CBP is only possible and only works because of the investment made in it by community-based organizations. Organisations may make this investment for a number of reasons.
It may be about wanting to contribute to the education of doctors. Many organizations see working with medical students as a way of positively influencing their awareness, understanding and skills. This might be in relation either to a specific issue, condition, group or community or enhancing their understanding of the social basis, context and determinants of health.
In some cases organsiations may see placements as a means of contributing to the reduction of stigmatization and social exclusion especially through championing the needs of individuals, groups or a community that is or has been poorly served by health services and professionals. Taking students on placements may also be way of providing clients or service users who might lack knowledge or confidence around accessing or talking to healthcare professionals with ‘safe’ contact with representatives of the sector and hence build bridges towards their engagement with the formal heath sector. In some situations, especially in the case of schools, contact with medical students may encourage children and young people who might not otherwise do so to aspire to Higher Education including the study of medicine.
Organisations may also be interested in the contribution that medical students can make to agency activities, functioning and/or development. Young, keen, intelligent people can represent an asset in the workforce, added human resource enabling a task or activity to be undertaken and a stimulus to reflective practice on the part of people within or connected to the organization.
Where involvement in CBP attracts a grant or payment this too can be an incentive although no organization that I met during my time at Monash (which offers 500 AUD for each student hosted) said that this was a major factor in their involvement in the CBP programme.
Making it work
Having a clear rationale for involvement in community-based education is important, but students also need someone to support them. In CBP at Monash this person is called the field educator – a term I like since it accurately reflects their primary function – to support students’ education in the field.
This person is students’ primary source of support and guidance while they are on placement, they monitor their work and contribute to the assessment of their learning. They play a critical role in knitting together the aspirations of the university for its students, students own learning objectives and the needs of the organisation itself into a coherent narrative organised around a piece of specific piece of work or cluster of activities. In these respects the field educator role is, in the proper sense of the word, crucial to the success of non-clinical community-based placements. It is these people who’s practice sits at the place where students, universities and community-based organisations meet.
Despite the wide variety of contexts that field educators work in, the differences in the particularities of their professional practice and backgrounds and training, there seem to be some common threads in their work. I want to try and pick some of these out here.
My analysis draws on conversations with a range of field educators: people working in facilities for the elderly, working with people experiencing mental ill-health, with community groups and with a wide variety of schools – special schools for children with physical and/or learning disabilities, schools for children newly arrived in the country and with English as second language, and so on.
It begins with some examples of their practice:
Rick is the field educator at a residential facility for the elderly. Rick’s work involves working with residents to organise leisure and social activities that promote health and well-being and quality of life.
Rick told me that he likes to work with a small group of medical students, to identify with them a project that they see through and then to steer their activities. For example, the current group have consulted with residents on a range of leisure activities that they might organise. Residents expressed an interest in Tai Chi. With no expertise to provide this activity to hand, the students had to come up with a creative way of sourcing a teacher. Rick prompted them to think about using local media to publicise the issue and to try and elicit a volunteer. The students wrote publicity materials, staged a press event and got some coverage in local papers. They are about to start dealing with the interest by the appeal.
Previous groups have worked on activities such as setting up a dementia group for residents, families and carers. This group proved sufficiently useful and popular that Rick continues to run it on a quarterly basis
Rick is very clear about his role – to support and guide students; to get them engaged with residents from the beginning of the placement and to take their lead in coming up with a project proposal from this contact; to facilitate their engagement as far as possible across the entire organisation in order to realise their project; to meet with the students at the beginning and end of every day on placement so that they could show him what they were planning and what they had achieved.
Rick said that he was patient with students. He said that he needed to give them time to think about the problems and challenges that they came across and to arrive at potential solutions. He said that they needed to see where medics and medicine fitted into the lives of the residents and life of the organization. He said that he was very open about his practice, about the values that underpinned it and the activities that made up his work.
Tracey is the field educator at project offering a wide range social, health and welfare support to communities – to people with disabilities, victims of crime, people needing employment services, housing and so on. She described her work with students coming to the bit of the organisation that offers legal advice and support to families that are facing or dealing with breakdown, separation or divorce.
Tracey told me that she offered students a very specific role when on placement with the agency. It was not appropriate to allow students contact with clients of the service so Tracey linked them to an adviser who worked with clients and gave them the role of holding one-to-ones with the adviser before and after each case meeting. The students were not simply informed by advisers about case-work but trained to provide the de-briefing that would otherwise be done by another member of staff. Students would spend a few weeks with an adviser before rotating to work with another.
Tracey was very clear about what she was trying to achieve with students. In her words, awareness ‘that we exist’ – meaning both family support and the complexity and importance of families in people’s lives; and, ‘how to look after themselves’ – meaning the importance of and techniques for looking after themselves and colleagues when working in a high stress environment.
Tracey was also very clear on a number of points about process. She emphasised the importance of the interview with students applying for the placement. Tracey regarded this as a job interview thereby signifying both the importance of the placement and the role that students would be playing. She always asked students, ‘why do you want to do this?’
There was also the issue of a fairly significant investment at the start of the placement to get structures and systems in place, embed practice and not least, to create a context in which understandable staff skepticism about the work could be allayed by experience of it. Tracey felt it had been easy after this – the virtues of the work for all involved and its capacity to save organisational resource and advisers’ time became apparent. Once the placement was up and running Tracey focused on organising the rota, ensuring student attendance and liaising with the university.
Carmen is a field educator in a school that takes children and young people who are newly arrived in the country and have English as a Second Language. Many of these children are refugees or have travelled with families seeking asylum.
The last group of student with whom Carmen worked undertook a project to develop and deliver a lesson and leaflet on healthy lifestyles for school pupils. Carmen said that she treated them like student teachers. She got them working with pupils, their families and staff to identify how they might use their knowledge, skills and position to benefit the school. Health education was an obvious choice. There was concern about some children’s low awareness of threats to their safety and exposure to fast food culture. Medical students could marshal and present information about these health issues with confidence and credibility. Carmen would work with them just as she would with student teachers; drafting lesson plans, producing resources and so on.
Carmen saw her role as supporting students by providing structure to their learning by helping them to identify a task or activity around which they could organise their placement. For example, they had to think through how one might negotiate cross-cultural communication and language issues in the context of a ‘real’ task involving providing information.
Carmen drew particular attention the importance of having daily contact with the students. This included asking to see their reflective journal entries after each day on placement. This meant she knew what they were thinking and learning and helped to shape the support that she gave them.
A checklist (of sorts)
The work of Rick, Tracey, Carmen and the other field educators that I spoke to suggests that field education should not be an onerous or difficult job. It does take time, and skill, but above all, it requires a thoughtful and creative approach to involving students in organizational practice and life in a way that adds value and creates space for them to develop and use their skills, knowledge and labour. As the work of Nick, Tracey and Carmen illustrates there are a number of things to take into account:
- Being clear about what you a trying to achieve as an organisation by taking medical students on placement. This means being clear about what you want them to get our of the experience, both now and in the future if they become doctors, what you want them to contribute to your organisation, and the ways that they might do this.
- Being confident that you have the capacity and structures that will support realisation of these aspirations. Being aware of how rostering of staff, workload and organisation of work might influence the kind of support that you can offer and the kind of work that students can engage with and do.
- Ensuring that activities and tasks and projects are appropriate and proportionate to the role, skills and capacity of the students.
- What medical students bring that you might be able to use of as an organisation. It might be specific knowledge or interests or skills. It might be their presence as representatives of healthcare services and professions or as the role models.
- Finding activities and projects that get students working with people – staff, volunteers, other agencies and service users and clients and communities – as a matter of course.
- Providing support that guides students, that harnesses their creativity and energy and providing supervision that checks their contribution and learning. Include regular and routine briefing and de-briefing and consider utilising mechanisms and systems that might already be place such as reflective writing logs.
- Provide training as necessary and where possible in line with that which the organisation would provide to any other volunteer/member of staff.
- Be alert to how organisational change can disrupt continuity in placements and hence their capacity to benefit students, providers and communities.