Postgraduate education in transfusion medicine in the ...

Transfusion and Apheresis Science xxx (2012) xxx–xxx

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Postgraduate education in transfusion medicine in the absence of formal residency training: Assessment of factors needed to develop and sustain a postgraduate diploma program Vernon J. Louw a,⇑, Marietjie M. Nel b, John F. Hay c a

Division of Clinical Haematology, Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Health Sciences Education, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa c School for Social Sciences and Language Education, Faculty of Education, University of the Free State, Bloemfontein, South Africa b

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Article history: Available online xxxx Keywords: Postgraduate diploma Transfusion medicine Curriculum development Delphi survey Program sustainability

a b s t r a c t Background: Quality education in transfusion medicine is key to delivering a safe and costeffective blood service, yet postgraduate residency programs are lacking in many resourcelimited countries and regions. The first formal, accredited, postgraduate training program in transfusion medicine aimed at medical doctors was developed and implemented at the University of the Free State in Bloemfontein, South Africa, in 2008. In the context of high demand and limited resources, ensuring sustainability of postgraduate training programs is essential. Study design and methods: A formal qualitative and semi-quantitative research approach was followed to determine and test the factors considered important in program sustainability, and consisted of a literature survey, followed by semi-structured interviews and a Delphi survey. Results: Fifty-five factors were identified from the semi-structured interviews. During the Delphi survey, consensus was reached on 41 and stability declared on a further 13. These factors formed the basis of a structured model informing the sustainability aspects of a postgraduate program in transfusion medicine. Conclusion: Literature on program sustainability in the field of transfusion medicine is very limited. This study identified the key factors essential to the long-term viability of a postgraduate program in transfusion medicine and should find broad applicability in other resource-limited countries and regions. It is envisaged that this will enable such programs to reach a state of self-sufficiency while not being overly reliant on external funding and support. Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction Postgraduate education in transfusion medicine is crucial to blood safety, blood banking practice and research.

⇑ Corresponding author. Address: Division of Clinical Haematology, Department of Internal Medicine (G73), Faculty of Health Sciences, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa. Tel.: +27 51 405 2907; fax: +27 51 444 1036. E-mail address: [email protected] (V.J. Louw).

In many countries, this need for postgraduate education is met by residency programs. In countries without residency programs, especially those that are limited in available resources, alternatives are required. According to the most recent World Health Organization (WHO) Global Database on Blood Safety of 2004–2005, only 47 (49%) out of 96 countries had a formal educational program in transfusion medicine leading to a university degree or diploma [1]. In South Africa, this issue was addressed by developing the first, formal, nationally

1473-0502/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.transci.2012.07.003

Please cite this article in press as: Louw VJ et al. Postgraduate education in transfusion medicine in the absence of formal residency training: Assessment of factors needed to develop and sustain a postgraduate diploma program. Transf Apheres Sci (2012), http://dx.doi.org/10.1016/ j.transci.2012.07.003

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V.J. Louw et al. / Transfusion and Apheresis Science xxx (2012) xxx–xxx

accredited, postgraduate diploma in transfusion medicine in English for Africa at the University of the Free State in 2008 [2]. This program is aimed at medical doctors from both urban and rural areas, with a balanced focus on both blood banking and clinical transfusion medicine. Students follow a two-year curriculum, part-time, with two to three contact sessions of 4 days each per year. Written assignments relevant to the student’s environment are completed and electronically submitted every 2–3 weeks and a formal research project in the form of an audit of transfusion practice is conducted in the second year. With an increasing demand for training while functioning in a resource-poor environment, sustainability was identified as a key issue in ensuring long-term viability of this program. Thus, concurrent with the development of the program, a formal research initiative was launched to study this and other aspects of the development of a postgraduate diploma in transfusion medicine. Sustainability has been defined as ‘‘using a resource so that the resource is not depleted or permanently damaged’’ [3]. Sustainability in programs related to healthcare has been defined in various ways, with some definitions emphasizing sustained health promotion capacities [4] as being at the core of a program, while others focus more on the persistence or ‘‘institutionalization’’ of the program [5]. Shediac–Rizkallahand Bone [6] have pointed out that these definitions are not synonymous and that ‘‘institutionalization’’ may be associated with ‘‘inflexibility and adaptation of a program in toto’’ while Pemba and Kangethe [7] from the Moi University in Kenya emphasized innovation, research, service provision and responsiveness to globally competitive knowledge markets in contexts where government support is declining. Sterling has commented on the importance of moving from a transmissive to a transformative paradigm, with sustainability requiring ‘‘vision, image, design, and action from all concerned’’ [8].Warburton has shown the importance of deep learning and interdisciplinary thinking in fostering sustainability [9]. Education in transfusion medicine has a number of unique challenges in that the practice of transfusion medicine takes place in a variety of very different contexts, for example, the blood bank, general medical practice and medical specialties, and both rural and urban settings. Careful reflection, planning and thoughtful consideration of a variety of factors are required to ensure that these programs meet the needs of a diverse student population drawn from the contexts and settings noted above, while simultaneously ensuring that such a program retains its appeal, relevance and status of being value-adding. These variables remain largely elusive with regard to the transfusion medicine context, as almost no literature is available on the factors required to ensure the sustainability of a formal university-level postgraduate education program aimed at medical doctors in this field. This study investigated factors necessary to develop and sustain this and similar programs, which will enable the provision of strategic guidance and direction for the future. Despite being focused on the South African setting, the findings should have applicability to most other countries and regions without residency programs.

2. Methods 2.1. Experimental design Approval for the research project was obtained from both the Dean and the Ethics Committee of the Faculty of Health Sciences at the University of the Free State. The study comprised three phases. A literature review formed the basis of the study in order to contextualize the problem and gain deeper insight into the most relevant issues that are important in terms of program sustainability. From this a questionnaire was developed which was used in semistructured interviews during which a large number of factors related to program sustainability were identified. Finally, these factors were tested in a Delphi survey to confirm the usefulness and value of each of these criteria. Written, informed consent was obtained from all participants. Experts were viewed as individuals with at least 10 years’ experience in medical education, as well as knowledge of and more than 10 years’ experience in clinical blood transfusion medicine. All of them had to have at least a postgraduate specialist medical degree. 2.2. Literature survey The literature related to sustainability in postgraduate medical education and transfusion medicine was studied making use of PubMed, Medline and Google Scholar searches. Also, the references from articles thus identified were used to find further articles to elucidate the topic. 2.3. Semi-structured interviews Semi-structured interviews comprising a number of open-ended questions were conducted with three South African and five international experts in transfusion medicine (one each from Belgium, India, Tunisia, the United Kingdom and the USA). Interviews were done in person, voice-recorded and transcribed. Statements were extracted from the transcriptions and categorized in themes. Finally, the collected data were integrated, summarized, classified and used to compile the statements used as criteria in the Delphi survey. 2.4. The Delphi survey The Delphi survey was conducted in order to establish a set of criteria needed for the development of a model for a postgraduate diploma in transfusion medicine, and to determine their relevance, importance and practical application. After evaluating the literature related to the execution of Delphi surveys, it was determined that 12 experts would form a statistically adequate number to provide useful information in the context of an a priori level of consensus set at 80%. This also ensured completion within a reasonable time period. The survey population thus included 12 national and international experts in the field of transfusion medicine education. The 12 participants on the Delphi panel were experts who had been trained in South Africa, and several of them had done postgraduate



studies overseas. This aspect was regarded as important in that the information gleaned from both the international literature and the outside experts needed to be tested for its appropriateness within the South African context. Participants were given 3 weeks to complete each round of the survey. Fifty-five statements related to sustainability were included in the Delphi survey and evaluated by the participants on a Likert scale, representing evaluation of each statement as ‘‘essential’’, ‘‘useful’’ or ‘‘unnecessary’’. 2.5. Data management Three rounds were required to obtain adequate consensus and stability. Candidates were also given the opportunity to provide additional comments if they so desired. Analysis was performed by calculating the frequency of responses for each statement on the Likert scale. Consensus was considered to be achieved if 80% of the panel members chose the same option on the Likert scale. All statements on which consensus was reached in a particular round were excluded from the next round. Feedback with the results of each round was provided to participants before starting a subsequent round. Participants could change their opinion if they wished to do so and could thus assign a different level of importance to any of the statements where they considered this to be appropriate. Only before completion of the last round, were the responses of fellow participants in terms of comments and choices on the Likert scale, made available to all participants in an anonymized fashion. 3. Results 3.1. Semi-structured interviews Fifty-five statements related to program sustainability were identified during the interviews. Statements could be classified by means of content analysis into 10 categories, which included (i) sustainability factors related to academic staff; (ii) value creation; (iii) networking; (iv) financial viability; (v) structure and organization; (vi) program content and outcomes; (viii) assessment; (viii) career-path creation; (ix) program recognition; and (x) continuous improvement. Table 1 summarizes the findings from the interviews. 3.2. Delphi survey All 12 members of the Delphi panel completed all rounds of the Delphi survey (100% response rate). After Round One, consensus was reached on 18 out of 55 statements. Consensus was reached on a further 10 statements after Round Two and another 13 statements after Round Three. Thus, consensus was reached on a total of 41 out of 55 statements. Stability was declared on 13 statements on which no consensus could be reached and where participants indicated no further changes. On one statement, no consensus or stability could be reached. The factors deemed essential by consensus of the Delphi participants, included factors related to the team organizing the

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programme, the programme itself, infrastructure and support, the qualification obtained as well as student-related factors. These are summarized in Fig. 1. 4. Discussion Developing a postgraduate program in transfusion medicine is an intensive process, not only in terms of financial, management and manpower requirements, but also in terms of ensuring that adequate foundations are laid that would ensure long-term sustainability. Having a properly qualified, highly motivated and dedicated team with well-defined roles who drives and manages all the processes – from program development to implementation – is the starting point. This approach will not only fulfil regulatory requirements, but also give credence to the program. Strong, supportive leadership based on an inspiring vision that is clearly communicated, is essential to the good functioning of such a team [10]. Combining these aspects with a well-structured program in an institution possessing not only the required infrastructure, logistics and administrative support, but also efficient management systems, will greatly increase the odds of the program having a long shelf-life. Using a combination of all these features effectively requires careful shortand long-term planning that is aligned with the vision of the program, which includes careful financial planning and budgeting with complete and transparent feedback provided on a regular basis to all stakeholders, especially funders and institutional management. This may enhance the chance of receiving repeat funding from donors and ensure on-going support from the institution and Faculty management, all of which are vital to long-term success. The organizers of the program should have a clear understanding of the needs of their target student group and the populations they serve, and make sure that these are addressed by the structure and content of the program. It will ensure that participants would find the training meaningful, relevant and applicable to their daily practice. Doing this will instill a sense of value in the education received and motivate students to apply their newly found knowledge in their working environments and to complete the course. Relevance of the program and its content to the students’ work settings needs to be considered carefully, especially in a context where participants may come from diverse environments, such as rural areas, private practice, and academic medicine or blood transfusion services. It is important to permit a degree of flexibility during assessment whereby students are allowed to provide answers to an assignment as it applies to their individual work environments. It is also important to provide balanced teaching that addresses all these different contexts, yet neither over- nor under-emphasizes the needs of one group in particular. Furthermore, the continuous medical education (CME) needs of medical doctors should be taken into account by having contact sessions with students and lectures accredited in order for them to obtain CME credits. Another key area that should enhance program sustainability relates to course content and structure. Having a curriculum that is broad enough to deal with the interrelated issues of transfusion science, blood banking, ethics,


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Table 1 Major factors identified from semi-structured interviews as being important in terms of program sustainability. 1. Academic staff Properly qualified team that runs the Diploma Roles of team members need to be clearly defined Expose students to a broad spectrum of lecturers from different backgrounds Use different lecturers at different times There should be good guidance for students Dedicated team needed Can use part-time faculty to compensate for an insufficient number of full-time faculty members 2. Value creation (and meeting of needs) Enough people must want to do it, i.e. there must be a need for the course The program must have value to the person who does it The course must empower students to research relevant issues in their clinical environment There must be value in obtaining the qualification Malpractice insurance levies for doctors who practice transfusion medicine without the qualification may make it more attractive Doing the course should allow the students to do things not otherwise part of their job description Blood banks should require that their doctors have a formal qualification in transfusion medicine There must be a follow-up program after the diploma, e.g. where students can come back annually for refresher courses Sponsor people to attend on a meritorious basis 3. Networking Input needed from a variety of role players Get buy-in from the private sector 4. Financial viability There must be a revenue stream Obtain sponsorship from the private sector, e.g. private laboratories 5. Structure and organization Must be a part-time program, i.e. doctor must be able to do it from his/her practice Dedicated administrative support is required Course can be short and full-time, but also reasonable to have a part-time course with intensive contact sessions Course must not be too long or take too much time Must have defined blocks of contact time Needs to be well organized There should be appropriate infrastructure for presenting the course Logistics to present course should be in place 6. Program content and outcomes The course must cover a broad spectrum of clinical issues The course must be relevant to clinical practice The course must be applied to clinical practice The course must not be too specialized Individual topics need to be well-structured Course must not be too intensive The curriculum needs to be clearly defined, e.g. with well-defined start and end Must have practical sessions that are relevant Include a problem-based component in the curriculum using case studies where people can learn from mistakes There must be exposure to the actual blood bank The curriculum needs to be organized in an integrated way There should be good program and educational material Outcomes need to be defined 7. Assessment There must be deliverable assignments Evaluate the practice and knowledge of the students There must be self-assessment programs Need to give feedback to students on assignments 8. Career-path creation Job possibilities need to be created, e.g. posts for doctors who take responsibility for clinical transfusion practice and the transfusion committee in a hospital Job opportunities for research in transfusion medicine 9. Recognition of program The program must be recognized by the relevant governing bodies A regulatory framework that requires certification in transfusion medicine Programs should be certified according to certain criteria There should be a certifying agency Continuous professional development (CPD) accreditation 10. Continuous improvement The outcomes and new developments achieved by the students who have qualified should be fed back into the course Get feedback from the participants One should diversify and broaden the interest in order to remain sustainable despite medical and technological advances

hematology and clinical transfusion medicine, yet deep enough to ensure a solid foundation in the basic science and philosophical principles underpinning the above, will

contribute to a horizontally and vertically integrated holistic whole. A key consideration here is the structure and organization of the program, which includes innovative



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Fig. 1. The essential elements of sustainability in a postgraduate education program in transfusion medicine.

curriculum design, clearly defined outcomes, high quality study material, appropriate use of technology, engaging and knowledgeable teachers and an authentic and reliable assessment system. These issues should be aligned with the institution’s educational philosophy (for example, outcomes-or problem-based), yet be flexible enough to accommodate novel educational paradigms as required. From a teaching methodology point of view, both theoretical and practical forms of teaching should be included, while taking into account that one deals with adult learners where a culture of lifelong learning should be cultivated and encouraged. Providing prompt, honest feedback to students and allowing them to do the same will enhance an atmosphere conducive to learning and growth that may lead to program improvement and thus enhance program sustainability. The latter would be one element of an overarching program of continuous improvement that is vital to the long-term survival of any modern educational program. From a practical point of view, providing such a program as a part-time course, perhaps with distance learning elements, will allow busy medical professionals to participate without too much disruption to career or family life. It is imperative that all the relevant stakeholders are identified early and that an inclusive and collaborative process is followed taking into account everyone’s needs. Care should be taken to harness the strengths of all relevant internal and external role players such as blood transfusion services, universities, professional bodies and societies, educators, communities, government, funders, alumni and students. These networks should be carefully cultivated and sustained by keeping communication channels open, being transparent and through the nurturing of good interpersonal relationships between partners. Finding areas for collaboration and developing cognate programs could be instrumental in creating a formal career path in transfusion medicine. Identifying factors that make a program sustainable is not a one-off exercise, but should form part of an education

program’s cycle of continuous improvement. With an increasing emphasis on corporate governance, it is imperative that resources are used in a way that is justifiable in terms of community needs and strategic health priorities. Doing this in an accountable manner should pave the way towards ensuring the sustainability of educational initiatives in transfusion medicine. Finally, the recognition of such a program and exiting with a formal postgraduate qualification and the creation of a previously non-existent career path, should add greatly to the perceived and actual value of such a program. Acknowledgements Prof. Ronald Strauss, Professor Emeritus at the DeGowin Blood Center, University of Iowa, for his insightful comments and guidance in preparing this manuscript, as well as his continued support as speaker and mentor of the postgraduate diploma in transfusion medicine at the University of the Free State. Dr. Daleen Struwig, medical writer, Faculty of Health Sciences, University of the Free State, for technical and editorial preparation of the manuscript for publication. References [1] World Health Organization (WHO) Blood Safety Unit. Global Data on Blood Safety Report 2004–2005. Available at: [Accessed 2 September 2010]. [2] Louw VJ, Nel TJ, Leipoldt EJ, et al. Challenges in transfusion medicine recruitment and training-a solution. Transf Med 2010;20:70–1. [3] Merriam–Webster Online Dictionary: Available at: [Accessed 11 April 2011]. [4] Jackson C, Fortmann SP, Flora JA, et al. The capacity-building approach to intervention maintenance implemented by the Stanford Five-City Project. Health Educ Res 1994;9:385–96. [5] Yin RK. Changing urban bureaucracies: how new practices become routinized. Lexington: DC Heath; 1979. [6] Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and


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future directions for research, practice and policy. Health Educ Res 1998;13:87–108. [7] Pemba SK, Kangethe S. Innovative Medical Education: Sustainability through partnerships with Health Programs. Education for Health 2007; 1–5. Available at: [Accessed 3 April 2012].

[8] Sterling SR. Sustainable Education: Re-Visioning Learning and Change. In: Schumacher Briefings. Devon, UK: Green Books; 2000. [9] Warburton K. Deep learning and education for sustainability. Int J Sust High Educ 2003;4(1):44–56. [10] Dickard N. The sustainability challenge: taking EdTech to the next level 2003. Available at: [Accessed 3 April 2012].
