Implementing community-based education in basic nursing education programs in South Africa

Kev words Abstract: Curationis 32(1): 25-32 Community-based education, nursing Education of health professionals using principles of community-based education is programmes, service learning, commu^ rec0mmencic(j national policy in South Africa. A paradigm shift to communitynity health nursing programme based education is reported in a number of nursing education institutions in South Africa. Reviewed literature however revealed that in some educational institutions planning, implementation and evaluation of Community-based Educational (CBE) programmes tended to be haphazard, uncoordinated and ineffective, resulting in poor student motivation. Therefore the purpose of this study was to analyse the implementation of community-based education in basic nursing education programmes in South Africa. Strauss and Corbin’s (1990) grounded theory approach guided the research process. Data were collected by means of observation, interviews and docu­ ment analysis. The findings revealed that collaborative decision-making involving all stakeholders was crucial especially during the curriculum planning phase. Further­ more, special criteria should be used when selecting community learning sites to ensure that the selected sites are able to facilitate the development of required gradu­ ate competencies. Collaborative effort, true partnership between academic institu­ tions and communities, as well as government support and involvement emerged as necessary conditions for the successful implementation of community-based educa­ tion programmes.


Introduction
To address population needs and eco nomic constraints, health care systems are changing in order to address eq uity, cost effectiveness and quality-re lated issues.Community-oriented pri mary care is attractive to many on a principled level because it envisions community participation in health care d ecisio n s (M ullan & E pstein, 2002:1749).This system o f health care was developed by two physicians in South Africa during the 1940's, partially adopted by many other countries, and used by the World Health Organization in their definition of primary health care.In 1997,3 years after the election of the first demographic government in South Africa, a policy paper (Transformation o f the Health System in South Africa: 1) called for the re-orientation of health professionals' education to a compre hensive primary health approach and community-based education (CBE) as the method to implement this approach.
The education o f health professionals must ensure that programmes are pro ducing graduates who are prepared to serve in community settings (Nokes, Nickitas, Keida & Neville, 2005:44) as a result o f the paradigm shift from fixed institutions, such as hospitals, to var ied settings in the community (Frank, A dam s, E d elstein , S peakm an & Shelton, 2005:283).Community-based education is an educational pedagogy that is used to link community service and students' learning.According to Salmon and Keneni (2004: 173), Community-based education takes place in the community where students are given an opportunity to apply theoreti cal knowledge in assessing, planning and participating in solving community health problems.

Background to the problem
An extensive review o f the nursing education literature focusing on South Africa (Adejumo & Gangalimando, 2000:3, Fitchardt, Viljoen, Botma, & du Rand, 2000:86, Fitchardt and du Rand, 2000:3, Gwele, 1997:275, Madalane, 1997:67;Mclnemey, 1998:53, Nazareth & Mfenyane, 1999:722, Uys, 1998:19) found that the implementation o f com munity-based nursing education var ied in different settings.Similarities included: a) extensive use of the com munity as a learning environment, b) partnerships between communities and academic institutions, c) community involvement, d) use of a problem-based approach in teaching, e) application of principles of adult learning, f) facilitat ing the development of transferable life skills, and g) basing the curricula on a health to illness continuum, with the focus on individuals, families and com munities.Differences included: a) types o f course assignments, b) dura tion o f time spent in the community during the entire educational program, c) timing o f the first community expo sure, d) organisation and sequencing of learning experiences in the curricu lum, e) the degree to which the commu nity was used as a learning environ ment, f) level of involvement in student experiences by members o f the com munity, g) the level o f involvement of other health team members and other members of the multidisciplinary team, h) the level o f involvement from other sectors such as agriculture, econom ics, and p o litic a l scien ce, and I)teaching/leaming approaches used.In addition, Madalane (1997:67) exam ined the quality o f facilitation and su pervision of community based learn ing experiences and found that some preceptors were inadequately prepared for their roles and responsibilities and, in some settings, community health workers were the primary preceptors of nursing students.The study by Salmon and Keneni (2004:173) revealed that in some educational institutions plan ning, implementation and evaluation of educational programmes tend to be haphazard, uncoordinated and ineffec tive, resulting in poor student motiva tion.Hence, the purpose o f this study was to analyse the implementation of community-based education in basic nursing programmes in South Africa.

Objectives of the Study
The objectives of this study were to: a) Analyse the process of imple menting community-based edu cation in basic nursing pro grammes in South Africa and b) Describe CBE antecedents, context, action/interaction strat egies, and intervening condi tions under which the phenom enon CBE occurs in basic nurs ing education in South Africa.

Research Method
This study employed a qualitative de sign and a grounded theory approach.
According to Chenitz and Swanson (1996) grounded theory makes its great est contribution in areas where little research has been done and when new viewpoints or gestalts are needed to describe the familiar phenomenon that is not clearly u n d ersto o d (p .7).
Grounded theory was thus appropri ate in a study o f this nature because very little has been done in terms of research aimed at understanding the phenomenon of CBE, either in South A frica or globally.Secondly, the grounded theory approach is a quali tative research method that uses a sys tematic set o f procedures to develop an in d u ctiv ely derived grounded theory about a phenomenon".The pri mary objective o f grounded theory, then, is to expand upon an explanation of a phenomenon by identifying the key elements o f that phenomenon, and then categorizing the relationships o f those elements to the context and process of the experiment.Strauss and Corbin's (1990) grounded theory approach in formed the study design, data collec tion, and analysis.

Research Settings
Using the published list o f all basic nursing education programs in South Africa (N=37), the researcher accessed the web sites of these programs and determined whether they were imple menting community-based education.Through this search, four university nursing schools running CBE pro grammes were identified and the staff of the South African Nursing Council (SANC) identified two additional nurs ing colleges which were using commu nity-based curricula.One of those two colleges had six campuses and one sub-campus.The researcher selected one campus situated in an urban area and one in a rural area for a total of 7 settings.

Data Collection
Data collection in grounded theory is directed by theoretical sampling, with sampling that is based on theoretically relevant constructs to ensure that data is relevant to the research questions or objectives (Davidson, 2000:pl).The researcher initially employed open theoretical sampling to identify indi viduals and documents that will con tribute significantly to the study.Later, during axial coding, the researcher adopted a systematic relational or vari ational sampling, with the aim of locat ing data that either confirmed the rela tionships between categories, or lim ited their applicability.The final phase of sampling generally involved discrimi nate sampling, which consists o f the deliberate and directed selection o f in dividuals, objects or documents to verify the core category and the theory as a whole, as well as, to compensate for other less developed categories, as stated in Davidson (2000:pl).
Multiple sources o f data were used.Through this analytic process devel oping concepts were described in terms o f their properties and dimensions.Some of the concepts were named from the words and phrases used by inform ants and some were derived from a pool of concepts the researcher knew from her academic subjects and professional reading.Strauss and Corbin (1990:68) refer to the later source of concepts as 'literature derived concepts'.Open coding included asking questions about data and making comparisons for similarities and differences between concepts.Similar events and incidents were grouped as categories.Guided by the premise that the study was aimed at uncovering the meaning of CBE in basic nursing education in South Af rica, not to compare different institu tions, the researcher, through the con stant comparative method of data analy sis, looked across all institutions that participated in the study to generate categories representative o f all.Open coding; which was the initial phase of data analysis took place concurrently with data collection.
Open coding was followed by axial cod ing.Strauss and Corbin (1990:96)  Selective coding was the final phase of data analysis.This phase was directed at refining the developing theory.Se lective coding involved verification of a core category around which the theory emerged.The theoretical sam pling used at this phase was referred to as 'discriminate sampling '.Discrimi nate sampling is used to select appro priate data such that weak connections between categories can be inductively strengthened and relationships that have already emerged can be deduc tively tested (Sarker et al, 2000:2).Dur ing this stage developed categories were further analyzed with an intention of finding those sharing similar char acteristics and merging them to form higher order categories.Through se lective coding diverse properties started to become integrated and the resulting theory began to emerge and eventually solidified.Selective sam pling of literature to determine the 'fit' of findings from earlier studies and ex isting theories with the present find ings was also conducted during the phase.The emerging theory was then validated against data to complete its grounding, as stated in Strauss and Corbin (1990:133) but this phase is not included in this article due to the speci fied length o f the article.

Discussion of Results
In grounded theory, the core category can be compared to the sun and sub sidiary categories are like the rays from the sun.The findings also reveal that there should be congruence between ex pected graduate com petencies and clinical learning sites to facilitate de velopment of expected graduate com petencies.According to the data ob tained through interviews, the curricu lum planners were guided by compe tencies required from the graduates in the process o f selecting appropriate learning settings.Furthermore, curricu lum developers took into consideration the levels in the health care system in South Africa (that is, primary, second ary and tertiary), as well as the under lying philosophy o f the health care system (PHC) s in their process o f se lecting clinical learning sites.The stu dents were therefore placed in a vari ety of clinical learning settings, includ ing community settings, PHC clinics, district hospitals, referral hospitals and rehabilitation centres to ensure ad equate exposure to all levels care within the health care system.
In CBE we say we want to produce graduates who will be able to serve communities at all levels, especially under-resourced communities.This should then be reflected in our selec tion o f community sites.

Development of stakeholders for the implementation of CBE
It emerged as crucial because CBE was an unfamiliar concept.The preparation of staff from the nursing education in stitutions, the health service person nel, the community, as well as, the stu dents and their parents came up as the key to the successful implementation o f CBE.The teachers were prepared through workshops, seminars, visiting well established local and international CBE programmes, attending CBE con ferences and inviting experts to come and assist along the process of plan ning and initiating CBE programmes, as stated below.
An expert from an overseas university had to spend the whole year helping us by running workshops and demon strating facilitation during the class room sessions.
Two sta ff members from our school at tended workshops in one o f the over seas universities....
Health service personnel, as well as, communities were prepared mainly through workshops and community meetings.The process o f preparing communities started with key figures who later invited communities to par ticipate.During the negotiation of com munity entry, it was important for the academic staff to understand the com munity's culture, language and to ob tain support o f community structures, as stated in this quote.I was specially employed to prepare the community because the academic sta ff o f the school had a problem in understanding the language and the cultures o f the surrounding communi ties.I worked with those communities fo r two years preparing them.
The preparation o f students and their parents emerged as another important factor because the students were go ing to be placed in community settings, the unfamiliar environment character ised by a number o f social as well as health problems, the environment con sidered as unsafe and uncomfortable.Meetings were held with parents in the beginning o f the first com m unity-based learning year, to allay their anxi eties.Special blocks were planned for the students to orientate them to CBE, basic community health nursing and PHC concepts, and to introduce them to transcultural nursing and multi-disciplinary approach to learning.

Our students arrive before the univer sity s scheduled opening time fo r a two week orientation block
Orientation includes introduction to CBE, cultural diversity, group dynam ics, PHC, community entry, community participation, how to do a rapid ap praisal and epidemiological studies, and learning contracts as means o f promoting self-directed learning.The students then visit the community sites where they will be placed later fo r their community-based learning.

CBE Curriculum implementation phase
Five subcategories emerged as under this phase; determinants o f the curricu lum, the nature and sequencing of com m unity-based learning experiences, teaching approaches, teaching/learn ing process, the nature o f the teacher, and the nature o f the learner.

Curriculum Determinants
The findings revealed four determi nants that shaped the CBE curriculum: priority health needs/problems in the surrounding environment (the commu nity in particular); students' learning needs; regulatory body (SANC) re quirements and the national health as well as education policies.These de terminants ensured relevance o f the curriculum content, they ensured that the curriculum was contextualised, dy namic and com munity oriented, as stated in these quotes.

The curriculum content is determined by the needs o f the community, the stu d e n ts' interests and the regulatory body.
The nursing council, as a regulatory body, gives directives on the impor tant issues to be considered in the cur riculum.
The Most o f our learning activities focus on the GOBIFFFF because we are pre paring graduates who are supposed to be PHC competent.They engage in these activities during home visits, at the clinics and sometimes as part o f their community intervention projects.

Teaching/Learning approaches
A problem-focused approach appeared to be the main approach used in four of the seven institutions with the aim of developing problem solving skills.The other three institutions were still using the expository approach, mainly be cause they were still writing examina tions set by a regulatory body.O f the four institutions, two were using paper problems and two were using authen tic unstructured problems from real life settings.The teaching learning ap proaches used ensured integration of subjects across the disciplines and a process o f generating context-based knowledge through students and edu cators engaging in a dialogue.
We use health problems as the basis in our teaching .The common understanding of the con cept 'partnership ' and the practice of true partnership emerged as an impor tant factor in the successful implemen tation o f CBE.The results in this study however revealed that partners did not understand this concept in the same way and that created some tension be tween partners.According to the data from interviews some voices were domi nating and other were not heard, or were faintly heard, especially the voices o f the communities.The rationale for this was that that the sources o f funds were academic institutions, whose fac ulty had to account for how learning was taking place.It seemed as if aca demic institutions had more power and say than other partners.
We were literally chased out in one o f the communities because o f our domi nating nature as nurses in the commu nity.This was one o f the best sites when it came to learning experiences.It had very rich learning experiences.We did not mean fo r this to happen but it was a learning experience.Our programme was still new then.

Government commitment
The findings in this study suggested that there arc concerns about the inad equate or lack of government involve ment in the implementation of CBE, es pecially because CBE is a directive from the government.A need for financial support as well as support with trans port to be used by students to commu nity learning sites was verbalised.The data however revealed that the gov ernment was somehow supporting CBE initiatives and the education of nurses.
One institution indicated that the gov ernment funded the building of an aca demic-community partnership struc ture in the community with a large sum of money.Some institutions indicated that the local government was support ing them with transport.
We have an agreement with the trans port department.The government au thorised that they provide us with buses to the community sites.This is helping a lot.

Conclusion
This

Objectives
The implied research questions trans lated to the following objectives: Firstly, to explore the experiences of the following role-players in providing health care services to a disadvantaged community during experiential learn ing: • the senior nursing and social work students • the health service delivery or ganisations • the disadvantaged community members; and The second objective was to investi gate what apparent health communica tion models are used in the efforts to link the needs o f the disadvantaged community with the provision of health services by students.The final aim was to formulate guide lines to enhance quality multi-discipli nary health care service delivery to a disadvantaged community by the stu dents, as part of their experiential learn ing.

Literature review
Theoretical perspectives on health care service delivery to a disadvantaged community by students are discussed to contextualise the study within the context of literature reports about simi lar investigations.

Health care service delivery
The Oxford Advanced Learner's Dic tionary (2005:690) defines health as "the state of being physically and men tally healthy".It is with this focus in mind that services are delivered to pa tients in the community.Service is also defined as "the system that provides what the public needs, organized by the government or a private company" (Oxford Advanced Learner's Diction ary, 2005:1335).Thus, health care serv ice delivery in the context o f this re search indicates an organisation that is tasked with the maintenance and pro motion o f public health within a spe cific area and for a specific disadvan taged community.The HIV/AIDS and STI Strategic Plan 2007-2011 (South Africa, 2007a:ll), states that in ten sificatio n o f the multisectoral national response, with the focus on better coordination and monitoring, is necessary.The govern ment, non-governm ental organisa tions, community-based organisations, faith-based organisations, private sec tors and the people living with HIV/ AIDS (in this research, people in the community needing health service) should employ a joint effort and be in volved at all levels of this Strategic Plan (P elser, N gw ena & S um m erton, 2004:308-309).Such a comprehensive approach to health-service delivery not only depends on one organisation or discipline, but on various role-players who must co-operate on a formal and informal level and in an integrated and co-ordinated manner as partners to render the health service.Within the context o f this research the university can be regarded as the informal and the health service organisations as the for mal role-players.The Social Welfare Action Plan (Na tional Welfare Department, 1998:121) further states that appropriate services should be provided to individuals and their families in communities who are unwell.The objective to achieve this goal is to develop home-based, familyoriented and community-based care strategies in collaboration with other stakeholders.A one-stop treatment service and a comprehensive district health and welfare service, which must collaborate to provide care, support and rehabilitation, is suggested by the W hite P aper for Social W elfare (1997b:88).

Disadvantaged community
According to the New Dictionary of Social Work (1995:18) and The Oxford Pocket Dictionary of Current English (2009) a disadvantaged community is a community functioning under unfa vourable circumstances and which has been disadvantaged educationally, economically and/or socially as a re sult o f inferior education, inadequate infrastructures and a lack of opportu nities for growth.People living in circumstances of pov erty cannot contribute to maintaining their own health.They cannot pur chase nutritional foodstuffs and this can lead to ill health, malnutrition and a high m ortality rate (Bezuidenhout, 1998:161;Bradshaw, 2008:56;De Swardt & Theron, 2007:29).A higher prevalence o f disease is listed among lower-income groups, including tuber culosis, diarrhoea and fever, while higher rates of mental and physical dis ability are found among the poor (Uys & Cameron, 2004:162).The infrastruc ture is not always there to address their health needs; for instance, there are few clinics in their area and there is no run ning water or sanitary facilities (Beytell, 2002:25).More than one third o f the South Afri can population o f 46 million is unem ployed, with almost one third living below the poverty line (Statistics South Africa, 2006).Because o f the high lev els o f unemployment and illiteracy in disadvantaged communities, they are to a large extent dependent on social grants.Currently the number o f ben eficiaries of grants and pensions is 12 million persons (South Africa, 2007b:4).Because of lack of money, their houses are inadequate, leak rain and dust, have weak foundations and are too small for the number o f people living in them (Swanepoel & De Beer, 2006:4).Over crowding can lead to a lack o f privacy, irritation with one another and children who tend to wander (Bezuidenhout & Joubert, 2003:59).There are almost no appliances in the houses such as stoves or fridges, and there is also a shortage of clothes and furniture in these com munities.Because o f the low level of education the members lack basic knowledge and skills, and the health care workers should develop programmes in which they could be trained in various skills.Income-generation and job-creation projects are some of the ways in which poverty issues could be addressed (Gathiram, 2005:127), because accord ing to Bradshaw (2008:57) education plays a fundamental role in health.There is a high incidence of HIV/AIDS in disadvantaged communities (Evian, 2003:21;Tladi, 2006:371;Uys & Cameron, 2004:162).According to Barnett and Whiteside (2006:296), pov erty assists the spread of HIV and AIDS and forces people into poverty, or makes it harder for them to escape from it.The health care profession with its specialised knowledge, skills and train ing needs to take responsibility for psychosocial services, and education and training regarding HIV and AIDS (Spies, 2007:291).AIDS orphans have to be placed in foster care, which re quires extensive administrative work.There is also the problem o f child headed families which requires atten tion (Evian, 2003:21;Schenck, 2004:159;Uys & Cameron, 2004:163.Another issue the members from the disadvantaged community bring to the attention o f the health care workers centres on family and marital problems.These include family conflict, domes tic violence, and alcohol and drug abuse (Schenck, 2004:161).Economic deprivation increases the level o f stress experienced by the parent and this, in turn, may negatively affect the parent's affective relationship with the child and h is/h e r q u ality o f p aren tin g (Bezuidenhout & Joubert, 2003:58).Frederick and Goddard (2007:335) re mark that child neglect is associated with poverty.In order for changes to occur in the circumstances o f a disad vantaged community, health care work ers should empower the community and provide community-based serv ices (Strydom, 2008:68).

Students who deliver services to disadvantaged communities
Students should be equipped to face these communities in a caring and un derstanding manner.Students should have particular personality traits in or der to meet the needs of the people and to render effective services.In a study conducted in KwaZulu-Natal partici pants felt that service providers should be caring and tolerant, down to earth and able to understand people (Evian, 2003:313-314;Simpson, 2003:159).All people value respect and desired to be treated as worthy individuals (Simpson, 2003:159).According to Simpson (2003:158) the experience of being accepted and un derstood makes for successful helping.She adds that good service providers are real people with whom patients can identify.According to Cummins, Sevel, and Pedrick (2006:49-50) this means that they need to acquire knowledge of a variety of cultural dimensions, such as attitudes, values, customs, commu nity patterns and spirituality that de fine particular cultures in order to re spond effectively to the needs o f di verse populations.Skills such as empathic responses, genuineness and clarification are helpful in establishing therapeutic relationships across all cul tural lines (Cummins, et al., 2006:49-50).In the study conducted in KwaZulu-Natal the participants mentioned that race was not a problem.They did feel, however, that it would be more helpful for the service provider to be able to speak the local language to improve communication between helper and patient (Simpson, 2003:158).

Communication
To create an in teg rated and c o ordinated health service there would be a need for effective health commu nication.It entails the process o f shar ing information according to a common system o f sym bols and language (Faulkner & Hecht, 2007:388).Commu nication is also conceptualised as a verbal and non-verbal human transac tional interaction in the sense that it is a continuous, ever-changing process that involves reciprocal influences.Health communication is a subset of human communication and refers to any human communication, the con tent of which deals with health-related issues (Rogers, 1996:15).Communication, though, is complex and entails more than the use o f a spe cific language.Therefore models have been created to reduce the complexity of the transactional process.With re gard to health communication, three possible models can be scrutinised to see how they portray communication: the therapeutic model, the Health be lief Model and King's Interaction Model (Airhihenbuwa & Obregon, 2000:10-16;N orthouse & Northouse, 1998:12;King, 1999).

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The Therapeutic Model is patient-centred and can be viewed as a communication skill that would help patients "adjust to their circumstances and to move in the direction o f health and away from illness" (Northouse & Northouse, 1998:12).This model has its ori gin with Carl Rogers (1951) who believes that the helper should communicate with empathy, positive regard and congruence (Rogers, 1951;Afifi,2007:52-56).

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The Health Belief Model is more complex with a different focus.This model would like to explain the nature o f individu als' health actions and consists of three major elements: Firstly, the patient's perception of vul nerability to and severity of the disease; secondly, the patient's perception o f the benefits and stumbling blocks to taking pre ventive actions to control and/ or prevent the disease; and thirdly, the cues available that would encourage the patient to sustain preventive health ac tions.So-called modifying fac tors such as age, sex, ethnicity and poverty can also influence the patient's perceptions and beliefs.Thus, the core of the model is to predict the likelihood of a patient to adopt certain be haviour (self-efficacy) as a function of the perceived threats and possible benefits.It focuses on the patient's percep tions o f preventive measures rather that the transactional na ture o f the patient-helper inter action.(Glanz & Rimer, 1995:19;Airhihenbuwa & Obregon, 2000:10-16).

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King s Interaction Model em phasises the communication process between helper and patient within a systems per spective, with the focus on in terpersonal systems.The inter action is dynamic, which in cludes a reciprocal interplay be tween the helper and the pa tient, resulting in a transaction established by both communi cators as they co-operate.Shared meaning and feedback are important aspects in this transaction (King, 1981:144-161;Beach, 2007:333-349).

Major factors influencing health communication
Because o f the unique nature of each communication interaction, it is not possible to classify each transaction solely under one o f the mentioned models.According to Northouse and Northouse (1998:17-21) the three major factors within health communication that should be part of health communi cation are relationships, transactions and contexts.
• The relationship can be any one of many possibilities among many role-players.It may also include social networks that are involved with the pa tient, like family members, friends and co-workers.The multidimensional involvement of many role-players is espe cially important in collectivistic cultures where face-saving and harmony within the group, fam ily or community are important (Dodd, 1998:92).If the roleplayers are of different ethnic origins, cultural issues should also be addressed with regard to the nature of the relationship.

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Transactions refer to any health-related interaction be tween participants during the process.This would include both the content (information) and the relationship dimensions o f messages (Courtright, 2007:319-326).The nature of the relationship influences how the content should be interpreted.
The continual feedback allows participants to make changes to the message and to adjust and readjust their communication according to many variables that may influence the partici pants and their messages.

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The contexts refer to the setting and the systemic properties in which the communication takes place.The physical setting as well as the socio-economic en vironment and cultural issues have an important influence on communication.Different health care settings and the number of persons involved have differ ent effects on the dynamics of the transactions that take place within these settings (Courtright, 2007).

Methodology Protection of Human Subjects
The research protocol was approved by the ethics committee of the univer sity.Permission to conduct the study was also obtained from the provincial Department of Health.Participants were provided with information about the background of the study and were in formed that participation was voluntary and that they could withdraw from par ticipation at any time.Participants were also assured of confidentiality of in formation.Following this explanation, each participant signed a written con sent form.

Research Design
A qualitative design was used to ex plore and describe (Mouton & Marais, 1996:45) the experiences of the roleplayers.Focus group discussions (Greeff, 2005:299) were conducted with the senior nursing and social work stu dents as well as the health service de livery organisations and unstructured one-o n -o n e interv iew s (G reeff, 2005:292) with disadvantaged commu nity members.

Settings
The study was conducted in two schools of the Faculty of Health Sci ences at the university concerned and in the disadvantaged community of the Potchefstroom district.Third-year B Cur. Nursing and fourth-year social work students were included as they had experienced experiential learning in the disadvantaged community con cerned.Focus groups with the health service delivery organisations were done at a central location close to their workplace.The individual interviews were conducted with community mem bers in their own homes or at the of fices o f the HSDO.

Populations and samples
Three populations were involved.The students consisted o f the third-year nursing ( 22) and fourth-year socialwork (20) students.The second popu lation consisted o f members from NGOs, FBOs, LAC and various gov ernment departments as health service delivery organisations.The last popu lation consisted o f disadvantaged community members who had received health care from the students con cerned.

Sampling
Non-probability purposive voluntary sampling was used and data saturation use to determine the size.Four (4) fo cus groups (one per mentioned popu lation) and nine (9) interviews were conducted with a total of 41 partici pants.Ten (10) third-year nursing stu dents and eight (8) fourth-year social work students were included in the fo cus groups.Ten (10) members from health service delivery organisations where nursing students were involved and four (4) members from health serv ice delivery organisations where socialwork students were involved were in cluded in the two focus groups with health service delivery organisations.Nine (9) patients were interviewed, six (6) of whom had received health care rendered by nursing students and three (3) by social-work students.

Data Collection
Participants were invited to come to the various settings or appointments were made with patients to visit them in their homes.According to Greeff (2005:299) focus groups are a means o f gaining a better understanding o f how people feel or think about an issue, product or service.All focus groups and inter views were conducted in Afrikaans and/or English and audio-taped.All participants were informed about mat ters of confidentiality, anonymity, pri vacy, risks, withdrawal and possible termination o f their participation prior to completion o f the data gathering processes.
In the case of the focus groups all the questions were evaluated beforehand by the research team and referred to experts for comment and a focus group conducted to evaluate the applicabil ity of the questions.The estimated time o f an hour for the focus group discus sion was communicated to the partici pants when they were invited to par ticipate.During the focus groups com munication techniques (Okun, 1992:70-71) and group facilitation strategies (Greeff, 2005:307)  Health service delivery organisations: • They were asked similar ques tions, focusing on their experi ences and perceptions of health care delivery by the students.
The questions to the disadvantaged community members: • How did you experience the service delivery rendered by the students to you? • How did you experience the communication with the stu dents as well as with the per son who made the arrange ments for them to deliver the service to you? • How do you think this service delivery by students could be enhanced?Field notes were taken at the end of each group or interview, focusing on personal, observational and methodo logical notes (Talbot, 1995:478;Polit & Hungler, 1997:307).

Data analysis
All the focus groups and interviews were transcribed verbatim and ana lysed using the open coding technique ofTesch (i'rc Creswell, 2003:153-155) to identify themes and sub-themes.The though we were loosing hope.They uplifted our spirits... Obtaining a grant provided outcome to the patient or the fact that the student did not lose hope gave them strength.It really meant a lot (obtaining a grant).The HSDO also felt supported by the students as they indicated their con cern for the burdens the students had to face.They are interested and they want to know how are you handling all these people.The students also provided much needed additional serv ices that the HSDO could not provide or initiate due to time constraints.They help with fo o d parcels, administrative tasks, start new projects and do group work.

Difficult to cope with student turn over
The patients found the changing of students less easy to cope with.The contact the patients had with the stu dents varied from one to but a few con tacts, making the building o f relation ships difficult.Contact was made in clinics, during home visits and during training programmes.It is not one per son coming.They change all the time.She is gone now and I am so heart sore and sorry.We get use to them.How ever, this did not prevent them from talking to the student or wanting them to come back.

Students question their worth
The students initially questioned their worth but became more aware of their worth to the community as the discus sions went along.I f I think about it, it is not enough.I think we do not al ways realise the difference we make.Just that little I give ... can help them along.You fe e l so small and helpless until the patient says thank you and you realise it was help.They felt they had provided a meaningful foundation for further health education and fo cused on various aspects of health that could be transferred to the rest o f the community.

Community comfortable with students
The community is comfortable with the students as they do not feel ashamed.You see they feel comfortable.It is hap piness.Students are seen to be pre pared to share their time with patients and be available.They feel today some body is coming to heel their wounds.There are at least people who care fo r me.
The placement in the community be came a very rich and rewarding experi ence for the students: It has enriched my life.I gained more than I gave.We have received so much from them in the end.

Communication sometimes effective and sometimes less effective
The students experienced the commu nication with the lecturer, making the arrangements for service delivery as sometimes effective and sometimes less effective.Changes made by lec turers caused problems if the students were not informed.It is difficult i f ar rangements are changed at short no tice.Here the morning this has been changed.Poor arrangements caused students to feel unwelcome in the prac tice area due to professional nurses not knowing that students were going to be there.Students verbalised the need to see lecturers more: My lecturer did not come when I phoned her.We do not always see them (lecturers).

HSDO's experiences varied from positive to negative
It seems as though the experiences of the HSDO with lecturers also varied from positive to negative.In the cases of well-planned and structured arrange ments that were provided well in ad vance the HSDO appreciated this fact.It is a set structure.In the most cases we are well informed.They appreci ated being aware o f expectations, like when to expect students, what the ex pectations were concerning these stu dents and what support was expected.They experienced the students as well prepared, making the placement more meaningful.When the students arrive they are prepared and know exactly what is expected o f them.

HSDO felt lack of involvement
The HSDO experienced the lack o f in volvement in arrangements negatively.They simply ju st place students there and that is the end.It was difficult if no pre-arrangements were made and stu dents only arrived in the clinical area, leading to people having to rearrange their schedule at short notice to accom modate the students.Sometimes ju st to be told in the morning you have stu dents and I have to change my plans.The HSDO or the students did not see the lecturers on a regular basis.The students need to see their tutors.We would like to see the tutor as well.

Communication during the health care service delivery
As different aspects of communication arc intertwined in the findings, the fol lowing is a synthesis focusing on com munication only.It is done according to the theoretical context discussed earlier.In general it can be deduced that the communication tended to portray to some extent the therapeutic as well as King's Interaction Model rather than the Health Belief Model.The experi ences of the students, and especially those of the patients, indicated that the students helped patients to adjust to their circumstances and provided them with valuable information to prevent possible illnesses: They taught us how to care fo r our children and how to treat them.We learned a lot.The importance o f interpersonal rela tionships and reciprocal interplay, which are core elements o f K ing's model, also came to the fore in the ex periences of all the role-players: We could always speak to ... i f we had problems.She had time to listen to us.She understood what I told her.The issue mentioned by the students about the possibility that some con tent would be lost due to the fact that the students did not understand Setswana indicated the concern o f the students to share and properly under stand meaning during communication.
The following findings will be grouped according to the three major factors within health communication: relation ships, transactions and contexts.One should realise that these aspects can be distinguished from each other, but in reality they do not function sepa rately.They are crucial interrelated ele ments of the communication system that influence each other (Courtright, 2007:313-315).

Relationships
It is clear that many relationships are involved.There is positive evidence of good relationships in most instances, especially between the students and the patients, as reflected in the follow ing statements of patients regarding the students: They really work nicely with us.The most important thing was the sympathy they gave.They give love and caring by playing with our kids.They are beautiful and you open your heart to them.The relationship between the univer sity lecturers and the clinical staff seemed to be ambivalent.The cause of this sometimes strained relationship seems to be due to a lack of adequate and effective communication about schedules and dates, and also due to last minute changes to the scheduled programme.The relationship between the patients and the clinical staff/NGOs appears to be sound as no specific problems were mentioned during the interviews.

Transactions Language
The concept transaction refers to the communication interaction during con tact.In most instances the transactions experienced were positive.One prob lem, though, seems to be the fact that most students do not speak the mother tongue o f most patients: They (pa tients) know we will not understand them and then keep quiet.It is certain things you want to tell or show them ... now you ca n ' t.An interpreter was o f value but it did lengthen the time of communication.They did not always know whether the interpreter inter preted correctly.Then someone has to talk on your behalf but you d o n ' t know that it is truly what you wanted to com municate.The HSDO confirmed that language was a possible obstacle dur ing health care delivery by students.The student's personality and emo tional maturity played an important role in overcoming the language problem.It is interesting to note that the stu dents experienced the lack of speaking in the patient's mother tongue as a big ger problem than the patients them selves.Those patients, who experi enced empathy, respect and honest in volvement did not experience language as a major stumbling block.If empathy and respect were present it made it pos sible to overcome the language barrier.Patients said: We did not struggle with language.We would talk to one an other nicely.They are friendly people and we talk to them.They spoke with respect.It is possibly attributed to the belief that good interpersonal relation ships and trust are firstly o f the utmost importance for effective communication within Afro-centric and collectivistic cultures.The presence o f trust and good will during the interaction even without the necessary language skills is preferable to language proficiency without the essential relationship o f trust and reciprocity.Another aspect of the interaction seems to be the tendency of students, in their urge to help and do something immedi ately, to react verbally and nonverbally before they even know

Context
A variety o f contexts are involved in the service of the students to the com munity.In most instances the role-players adjust well to different contexts.One issue that needs to be addressed, though, is the totally "new" and differ ent cultural environment which the stu dents have to accommodate in order to communicate optimally from the begin ning (Littlejohn & Foss, 2005:147-153).The real life experiences such as pov erty and death can be such a shock for the students that the help and support they are supposed to give can be nega tively affected.The possibly uncon trolled emotions which the students might experience could interfere with the ideal of reciprocal communication during the interaction.Specifically in your first year.You stay in your town and never go to the disadvantaged community.Now you have to.It is a big adjustment and a total new dis covery ...I was so frightened I did not want to look out o f the window when we travelled in the community.However, it seems that most students learned to adjust rather quickly.It is also evident that the students experi enced more confidence within the con text o f a small group than a context where they had to interact on an inter personal level.Groups were easier as they help one another i f they do not understand.Although the communica tion appeared to be relatively good in many instances, it can be improved to optimise the service delivery to the community.

Conclusions
Although there are smaller differences in the experiences of the three groups, there are many similarities.Community outreach is built on a trust relationship, with empathy and respect as corc ele ments.Both students and HSDO men tioned the initial shock experienced by students when they were confronted with the disadvantaged community for the first time.The students found cir cumstances in the disadvantaged com munity shocking and heartbreaking, as it was very different from their own pro tected environment as well as their more structured learning environment (the hospital).However, the students quickly overcame this challenge and adjusted to the situation.Cultural differences existed but were overcome with understanding and re spect from the side of the students.The needs o f the community were vast and basic and the students felt that they could meaningfully contribute to this with the knowledge they had.Patients welcomed students in their homes.However, it was difficult to build a rela tionship o f trust with students if they only went on home visits once or twice.The availability o f students to listen to the stories o f patients was a key factor to their successful acceptance by com munity members.Students realised that the community valued their presence and that there was a general trend of respect and appreciation.The HSDO stated that the community experienced the students as compas sionate and respectful.They felt that students were prepared to spend time with them.Communication with the lec turers varied from effective to less ef fective.Aspects like being involved and informed about plans and expecta tions were important aspects of a suc cessful relationship between the uni versity and the HSDO.Both students and the HSDO experienced language as a barrier but patients did not experi ence it as a stumbling block.Honest human caring and genuine interest bridged this gap.All the groups ben efited from this deeply human experi ence and gained more than the initial goal had intended.There is a fine line between the goals o f the required ex periential learning and meeting the spe cific needs o f the disadvantaged com munity.

Limitations of the study
The following limitations were identi fied in this study: With regard to different languages, lec tures in the relevant language of the community would help to overcome the language barrier.The problem is that the necessary intercultural com petencies, which involve more than just language proficiency, take time to ac quire, but even a basic spoken knowl edge of the language would be of great assistance.At the same time, students must be informed and prepared to, firstly, earn the trust o f the patient by listening well and building a relation ship before they, secondly, respond by saying and doing what would be con gruent with the patient's needs.The already good relationship between the students and the patients can be enhanced if it would be possible for the same student to help the same pa tients over a longer period of time.The relationship could grow in depth, and quality o f help would benefit from the longer involvement.Well-structured arrangements should be made well in advance and communicated to the rel evant parties.The problem is that the relationship between the students and the clinical staff can be jeopardised if the communication between the two organising role-players is lacking or not properly done, while the "innocent" students would be the role-players to suffer.
A system should be developed for both the patients and the students to evalu ate the health services delivered.De briefing sessions for students to over come the experience o f the harsh con ditions in the community should be built into the programme.The ideal would be, as many requested, to send a multi disciplinary team o f students to the community.
The knowledge gained from this re search should be ploughed back into education, research and community outreach planning.
Students should be prepared for and informed about the different contexts they will be facing, either by students previously exposed to the situation (3rd and 4th years) or by the clinical staff members who are working in the com munity.They should be prepared for the harsh reality, problems and cultural beliefs and customs before their first community encounter.Students who participate for the first time should also visit the relevant sites before they ac tually become involved in the commu nity.Lectures in intercultural communication could help overcome cultural barriers.Ideally, these aspects should form part of the curriculum.Students should be helped to work through any precon ceived and prejudged thoughts and feelings before they start to work in a disadvantaged community.Students who participate for the first time should initially be accompanied by more expe rienced students/HSDO.Any form of guidance would have enhanced the student's confidence and ability to communicate more effectively.Stu dents should also be prepared by the lecturers or HSDO when the sessions shift from the clinical environment to the homes or informal settlem ents where the people are living, and often dying.A much more co-ordinated ef fort should be introduced to ensure quality health service delivery to a dis advantaged community.