Interprofessional Mentoring of Pharmacy Students in Primary Healthcare Settings in South Africa

Abstract

Professional nurses assume clinical mentoring roles for pharmacy students in Primary healthcare (PHC) settings in South Africa due to the chronic shortage of pharmacists in these settings. This study sought to describe the experiences, challenges and needs of professional nurses mentoring pharmacy students within the primary healthcare settings of South Africa. A descriptive qualitative study design was employed and 35 semi-structured, individual interviews in 18 primary healthcare settings were conducted. Data was analyzed using thematic content analysis. While some professional nurses are supportive of mentoring pharmacy students during healthcare delivery, others believe it increases workload and slows down healthcare delivery. The professional nurses enjoyed mentoring pharmacy students but indicated a lack of confidence due to non-preparation and not being involved during the planning or preparation for the pharmacy students’ clinical placement visits. They needed short courses to train them to perform better in mentoring pharmacy students in PHC settings. To facilitate the successful implementation of interprofessional mentoring of pharmacy students, deeper collaboration between the university and the professional nurses in primary healthcare facilities is needed to improve interprofessional mentoring of students in primary healthcare settings. Universities must provide clear information, guidance, and feedback on students’ clinical placements, while professional nurses require in-service training on interprofessional mentoring and recognition from universities for their educational contributions.

1. Introduction

Work-based learning (WBL) is critical in preparing work-ready pharmacists; therefore, the South African Pharmacy Council (SAPC) requires pharmacy students to complete 400 h of clinical placement, for learning and role taking, to qualify as pharmacists [1,2,3]. Work-based learning in pharmacy education takes place across all levels of health services in South Africa, including Primary Healthcare (PHC). North-West University pharmacy students are required to undertake 80 h of structured and supervised compulsory WBL in PHC settings in South Africa to qualify for registration with the SAPC [4]. Primary healthcare settings, known as PHC clinics and community health centres or community centres, treat minor conditions and refer patients to hospitals [5].

Although South Africa ranks among the top five countries in the African region in terms of density of health workers per 1000 population, with 78.19 doctors, nurses, midwives, dentists and pharmacists per 10,000 population in 2022 [6], further analysis shows that South Africa was among the countries with the least improvement in the density of pharmacists between 2018 and 2022 [6].

Furthermore, the country faces a growing paradox of health workers’ unemployment [6,7] amidst a shortage of pharmacists in practice settings as a result of fiscal space constraints [8]. As such, many PHC settings in South Africa do not have dedicated pharmacists, as indicated on their organograms. Instead, a single pharmacist is assigned to oversee and support a group of clinics. Consequently, professional nurses who serve as the primary caregivers in these PHC settings take on patient consultations, diagnosis, medication dispensing and referral roles [9].

In addition, professional nurses double as clinical mentors for pharmacy students who are placed in PHC settings for learning, as there are no pharmacists to do so. Although mentoring normally takes place between mentors and mentees from the same profession, there are occasions where health professionals mentor students from different professions, a phenomenon termed interprofessional mentoring [10,11,12]. Some studies [10,11,12] published on interprofessional mentoring have shown that it provides the opportunity for health professions’ students to learn how to collaborate with other professionals in a professional team and acquire the necessary clinical skills and knowledge required for a specific clinical placement period.

Unfortunately, the experiences, challenges and needs of the nurses mentoring pharmacy students in the South African PHC setting have not been explored nor described to provide empirical evidence for the improvement of pharmacy education; this study sought to close this gap in the literature.

2. Materials and Methods

2.1. Study Design

The study employed a qualitative descriptive design [13], which enabled a thorough and comprehensive exploration of the phenomenon under study [14] in order to provide an explicit account of the phenomenon. The design and reporting of the study were guided by the consolidated criteria for reporting qualitative research (COREQ) [15].

2.2. Study Setting

This study was conducted in 18 PHC settings, comprising five community health centres (CHC) and 13 community centres (CC), in the North West province of South Africa. The CHCs operate 24 h a day, while community centres are open eight hours a day.

2.3. Population, Sampling and Sample

Professional nurses, working in PHC settings in the Dr Kenneth Kaunda district of the North West province of South Africa, who were involved in mentoring pharmacy students from 2017 to 2023, constituted the population of this study. After obtaining all the necessary scientific and ethics approvals, permission was obtained from the PHC settings to recruit and enrol nurses into the study. Purposive sampling was employed to recruit 35 professional nurses from the 18 PHC settings. Only professional nurses who had been involved in clinical mentoring of pharmacy students for at least a year were included in the sample to ensure the participants had the required experience to share.

2.4. Data Collection

With the aid of an independent research assistant, informed consent was signed by the participants. The first author conducted semi-structured individual interviews with participants at a conducive place, selected by the participants, with the aid of a researcher-developed semi-structured interview guide. The interview guide was developed by the first author (MM), in English, reviewed by two co-authors (MV and CC) and pretested with three professional nurses prior to the interviews. Comments from the pretest were used to finalize the interview guide, and data from the pretest was excluded from the main study. The semi-structured interview guide comprised seven main questions with probes and a concluding question (see

Table 1. Semi-structured interview guide.

No.	Question
1.	Please tell me the importance of students’ clinical visits to primary health care settings.
2.	Please tell me how you assist students in having purposeful and meaningful clinical learning experiences.
3.	Could you share your experience as a professional nurse mentoring pharmacy students?
4.	Please tell me how you facilitate student learning in the PHC setting. [probe student involvement, teaching methods, assessment methods, any debriefing or clinical conference sessions].
5.	What, in your opinion, are the challenges of interprofessional mentoring of pharmacy students? [Probe: To what extent did the interprofessional mentoring programme affect your day-to-day activities?]
6.	Do you think you are well prepared for the interprofessional mentoring job? [Probe: (a) What about your competencies? (b) What are your training needs for the interprofessional mentoring programme? (c) Discuss the support received from the University regarding your involvement in training the pharmacy students.]
7.	Concluding question: Do you have anything you would like to share concerning interprofessional mentoring of pharmacy students that we have not discussed or talked about?

).

The interviews took between 30 and 45 min and were audiotaped. The audiotaped interviews were listened to several times by the researcher to ensure clarity before transcription. The transcription was verbatim and emailed to four participants for member checking, after which they were transferred onto Atlas.ti for analysis. Data was collected from 10 October to 20 November 2023.

2.5. Data Analysis

The six steps of data analysis derived from Braun & Clarke [16] were used to analyse the data with the aid of Atlas.ti, version 24. The scripts were read thoroughly by researchers. The researcher and an independent co-coder coded three scripts, and a research meeting was organized to compare the codes for consensus building. After consensus, the researcher coded all the transcripts with the coding system. Similar codes were combined and described as sub-themes. Similar, related sub-themes were combined under a theme and described.

2.6. Ethical Considerations

Scientific approval was received from the Health Professions Education (HPEd) Scientific Committee. Ethics approvals were received from the North-West University Health Research Ethics Committee (NWU-HREC), the North West Province Department of Health Research Committee, and the Dr Kenneth Kaunda District Ethics Committee. Permission letters were received from the nurse managers of all 18 PHC facilities involved in the study. All participants completed the informed consent form before taking part in the study. Anonymity, privacy and confidentiality were strictly adhered to by the research team. The researcher used member checking, independent co-coding, accurate note taking, and an independent research assistant to improve the trustworthiness of the study [17].

3. Results

3.1. Demographic Characteristics

Most of the participants (28 of 35) were female, and seven were male. Three participants served as operational managers in PHC settings. In terms of racial distribution, only two (2) of the 35 participants were white, while the remaining participants were African.

3.2. Themes

Three main themes were identified and described: (a) experiences of professional nurses mentoring pharmacy students, (b) challenges faced by professional nurses mentoring pharmacy students, and (c) needs of professional nurses mentoring pharmacy students (Figure 1).

3.3. Experiences of Professional Nurses Mentoring Pharmacy Students

The experiences of the participants were conceptualized around their day-to-day encounters with pharmacy students in clinical settings. They discussed their experiences with respect to (i) nurses’ impressions about students, (ii) orientation to the workplace, and (iii) mentoring practices.

3.4. Impressions About Students

The nurses had positive impressions regarding the presence of pharmacy students in their institutions. Most of the participants stated that students’ presence positively impacted their workload, making their work easier and providing them with more time to interact with patients. The senior students took on pharmacy duties, such as organising medication cupboards, labelling medications, and providing health education to patients, which nurses often could not complete due to their heavy workload. The participants also found that the students were easy to mentor, as they were hands-on, friendly and eager to help and learn.

“It helps a lot because they help us. Because sometimes we don’t have time, especially in the morning…”

—Participant 5

“I think it positively affected us because when the students come, they are very hands-on, so they help us with the pharmacy, packing it well, and stuff like that…”

—Participant 1

“So, it was very nice for me because the students I got were willing to learn, asking questions when necessary…”

—Participant 11

3.5. Orientation to the Workplace

Before the students’ arrival, the supervising pharmacist attended an orientation meeting with the university to plan the clinical placement. The pharmacist then informed the nurses in the PHC settings that there would be pharmacy students coming for clinical placement. The nurses indicated that upon the arrival of the students, they reviewed the accompanying folder, which contained the students’ year of study and the learning objectives for the clinical placement for the specific period during which the students were placed in the setting. The professional nurses stated that they orientated and provided activities according to the clinical objectives provided by the university upon the students’ arrival. Some of the PHC settings in the study had no stationed pharmacists, and nurses served as the first point of contact when students arrived.

“The first thing to do is ask about their objective for their current study level and then provide activities related to that objective…”

—Participant 2

“Yes, we do. We delegate them according to their objectives. They must do what they should do. They must learn from what they are studying that year. We don’t just delegate them personally. So, they must do their objectives…”

—Participant 12

3.6. Active Mentoring Practice

Most of the participants shared their experiences about their mentoring activities, which included ensuring active supervision and active participation of the students. The participants stated that they continually guided and supervised students throughout the tasks assigned to them. They gave the students the opportunity to observe while the nurses performed their roles related to the students’ learning objectives. Some activities the nurses mentioned included the use of medications and the observation of consultation sessions and provision of prompt feedback.

“Yes, we do involve them [students]. First, we show them [students] how we examine patients, let them [students] do it on their own, assist them [students] where they [students] go wrong, and then show them [students] the correct thing…”

—Participant 5

“Before dispensing, I take out medication and do the quality test [with the students].”

—Participant 2

“Mostly, it’s a one-on-one conversation because they’ll be asking there and then, and you’ll be answering where you can…”

—Participant 8

3.7. Challenges Faced by Professional Nurses Mentoring Pharmacy Students

Participants faced challenges regarding interprofessional mentoring of pharmacy students, which included heavy workload, language barrier, patients’ privacy concerns, lack of clarity on mentoring role and university support, and passive student engagement.

3.8. Heavy Workload of Professional Nurses

All the participants expressed immense work pressure caused by their heavy clinical workload. The professional nurses stated they were overworked due to numerous patients, limited resources, and staff shortages at their workplace. They reported long patient queues, particularly during the morning shift. Further, the additional responsibility of mentoring students, including pharmacy students, during clinical placements, exacerbated their clinical workload. Nurses expressed that the pharmacy students on clinical placement slowed down their completion of clinical duties to their patients, as they had to allocate part of their time for the students’ engagement with patients to enable them to meet their learning objectives successfully.

“Of course, we work under pressure; there are always many people. Overworked, we have too many patients…”

—Participant 4

“You still need to give the student time to interview. So, we move a little bit slower on the days when we have students…”

—Participant 11

“They want to go deeper. And then you don’t have time. The queue is too long. We only highlight all the most important things. So, the challenge is that they expect you to go deeper. So, we normally tell them, you know what, can I kindly finish with this patient…”

—Participant 3

“Our clinic is hectic, especially in the morning. So, when they are here, they help us with checking the expiry date and then packing the cupboard and organizing the medication appropriately…”

—Participant 4

3.9. Language Barrier

Four participants stated that language was a barrier to pharmacy student mentoring during clinical placements and added to their workload, as engagements with patients often required translation. Most of the patients spoke Setswana and most students spoke Afrikaans. One participant explained that she had to translate for both students and patients to ensure mutual understanding during their interaction.

“Yes, yes. I’m sorry if I’m a bit out of line. Most of them [students] are white or Afrikaans and most patients are Setswana.”

—Participant 9

“The challenge may be that some are struggling to understand English. They prefer Afrikaans, and then, you see, I’m not fluent in Afrikaans, so I’ll struggle to explain something they don’t understand well. So, they’ll need… but sometimes I have some good Afrikaans interpretation when Dr. N is here…”

—Participant 12

3.10. Patients’ Privacy Concerns

Twenty-one participants stated that the presence of pharmacy students in the consulting rooms created some uncertainties regarding patient privacy and confidentiality issues. They mentioned it was difficult to know when to dig deeper into a patient’s condition or illness while students were in the consulting room.

“In our case, the only risk is the confidentiality and privacy of the patient. Some patients care when there is a third person present; if you forget to introduce them, it can create tension…”

—Participant 2

3.11. Lack of Clarity on Mentoring Role and University Support

Half of the participants reported understanding their responsibilities as nurses but expressed uncertainty regarding their role as mentors. Many indicated a lack of clarity on student expectations and felt inadequately informed about the clinical placement process. The information provided about the clinical placement of pharmacy students in PHC settings was viewed as insufficient, given the students’ different professional and educational backgrounds. Participants believed that they had received limited information regarding the students’ learning objectives, the rationale for their placement, placement schedules and whether their learning expectations were being met.

“When they come, it is like there is a gap between a professional nurse and a pharmacist You don’t actually know what you need to teach them…”

—Participant 1

“If we have been told earlier and given the expectations, what do they expect from us and their objectives…”

—Participant 7

“We don’t know when to do this; please, let us have a schedule where we know that our students will come at this time. They must not just pop out of nowhere. Maybe someone knows, but the professional nurses don’t know when they come. But if we can have a schedule to know at this time…”

—Participant 1

Half of the participants said they did not receive university support. The professional nurses who mentored the pharmacy students felt that the university did not support them; the pharmacists were the only ones they saw during clinical visits, and with these interviews, they hoped they would receive more support and information in the future.

“The university? I don’t know; maybe they contacted the primary healthcare managers, but we have nothing to do with them…”

—Participant 4

“Currently, there is none, but you’re coming here, which shows that something may be done…”

—Participant 1

3.12. Passive Student Engagement

Two participants reported a lack of student engagement. The professional nurses noticed that some of the students did not pay full attention to what they were supposed to do and were reluctant to participate in the activities carried out in the facilities. Participants recognised the importance of clinical learning and ensured that they did not leave reluctant students behind. These students were given opportunities to engage and provided with additional time to reach their learning objectives.

“Okay, some of them are not interested. They arrive early in the morning, two hours before. The others stay up until four. So, there’s a different kind of student. Not all of them are 100%…”

—Participant 4

“Yes, most of the time. I guess some of them will not show interest when they show interest…”

—Participant 12

3.13. Needs of Professional Nurses

Twenty-eight participants felt that, due to the challenges they experienced during the interprofessional mentoring of pharmacy students, the university needed to consider their needs regarding the mentoring programme. Four needs were identified: the need for adequate information, enough guidance and feedback, required knowledge and skills, and deeper university involvement.

3.14. The Need for Adequate Information

Many (21) participants mentioned that they needed to acquire adequate information from the university on the students’ objectives before they arrived. Although the PHC centres were informed prior to the students’ clinical placement, this information did not get passed on to the practising nurses. Those who may have been aware of the dates seemed not to have the details of the clinical placement objectives to enable them to provide the needed mentorship. They also indicated a lack of capacity to mentor the pharmacy students, as their knowledge base in pharmacy was limited. The participants indicated their need for information on the clinical placement process, how to mentor, what was expected of them, their roles and responsibilities, more about the learning objectives, and placement schedule.

“…Please, let’s have a schedule [objectives] where we know our students will come at this time. They [students] must not just pop out of nowhere. Maybe someone knows, but the professional nurses don’t know when they [students] will come.”

—Participant 1

“For us, what we know is that when we just come to the pharmacy, we only know about the stock cards and then about the medication…”

—Participant 5

3.15. Guidance and Feedback

Most of the participants believed that if the university provided them with guidance, learning outcomes and feedback, the mentoring provided to the pharmacy students would improve. The professional nurses requested guidance on mentoring for the pharmacy students’ clinical placement, as well as feedback on previous encounters to assess whether their mentorship met expectations and how they could improve their practices.

“…if we can know what the objectives and the outcomes are for the students. What is required? How can we help them? If we are taught how we can help the students, then we can help them. I think it will also help us know exactly what we should get them on…”

—Participant 1

“I would suggest that the [university] make a small programme yearly where they take us for a week or so to give us briefs and whatever we need to know about pharmacy because things change…”

—Participant 8

“I think the continuous evaluation from the personnel of the university…”

—Participant 6

3.16. Knowledge and Skills Needed

Most of the participants touched on the need to receive basic skills training on what was expected of them when the students visited the facilities, for them to perform their duties successfully.

“We don’t have much knowledge about pharmacy. Perhaps getting some basic training will be better if we can get some basic training…”

—Participant 7

“But generally, I don’t know exactly, I don’t know exactly what to do. The pharmacy department can start offering a dispensing course if the university can do so…”

—Participant 1

“I would like to be trained in pharmacy because we are usually not trained with pharmacists. So, how do they work, what is their scope of practice, and what procedures do they follow in pharmacy? Because we know that when we just come to the pharmacy, we only know about the stock cards and the medication…”

—Participant 5

3.17. Deeper University Involvement

Half of the participants stated that although university representatives occasionally checked on the students, greater institutional involvement in the clinical mentoring was needed. They suggested appointing someone permanently at the PHC facility to oversee clinical placement. Additionally, they stated the importance of regular visits by university representatives to evaluate what they were doing and provide constructive feedback.

“Being more present when the students are there and then being able to reach out to the other categories [professionals] that are in contact with the students…”

—Participant 2

“As they bring students, they should come and check how they are doing. Are they managing or coping? Do they have any challenges? They should not wait until students return to the university and ask them questions. Between them being here, they should come and assess. It will also help us know exactly what we should get them on…”

—Participant 6

4. Discussion

This study sought to describe the experiences, challenges and needs of professional nurses mentoring pharmacy students in PHC settings in the North West province of South Africa. We found mixed perceptions regarding student presence in primary healthcare settings. While some practitioners saw students as additions to the health workforce, others perceived them as distractors who ate into practice time, increasing workload. The professional nurses found that students presented positively towards their work.

Both perspectives have been confirmed by existing literature: some authors [18] found that pharmacy students contribute their expertise to the interprofessional team in caring for clients, while others [19] viewed the time taken to plan and supervise students in the health care setting as enormous and resulted in increased workload.

Further, the nurses tasked with clinical mentoring of pharmacy students reported feeling uncertainty in their roles, citing insufficient pharmaceutical knowledge and skills to effectively support the students’ learning. It was found that communication between the university and the PHC settings was not inclusive, as many professional nurses mentoring the pharmacy students did not have the objectives of the clinical placement programme. Additionally, nurses indicated not being aware of when students were arriving at the facility for training. Further, professional nurses were not certain or aware of how the university clinical placement programme of the pharmacy students in the PHC setting was run. The participants recommended that the university provide them with feedback and closely evaluate the clinical placement programme.

Although it is well established in the literature that pharmacy students’ presence in health facilities increases pressure on practitioners [20], Rudland et al. [19] argued that the contributions of pharmacy students on clinical placement outweighed the pressure they placed on the clinical workload of practitioners; however, higher education institutions should invest more in the planning, funding and implementation of clinical placement for pharmacy students.

Research has shown that clinical mentors who were not prepared for the role were likely to base their supervision on intuition and their own experiences, which could cause feelings of insecurity due to a lack of confidence in their performance [21]. Other studies have shown that nurse mentors often feel uncertain of their teaching abilities, highlighting the need for additional training [22]; this intervention has been associated with increased professional pride and a sense of dignity [23].

The professional nurses indicated a willingness to capacitate themselves but required some collaboration from the university in organizing short courses to upskill them into the role of clinical mentors for pharmacy students. Providing such training opportunities would be essential. Further, Juntunen et al. [24] found that interprofessional mentoring required some specific competencies that differed from profession-specific mentoring, hence health professionals engaging in interprofessional mentoring would need training to fulfil their roles adequately [24,25].

Research conducted by nurses [26] indicated a desire for more in-depth discussions and enhanced communication with universities concerning the distribution of student placements. Additionally, it was essential for stakeholders to collaborate in order to optimize clinical placement opportunities for students [27]. Other studies found that clinical mentors saw clarity in their roles as critical in helping students achieve their clinical placement objectives [26,28].

Lastly, it has been highlighted that poor communication between educational and clinical settings is a global challenge in the nursing profession [29,30]. A potential cause of the theory–practice gap could be a lack of mentorship training [31], which often leads to feelings of unpreparedness to take on the clinical teaching role [32], which is contributed to by factors such as lack of organisational support, the absence of a learning culture and mentors [33]. Juntunen et al. [24] posit that joint planning of the clinical education curricula is essential in effective interprofessional mentoring, as the clinicians have the chance to contribute to the programme and have buy-in from the start.

5. Conclusions

Interprofessional mentoring of pharmacy students by professional nurses is inevitable within the primary healthcare settings of South Africa. Critical challenges, such as the inadequate involvement of professional nurses in the planning of clinical placements by the higher education institution and the uncertainty of the professional nurses in taking on the mentoring roles, pose risks to the realization of the aim of clinical placement of pharmacy students, which will, in turn, affect their preparedness for clinical practice.

Although pharmacy students contribute to clinical practice activities, priority must be given to their clinical placement objectives and monitored carefully to ensure they realise them. Training of the professional nurses who mentor pharmacy students in PHC must be given urgent attention for the pharmacy students’ goals of clinical placement to be realized. Further, students’ experiences on their clinical placement and learning in the PHC should be constantly monitored to provide them with the necessary support.

6. Policy Implications

Although interprofessional mentoring provides a useful clinical environment for students to learn from and collaborate with health professionals from different health professions, the planning and implementation of the programme is critical in realizing these outcomes. Institutions already implementing or intending to implement interprofessional education should consider collaborative planning and implementation of the programme with the clinical setting and providing the opportunity for health professionals to acquire the necessary competencies needed for facilitation.