the EM registrar participants, these contributions were provided under the categories of “knowledge”, “Skill”, and/or “Attitude” contribution, as this is generally accepted as the components which make up competencies.

Table 2.

Delphi round one contributions.

	Knowledge contributions	Skills contributions	Attitudes Contributions
Airway and Ventilation	19	10	12
Circulation	17	17	10
Confusion and Coma	10	13	9
Drugs, Therapeutics and Protocols	10	7	6
Infection and Inflammation	12	18	7
Clinical Examination, Monitoring and Investigations	10	11	6
Patient and Societal Needs	11	7	9
Trauma	9	19	9
Equipment	8	10	7
Team-working, Organisation, and Communication	8	8	9
Other	0	0	0
Total	114	120	84

The primary area of healthcare specialization of round two participants is represented in Fig. 2.

Fig. 2.

Primary area of healthcare specialization of round two participants.

Table 3 represents the final results of the Delphi study as there were no further contributions from round three. It also highlights the strength of agreement or no-agreement as defined amongst the expert grouping despite their differing healthcare specialities. These results could be attributed to the fact that the curriculum relates to undergraduate medical education as opposed to post-graduate specialist training where greater disparity might be present.

Table 3.

Results of the round two Delphi Study.

Competencies	Mean Score
Airway and Ventilation
Describe the basic anatomy and variations of a patient's airway.	1.1
Demonstrate the ability to effectively evaluate a patient's airway in the acute setting.	1.0
Demonstrate the ability to use oxygen administration using various delivery devices.	1.3
Demonstrate the ability to perform basic airway manoeuvres (Jaw Thrust, head-tilt-chin-lift).	1.0
Demonstrate the ability to inserting basic airway adjuncts.	1.0
Demonstrate the ability to perform adequate bag-valve-mask (BVM) ventilation.	1.0
Demonstrate the ability to perform endotracheal intubation.	1.3
Describe the potential complications associated with intubation.	1.3
Demonstrate the ability to set up a mechanical ventilator for the acutely ill patient.	1.7
Demonstrate the ability to implement lung-protective ventilation strategies in the acutely ill patient.	1.6
Demonstrate the ability to insert a supraglottic airway device.	1.4
Demonstrate the ability to perform surgical Cricothyroidotomy.	2.1
Circulation
Describe the anatomy and physiology of the circulatory system.	1.1
Demonstrate safe and effective intravenous (IV) cannulation.	1.0
Demonstrate safe and effective Intraosseous (IO) cannulation in:	-
I. Adult patient	2.0
II. Paediatric patient	1.6
Demonstrate safe and effective Central Venous Catheter (CVC) insertion.	2.4
Describe and demonstrate the management of shock.	1.1
Describe and demonstrate the management of hypertensive emergencies.	1.3
Demonstrate the safe and effective use of synchronised cardioversion.	1.4
Demonstrate the safe and effective use of transcutaneous pacing.	2.6
Demonstrate the safe and effective application of vagal manoeuvres.	1.7
Describe the principles of haemorrhage control in the acutely ill patient.	1.0
Demonstrate the management of cardiac arrest.	1.1
Demonstrate the ability to administer fluids (including blood products) during the resuscitation of a critically ill patient.	1.4
Demonstrate the ability to commence inotropic support in the acutely ill patient.	2.1
Confusion and Coma
Describe the anatomy and physiology of the neurological system.	1.3
Describe the common causes of altered level of consciousness.	1.1
Describe and demonstrate the management of cerebrovascular accident (CVA) emergencies	1.1
Demonstrate the ability to conduct systemic general neurological examination.	1.1
Demonstrate the effective airway management strategies in the confused/comatose patient.	1.3
Demonstrate the ability to effective mechanically ventilate a patient with a traumatic brain injury (TBI).	1.6
Demonstrate the ability to conduct a Glasgow Coma Scale (GCS) assessment.	1.1
Demonstrate the ability to test for brain stem death.	1.9
Demonstrate the ability to safely restrain the confused patient.	1.1
Approach the confused/comatose patient in a non-judgemental manner.	1.3
Know when to call for help.	1.0
Drugs, Therapeutics and Protocols
Demonstrate the preparation and initiation of various infusions.	1.3
Demonstrate the ability to administer medications via various routes of administration (IV, IM, PO etc.)	1.1
Describe the general prescription principles.	1.1
Demonstrate the ability to interpret and implement an algorithm/protocol.	1.0
Describe the common resuscitation drug dosages.	1.7
Describe the common medications used during rapid sequence intubation (RSI).	1.1
Describe the common medications used during cardiopulmonary resuscitation (CPR).	1.1
Describe the commonly used antibiotics in the management of the acutely ill patient.	1.4
Describe the common emergency protocols (BLS-HCP, ACLS, PALS).	1.4
Demonstrate an awareness and implementation of memory aids (hardcopy and electronic).	1.1
Be mindful that pharmacology is everchanging.	1.4
Infection and inflammation
Describe the general principles of infection and inflammation.	1.4
Describe the common pathogens.	1.4
Demonstrate the ability to effectively apply an N95 face mask.	1.3
Describe the principles of safe antibiotic stewardship.	1.3
Describe the pathophysiology of sepsis.	1.3
Describe the general principles of infection and infection control.	1.1
Demonstrate the ability to effectively manage a patient in sepsis.	1.0
Demonstrate effective hand washing technique.	1.0
Demonstrate the ability to effectively don appropriate personal protective equipment (PPE).	1.3
Demonstrate aseptic gloving techniques.	1.1
Demonstrate the ability to implement ‘goal-directed therapies.’	1.1
Clinical Examination, Monitoring, and Investigations
Describe the basic surface anatomy.	1.1
Demonstrate the ability to conduct common clinical examination techniques.	1.0
Describe the general patient monitoring techniques (Blood pressure, oxygen saturation etc.).	1.1
Demonstrate how to perform the following procedures:	-
I. Blood culture	1.0
II. Lumbar puncture	1.1
III. Urinalysis	1,0
IV. Abscess drainage	1.4
V. Phlebotomy	1.1
VI. Intravenous cannulation	1.0
VII. Fine needle aspiration	1.9
VIII. Blood gas interpretation	1.3
IX. Ultrasound	2.0
X. ECG application and interpretation	1.3
XI. Chest x-ray interpretation	1.3
Demonstrate effective auscultation technique.	1.1
Patient empathy and respect while conducting an examination.	1.0
Patient and societal needs
Demonstrate the general principles of breaking bad news.	1.3
Describe the common referral pathways.	1.1
Be culturally and socially aware.	1.3
Demonstrate effective counselling skills.	1.6
Describe ‘Batho Pele’ principles.	1.7
Demonstrate the approach to a sexual assault victim.	1.1
Describe the signs and symptoms of abuse (child and elderly).	1.4
Describe the general principles of the biopsychosocial approach.	1.1
Demonstrate the principles of confidentiality.	1.3
Describe the principles of ethical medical practice,	1.3
Trauma
Describe the anatomy and physiology of organ systems.	1.1
Demonstrate the approach to the “trauma” patient.	1.3
Describe the principles of blood transfusion.	1.3
Demonstrate the principles of burn wound management.	1.3
Demonstrate the management of the ‘polytrauma’ patient.	1.4
Demonstrate airway management techniques in the trauma patient.	1.1
Demonstrate the principles of c-spine immobilization.	1.1
Demonstrate the management of shock.	1.1
Demonstrate how to perform the following procedures:	-
I. Intercostal chest drains (ICD) insertion	1.4
II. Pelvic binding	1.6
III. Fracture splinting	1.3
IV. Basic suturing techniques	1.1
V. Intraosseous (IO) cannulation	1.7
VI. Wound care techniques	1.3
VII. Haemorrhage control methods	1.1
VIII. Needle thoracentesis	1.3
IX. Fracture reductions	1.6
X. Extended focused assessment with sonography for trauma (efast)	2.3
Equipment
Demonstrate the ability to check common equipment for operation and troubleshooting	1.3
Demonstrate safe and effective usage of the following equipment:	-
I. Manual defibrillator	1.1
II. Mechanical ventilator	1.7
III. Bag-valve-mask (BVM)	1.0
IV. Ultrasound machine	1.9
V. Arterial blood gas (ABG) machine	1.4
VI. Syringe drivers/infusion pumps	1.6
Demonstrate a sense of respect for the equipment.	1.1
Appropriate and judicious use of equipment.	1.3
Teamwork, Organisation, and Communication Skills
Demonstrate the principles of ‘closed-loop’ communication.	1.4
Demonstrate conflict resolution skills.	1.4
Describe the principles of debriefing.	1.7
Demonstrate effective skills in giving feedback.	1.4
Demonstrate effective team leader skills.	1.4
Demonstrate the ability to work within a team.	1.3
Demonstrate the ability to adapt to various situations.	1.1
Maintains professional attitudes and relations with colleagues.	1.1

Discussion

This study contributes to developing a comprehensive list of undergraduate acute care clinical skills competencies required for the South African environment.

As similar studies have been conducted, namely the ‘Acute Care Undergraduate Teaching (ACUTE) Initiative’ [5], it would follow that this is an appropriate point of departure of discussion. While both studies looked at the acute care clinical skills competencies at an undergraduate level, the key distinction was the context within which the study was conducted. The ACUTE Initiative was conducted in the United Kingdom (UK) whereas this study was conducted in South Africa. It must be noted that the purpose of this comparison was not to determine whether one curriculum is superior to the other, but rather that geographical location, patient demographics, healthcare system priorities and many other factors all play a role in identifying the competencies required to address the local healthcare needs and that simply transferring competencies developed in another context could be problematic. Furthermore, it must be noted that the ACUTE study was published in 2005, which in itself would account for much of the differences in competencies as the required competencies of a healthcare system changes over time. Despite this, the authors believed that there is still value in interrogating the original ACUTE initiative study, as it was pivotal in the conceptualisation of this study. To supplement the discrepancies in the original study (namely, geographical location, differences in data collection period) and in the absence of a more recent ACUTE study, the authors interrogated more recently developed curricula globally such as the ‘Outcomes for graduates-2018’ as published by the General Medical Council (GMC) of the UK [9], as well as curricula that are geographically closer such as Zimbabwe [10]. Interrogating studies such as the one by Mtombeni et al. was important as it was conducted in a lower-middle-income country (LMIC) context [10].

It is evident that many of the headings have some striking differences; for example, the list of ‘Trauma’ competencies developed from the Delphi study is more extensive. Some of the possible explanations could be attributed to the higher trauma-related injuries experienced in South Africa compared to the rest of the world - one study found that injury-related mortality rates are six times higher, and road traffic injuries double the global rate [11]. Consequently, the competencies developed through the Delphi study reflect those necessary to manage the higher levels of trauma experienced in South Africa. They include practical skills such as ‘fracture splinting’, basic suturing, etc. but also more holistic trauma competencies such as ‘management of the polytrauma patient’, and ‘airway management in the trauma patient’.

When interrogating a study conducted within a healthcare system more akin to South Africa in terms of resource availability, an article by Mtombeni [10] titled ‘Identifying the procedural core competencies for undergraduate emergency medicine education at the University of Zimbabwe College of Health Science’, 98 core competencies were described. There were areas of overlap between that study and the competencies developed in this study, particularly around ‘Resuscitation’ competencies, as well as ‘Airway, Breathing, and Circulation’ competencies; however, as that study focussed on procedural skills only, it omitted addressing any of the attitudinal and behavioural competencies required by undergraduate medical students.

Under the heading ‘Patient and societal needs’, this trend continues; as the Delphi study not only presented a more extensive list of competencies, but also a more culturally diverse set of competencies. The list of competencies under this heading included contributions such as, ‘Describe the signs and symptoms of abuse (child and elderly), ‘Demonstrating the common referral pathways’, and ‘Describe the general principles of the biopsychosocial approach’; but also included some uniquely South African contributions such as ‘Describing the ‘Batho Pele’ Principles’.

‘Batho Pele’ which is a Sotho-Tswana word loosely translated as ‘People First’ is a South African governmental initiative first introduced in 1997 to improve the delivery and services to the public; furthermore, it seeks to enhance the quality and accessibility of government services by improving efficiency and accountability to the recipients of public goods and services [12,13].

The inclusion of these competencies highlights that the participants recognise the importance of a patient-centred approach to patient care, which has been adopted by an increasing number of medical institutions around the world [14].

Under the heading of “Patient and Societal needs”, one of the major inclusions not represented in the ACUTE Initiative was around Sexual Assault- ‘Demonstrate the approach to a sexual assault victim’, and Abuse – ‘Describe the signs and symptoms of abuse’ [5]. The omission of these competencies could be attributed to various factors, such as differences in referral pathways, varying patient demographics, and the available allied health resources within a given health system. The point that the authors wish to convey is not so much the omission of the competencies in the ACUTE study, but rather advocate for the inclusion of these specific competencies in the curriculum.

South Africa has one of the highest rates of sexual assault against women and children in the world with one in five female homicides and nearly one in ten child homicides identified with an associated sexual crime [15]. The inclusion of competencies around sexual assault is supported by Mtombeni [10] who included ‘Examination of sexual assault victims’ as a core procedural skill. Zimbabwe, like South Africa, has a higher incidence of sexual assault as compared to the global figures; according to the Zimbabwe National Statistics Agency, Zimbabwe experiences an average 22 rape cases per day [16]. In response, there have been increasing calls advocating for the inclusion of sexual violence education in the undergraduate medical curriculum [17] as these victims often present to the emergency department for treatment [18].

It must be noted that it is unclear whether the competencies provided by the experts are representative of what is appropriate for an undifferentiated medical practitioner who is yet to complete an internship or whether the competencies provided are because of a failing apprenticeship model, one in which students are inadequately supervised and expected to perform skills above their competencies. Either way, the literature suggests that students are performing invasive procedures without the necessary supervision [3,19], and the authors believe that there is an inherent responsibility of medical programmes to adequately prepare their graduates for what they are realistically going to encounter.

Conclusion

There is an urgent need to adequately prepare newly qualified medical doctors for practice [20]. This need is exacerbated within developing world contexts where resources are generally constrained, and the healthcare system is under tremendous strain. The current model of medical training within South Africa relies heavily on collaborative work within the clinical environment, meaning that any strain on the healthcare system will most likely result in less-than-optimal conditions for learning to take place in that system. Through interrogating the findings of the Delphi study as well as the existing literature (albeit scarce), the authors were able to formulate a comprehensive list of competencies (knowledge, skills, and attitudes) that are locally relevant and addresses the needs of undergraduate medical students.

Limitations

The authors made all reasonable attempts to ensure the research is robust. A limitation of the Delphi study was the selection of Round one contributors, namely the EM registrars. It could be argued that enlisting registrars to provide undergraduate competencies is problematic. However, the authors believed that EM registrars are ideally positioned to contribute, as the study focused on clinical skills competencies for acutely ill patients, an area of interest for this cohort. Additionally, all EM registrars in South Africa have completed internships and community service, providing them with relevant experience in managing acutely ill patients.

To mitigate the risk of inappropriate competencies, the authors emphasized during recruitment that the contributions were for an undergraduate curriculum. A multi-professional team of curriculum experts in Round two reviewed and rated the contributions based on consensus.

Authors' contribution

Authors contributed as follows to the conception or design of the work; the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content: MJ 50%, NH 30%, DG 20%. All authors approved the version to be published and agreed to be accountable for all aspects of the work.

Dissemination of results

Results from this study was shared with participants of the research process and is available as part of an open access PhD thesis.

Declaration of competing interest

The authors declared no conflicts of interest.