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Introduction
Supply and training of human resources that are committed, professional, efficient and entrepreneur based on local and national needs is one of the important missions of higher education in the field of health in Iran. In this regard, some programs have been developed and innovation in medical education based on the Health Sector Higher Education Plan. This document includes important packages such as strategies for realization of macro-policies aiming at reducing the displacement of clients in search for specialized services. This is done by the deployment of specialists in different endemic areas. There is also a responsive and equitable training package, which includes establishing a system for recognition and evaluation based on community needs, revising and developing training programs to meet the community needs, designing a system for increasing accountability and incentives to better meet the real needs of the society, and paying due attention to the social determinants of health.1 In their qualitative study, Ahmadi et al.2 suggested that in recent years, there has been much debate about the need for change in medical education in Iran. One of the desired changes is to increase accountability among medical students. In their study, they suggest eight proposals for education policy makers to develop accountable medical education including organizing accountable educational councils, developing community-based curricula, providing training in the real community contexts, organizing educational processes, integrating and coordinating educational rules and regulations, pursuing proper budget management, paying attention to educational outcomes, and carrying out educational programs in the wards. An example of fairness is to ensure equitable access of all people to health services.
Kulbok et al.3 found that community health nursing is a community-based practice, which requires unique knowledge, competencies, and skills. The role of nurses in primary health care is beyond just patient care and covers issues such as the protection of clients' rights, social organization, health education, and promotion of social and political reforms. They believe that community health nurses can help the solution of multifactor community problems by encouraging people's participation in society. Development of students’ capabilities during their education is the goal of all leading universities. In a study carried out by Zandee et al.4 in the Calvin College, Department of Nursing community health nursing students worked with public health staff to provide service and training to West Michigan community. Nursing students in the program focused on cultural issues, critical thinking, nursing process, health indicators, available resources, social justice, vulnerable populations, and evidence-based practice. During the past decades, community-based education has been implanted in many developed and developing countries for providing health services.5,6 In Iran, although community-based activities are abundant, there is little evidence about the provision of such services in remote and underdeveloped areas. Therefore, given that the training and internship program of the nursing students participating in this study was in the form of providing services in remote rural areas in the form of community-based home care, this study aimed to investigate the perception of clients, as well as the nursing students and instructors regarding community-based home care internship. The aim of this study was to determine the attitudes of nursing students and professors, and clients towards community-based training and internship in order to plan for the future development.
Methods
This was a qualitative research with content analysis approach. The community based training and internship planning conducted for one year from January 2016 to January 2017 in mianshar and villages around the city of Fasa in southeast of Fars province, Iran. The data from students and professors were collected using semi-structured in-depth interviews in five focus groups. The clients’ attitudes were collected using field notes collected in 800 home care events. Out of the 77 students participating in the program, 17 students were chosen and interviewed. Three professors who had assumed the responsibility of leading the program were also interviewed. The interviews continued until data saturation. Interviews and notes were transcribed in word files. The interviews were listened over and over again so that a general perception was formed. Then, generating initial codes and searching for themes among codes were carried out. Then abstraction of data was done using open, axial and selective coding. Constant comparison was used for data analysis. Max QDA was used for analysis. Ethical clearance was obtained from the university's ethics committee. Participation was voluntary and informed consent was obtained from the participants. Gathered data was treated confidentially and code numbers were assigned to participants' taped transcripts to ensure anonymity.
Results
Providing health services in remote areas in the form of home care creates a mutual experience between clients, students, and professors. In addition to promoting fairness, it causes mutual empowerment of clients, students, and professors and creates a positive outlook towards health care system since the provision of services occurs in a warm and friendly environment. The results were classified into two main categories: "preservation and promotion of health" and "promotion of student abilities".
Preservation and promotion of health
The results of this study showed that students in this curriculum made attempts in the course of maintaining and improving the health of people who lived in remote areas and had insufficient access to health services. Their efforts resulted in client satisfaction of students and professors. The main category of preservation and promotion of health had two sub-categories: education and follow up and referral.
Education
The results showed that the students could play an educational role under faculty supervision in the curriculum and that they deemed their role in this area helpful. In addition to providing home care, the students provided instructions in urban and rural environment hygiene, home and school hygiene, occupational health, lifestyle, common diseases in the region, and mental health. In addition, students distributed pamphlets on nutritional control in patients diagnosed with hypertension and diabetes. The results showed that the instructions were useful for both clients and students:
Community-based research is widely done in the world today. This means that you must check the real problems of the society. A fact that was very interesting for me was that the students saw people's real problems and dealt with the status of hygiene in their environment and buildings, and the common diseases in the treated area. Just like when we were dealing with the disease in the city of Fasa, the students themselves observed the health conditions in schools and talked to the teachers and school principals. In all these cases, professors and students taught the necessary points [Participant 20, professor]; Students instructed people on hypertension, diabetes, and cutaneous leishmaniasis and ways to prevent them; kidney stones and preventing water stagnation; separation of the livestock living place from that of the humans; the need to wear boots and gloves when working with livestock and wear a hat by farmers to avoid skin cancer; healthy diets to reduce the consumption of oil, salt, sugar and sweets; and ways to prevent back pain. People benefited from the instructions and students recognized the gap between theoretical knowledge and practice and tried to bridge it [Participants 21, professor]; Today I visited a patient who had been suffering from dental abscess since a few days ago. He had used multiple antibiotics arbitrarily, but the abscess area was still swollen and red. I instructed him that self-medication might cause severe effects. I encouraged him to go to the dentist or a doctor to determine the treatment and the proper antibiotic immediately [Participant 5, student]; One of the important things that we did was to provide instruction. For example, if the patient refused to use medicines, we instructed him/her about the importance of the drug and complications resulting from not taking the prescribed medicines [Participant 7, student]; I am grateful that when you came last time, you controlled my blood pressure, listened to me, and encouraged me to go to a doctor. I had not checked my blood pressure and my health status. When I went to the cardiologist, they said that I had some narrowed heart arteries and cardiac surgery was needed. I'm fine now after the operation. If you had not instructed me, I would have died. I thank those students who helped me realize about narrowing of my heart vessels [Field note 130, 65-year-old patient].
Follow up and referral
In this curriculum, students checked the blood pressure and glucose of some family members when they entered their homes. Some patients were new cases of hypertension and hyperglycemia that were diagnosed and notified by students. New cases of a disease were referred to health centers at the village or nearby city and sometimes were sent to specialists via a referral letter by the University of Medical Sciences. The results of the study showed that clients, students and professors were satisfied with screening, follow-up, and subsequent referrals:
I did not know that I had hypertension. I will go to a doctor and follow up my treatment [Field note 300, 50-year-old patient]; That’s very good. I like health training and internship in the field more than hospital internship, because I can play a stronger and more important role here. For example, people who have not ever gone to a doctor and have not checked their, for example, blood glucose and pressure, are visited and can finally follow up their treatment. For example, today we visited a case that had been diagnosed with hyperglycemia a week ago, with a blood sugar level of 407. Now she has controlled the disease. It’s really nice [Participant 18, student]; When the students went to provide care, people asked them questions. They asked about diabetes, cutaneous leishmaniasis, and hypertension, for example, and the students would answer the questions as far as they could. Sometimes the students came to the conclusion that they need to study more and more. In these cases, the students did their best to the answer the people’s questions. One thing that encouraged both the students and us was those cases that were followed up. For example, some of the people we visited at their homes, were not aware that their blood pressure or sugar levels were high. We introduced them to health centers, hospitals, family doctors or specialists [Participant 19, professor].
The promotion of students’ abilities
The results of this study showed that as people benefited from nursing students and professors, going to serve the community and the people in real context enhanced the capabilities of the students. The main category of promoting students’ abilities is divided into two sub-categories: improvement of interactions and development of professional competence.
Improvement of interaction
The results of this study showed that both students and professors believed that students’ interactions had improved during the program. Students enjoyed communication with lonely elderly people, who sometimes lived without care and empathy from people around them:
Some patients had psychological problems. If they could feel better psychologically, the treatment of their physical diseases would be easier. They felt better as they talked to us. We needed to obtain their consent and confidence to enter their homes and our empathy was necessary [Participant 7, student]; The good experience I have regarding the students’ improvement is that many of the students had trouble communicating when they wanted to get into the homes to deliver the services, but some were capable in this regard and started communication earlier. Later on, we assigned the responsibility of the communication to students with weaker communication skills so that they can improve in this regard. The mere contact with rural community was very useful. The sincerity the students saw in the village was very interesting for them. People in the rural community accepted students more easily compared to people in urban areas [Participant 19, professor]; I'm so glad I’m here in this house, because this 72-year-old woman is very lonely and is feeling depressed. She has become very happy to see us. I also learned that elders are a blessing and we should not leave out parents alone [Participant 12, student].
Development of professional competence
Based on the results of this study, both students and professors believed that the professional competence of students improved. Such competence includes their health-oriented perspective, policy making abilities, a sense of responsibility and concern for people, and the use of community experience and evidence, which sometimes lead to misconceptions in society and sometimes generate research ideas and innovation in health care:
If we can prevent diseases right here, there will be no need to bring the patient to the hospital. A small measure here can prevent a big problem, like for example, open heart surgery. If we had visited the villages, they would not have been forced to come to the hospital, faced with high costs and other consequences. I like this much more than I like working at the hospital, because it is more beneficial. It is as if we give life and opportunity to the people again [Participant 18, a student];
This program changed the medical students' focus from medical to health aspects. And even some research topics can be derived from these visits [Participant 20, professor]
Other examples of development of professional qualifications were the result of the experience and evidence they collected on health issues in their contact with people. Students may not find these experiences in their textbooks. Using critical thinking, the students modified the myths in their minds and the beliefs in need of reform. They also viewed some experiences as sparks of research ideas. Based on field note 570, the students visited a family consisting of husband, wife, and two children one aged five and the other two. The two-year-old child had multiple lesions of cutaneous leishmaniasis. The students listened to the experience of the family in treatment of their child: We never took our child to hospitals or care centers for treatment. Cryotherapy makes the situation worse and increases the size of the wounds. We burnt wands of Tamarix, and mixed its soot with fig tree resin. The mixture had better results. Based on note 230, the students visited a 27-year-old woman, who had a bachelor's degree, and listened to her experience in reducing the delay in fertility: I did not became pregnant until about three years after marriage. In order to enhance the performance of my ovaries, I started eating the plant Ferula assafoetida (Stingingassa Asafetida). Then I became pregnant and I have a son now. Field note 909, which is the last one, includes comments by students indicating the fact that clients’ concerns have become the students’ concerns. Nursing students said: All students in the class have collected some money. We want to give it to a child who had lost her parents and grandparents who do not have a good economic situation take care of her.
Discussion
Discussing the development of medical education, some believe that training medical students is a responsibility that should be done collaboratively and requires the participation of universities, educational institutions, community institutions and service providers.7-9 This study showed that although community-based training and internship along with professors have some challenges such as shortage of facilities, equipment, and human resources, it was evaluated as useful for the community by students and professors participated in this study. The results were in line with those of similar studies.10 As the results showed, the main category of "preservation and promotion of health" had two sub-categories: "education" and "follow up and referral". In the provision of home care in remote areas, students played an important instructive role and the people benefited from the instruction provided by students and professors. This result was in line with the results of a study done for reform of medical sciences in Brazil, Falavigna et al.11 suggest that there should always be a connection between the health system, universities, and the community. They believe that medical education and training must act as a means for providing service within the community. Sarrafzadegan et al. ( (12 studied a community-based interventional program designed to develop Healthy Heart Program in Isfahan, providing educational materials and training were important. They found that developing teaching materials and provision of instruction were more important. Despite the lack of human resources, the nurses did their best in training. In such programs, preparing students and encouraging them to participate can resolve the problem of lack of human resources to some extent and create a synergy in teaching.
The results of this study showed that the students and professors involved in the study performed screening in the area of diseases like diabetes and hypertension and made a referral and did follow up measures if necessary. All patients expressed their satisfaction with the screening, referrals, and follow-up measures. This finding of this study was consistent with studies stressing the importance of screening programs, follow up and referral, and those recommending the need to clarify the screening processes, using repeated reminders to patients to control the retina damage and other diabetes complications, including and repeating this advice in screening programs, and educating the public on the treatments of damage to the retina. It is also consistent with results on the role of nurses in public health promotion.13-18
The second main category, “promotion of students’ abilities”, is divided into two sub-categories: "improvement of interactions" and "development of professional competence”. The results showed that although providing home and community-based services was primarily accompanied with challenges such as defects in communication or in gaining the trust of the families, over time, the students developed their interaction skills and completed the care process well. This is consistent with the results of studies suggesting that community-based training and internship improved socialization of students and made them acquainted with the social realities and needs of primary care.(19, 20) The results showed that home and community-based health care services help the development of professional competencies such as health-oriented perspective. This is consistent with findings of Martin21 and Peterset al.22 suggesting that nurses believe that entering the field of primary health care is essential due to the increase in the workload of non-communicable diseases.
In the field of policy making and economics, students understood issues such as the effect of health and poverty on the human’s disease and health process, as well as the impact of diseases on the family economy. In their collective work, they tried to solve the economic problems faced by some people. This result was in line with the results by Freire,23 who believed that in this type of training and internship, students are fused with the community and from a liberating perspective, understand the oppression from the perspective of people. For example, in the field of health, students understand health and social problems caused by the unfair distribution of resources or social injustices and shortages. They try to resolve the shortage of knowledge resulting from social, psychological, political, economic and cultural factors on people. Students also have a responsibility to inform people about the factors affecting their health and about the changes needed.
The results show that bilateral development and empowerment is a central variable. Moving education and health services to remote areas can improve the development and empowerment of individuals, families, and clients. In addition, the students can develop interactions and professional qualifications in such programs. This is consistent with the results of the study by Kulbok,3 who found that community health nurses can increase participation of community members and empower them in health promotion and prevention. Such empowerment can in turn reduce threats to their health and increase social justice. However it was inconsistent with some studies that had shown an inverse relationship between society and higher education and deemed people as just passive receivers of services.24,25
The conclusion of this study is that community-based program of training and internship provides learning opportunities for undergraduate nursing students. Increase in non-communicable diseases and the growing population of the elderly in the community has increased the need for nurses who provide community-based home-based health care services. Therefore it is better to start education on provision of services beyond hospital beds.
Some limitations of the study is that the researchers were all healthcare professionals, which may have influenced the subjectivity of the findings. Like all other qualitative research, it is also acknowledged that the findings of this study have some limitation in their generalizability. However, qualitative research designs are often not generalizable although they offer opportunities of 'transferability to similar context.
We recommend community-based training and internship programs for students in the form of teamwork can be enriched with the participation of all health students, especially medical students; the participation of all university deputies; improvement of equipment; removal of weaknesses of the community-based programs based on opinions of clients, students and professors; and arrangement of workshops for students on dealing with common regional diseases and problems. At the regional level, recommendations include continuing community-based training and internship; and transferring comprehensive health service delivery to remote and underdeveloped areas, for example via employing resident health workers, lowering health care costs, making visits doctor or hospital referrals easier for people in remote areas. At the national level, cooperation is needed on the part of the Ministry of Health, Treatment and Medical Education, the Ministry of Cooperatives, Labour and Social Welfare, and other supporting organizations such as the Organization for Social Welfare, and Relief Committee to allocate one to five quotas to health workers supporting the poor, so that the deprived people in the country are covered by support efforts in the form a network.
