Participants

All students from all 14 MCHA schools were asked to participate in the study. Given the large number of students (750) self-administered questionnaires were used to determine student satisfaction with the learning and teaching environment. Each school takes approximately 40–60 students in each cohort with a total of 1258 h of taught theory from 10 teachers per school. At the request of the MoHS, all 14 schools were included in the programme to prevent any school being potentially disadvantaged. In addition to the tutor training, each school received skills room equipment and audio-visual aids to assist tutors in developing more interactive teaching methods.

Data collection

From 2013 to 2014 four education experts from the research team facilitated four district based, 2-day workshops for 10 core teaching staff (including the School coordinator) from each of the 14 MCHA schools (140 core staff in total). There were 35 tutors in each work shop. None of the MCHA tutors had a formal teaching qualification.

The workshop aimed to develop tutors understanding of teaching and learning theories and how to apply these in practice; to understand the concept of student focused learning; to understand how to apply different teaching methods within the classroom and to develop skills in reflective practice. The workshops covered active teaching and learning methods, lesson planning, writing learning outcomes, reflective practice, supportive supervision, mentorship and effective learning environments. During the final session of the 2-day workshop tutors developed an action plan for their own school to implement their learning from the workshop into practice. In addition, tutors also took part in formative teaching practice both in the classroom and simulation or skills room.

All workshops were completed within a two-week period and first follow up observations conducted 3 months afterwards. It was anticipated that this would allow tutors time to start implementing changes in some of their lessons. Observed classes included only those tutors who had been to the workshop.

A descriptive analysis of the age and entry qualification of MCHA students at the time of the study was conducted by reviewing admission records. This was to establish compliance with admission criteria as there is a high potential that less qualified students (on entry) may find it more difficult to cope with the curricula.

Prior to the tutors training programme a baseline visit was conducted for each of the 14 MCHA schools in August–September 2013. Three follow-up visits were planned to all 14 MCHA schools across Sierra Leone. The follow-up visits were timed to coincide with key dates during the MCHA training.

First follow-up was at the end of the students first year (3 months from baseline). Second follow-up occurred immediately prior to their second year examinations (6 months from baseline). Final follow-up was conducted at the end of the programme (12 months from baseline).

Due to the Ebola epidemic in Sierra Leone which occurred from May 2014 to December 2015 the MCHA schools were closed in August 2014. Only 10 of the 14 schools could be visited for the second follow-up and no schools could be visited for the third follow-up. Final results are based on the 10 schools seen at second follow-up only.

At each visit (baseline, 3 months and 6 months), both qualitative and quantitative methodology was used to gain as full a picture as possible of the teaching and learning within each school and allow for triangulation of data. Data collectors worked in pairs to administer the student questionnaire but conducted independent observation of the teaching using a standardised data collection tool.

The aim was to observe two one-hour teaching sessions at each visit in each MCHA school (2x14x3 visits = 84 observations) and ask 750 students to complete a questionnaire at each visit (3 × 750 = 2250 questionnaires). Outcome measures were student evaluation of teaching and learning an increase in student focused sessions, reduction in the use of didactic teaching methods and increase in student learning.

Both tutors and students were provided with written and verbal information about the study by the research team and asked to sign a consent form if they agreed to participate.

Data analysis

Qualitative data analysis was completed using the Framework Analysis approach. This approach is useful where data covers similar topics or key issues and so can be categorised [20]. In this study the structured observation form used a deductive approach to pre-select key themes of teaching and learning which could be considered as the key issues [20]. It was expected that other sub themes may also occur at follow-up visits which would be incorporated into the Framework analysis.

All student questionnaires were electronically scanned and processed using Formic^®. SPSS version 22 was used for analysis. New random samples were selected on each occasion, so most students completed a questionnaire at just one of the three assessment times; these samples were considered to be statistically independent. One-way analyses of variance (ANOVA) were used to evaluate the changes in mean student satisfaction scores across the three assessment points; statistical significance was set at the conventional alpha level of 5% (p ≤ 0.05). Each of the test items (questions) were analysed individually and then the total score across all 19 items was evaluated; Cronbach’s alpha (coefficient of reliability) was calculated to ensure adequate internal reliability of this total score.

Student evaluation of teaching and learning

Variables which could be considered to be important in developing more student-focused learning and therefore to be influenced by the training workshop included; the teaching methods used, being encouraged to think and to ask questions, the availability of tutors outside of lessons and the breath of learning and student interest in the subject. There was a statistically significant increase in student scores at follow-up compared to baseline. Students also reported that lessons were better organised and tutors more respectful to their students. A decrease in the number of students reporting that lessons were difficult from baseline to follow-up may indicate the positive impact of the new teaching styles on student learning as they moved into their second year.

There was a statistically significant increase in the positive evaluation by students of variables which could be considered to be indirectly influenced by what goes on in the classroom; these included students completing homework and the numbers attending all lessons. Students continued to report that it was difficult to find time for self-study which may be influenced by commitments outside of the school including family.

Cronbach’s alpha for the total score using all 19 questions was 0.71; this increased to 0.72 when the question on ‘Hours of self-study’ was not included and to 0.79 when the questions on ‘Content of lesson too hard’, ‘Hours of self-study’ and ‘Difficult to find time’ were not included. This total score increased highly significantly between baseline and the first follow-up assessment but there was only a very modest and non-significant increase between the first and second follow-ups.

Observation of teaching

Main findings

Both tutors and students contribute to the success of teaching and learning. From a tutor’s perspective how they engage and work with students can contribute to the overall effectiveness of their teaching. The workshop intervention was deemed successful in encouraging tutors to change their methods of teaching with a decrease in tutor-focused and an increase in student-focused methods of teaching. The aim of the training workshop was to train and encourage tutors to use a wider variety of teaching methods and move away from simple didactic teaching, and in this respect the workshop was successful. However, this change in teaching also needs to be recognised as being useful by the students for their learning.

Data from the student questionnaires showed a positive evaluation of teaching and learning in the schools as the number of student focused lessons increased. Interactive teaching methods have increased in popularity in high resource areas but less so in low resource areas such as Sierra Leone. Where there is a lack of education and information technology resources then the teaching methods used take on an even higher importance as they are often the only information resource available to students. Encouraging students to be part of developments in teaching by asking them to evaluate new methods can further help to develop the learning and teaching environment.

Though there is an agreed minimum qualification for entry to the MCHA training programme in Sierra Leone, 12.5% of the students did not have this and this may have affected their ability to learn at the required level. At follow-up there was a decrease in students who reported finding the lessons difficult (mean 2.98 at baseline compared to 2.86 at second follow up follow-up). Despite the difficulty of lessons increasing as the students moved into their second and final year when more complex subjects were taught. This may be a reflection of the impact that the move from didactic to student focused teaching was having with students reporting an increase in being encouraged to think, ask questions and a greater breadth of learning.

Some areas of learning and teaching are less easy for tutors to influence (hours of self-study, finding time to study) and it is reasonable to expect that just changing the methods of teaching could not influence these. Nevertheless, it is important for the overall picture of teaching and learning within the MCHA schools to know if there are factors outside of the classroom that may hinder learning. All of the students are female who have family commitments outside of their studies and which could reasonably be expected to impact on their self-study time. The majority of students lived in homes without a regular electricity supply further hampering study at home. Further research is needed to understand which particular enablers of student learning can be strengthened and how in this context.

Researchers were surprised to find that tutors advised students not to take notes. There is contradictory evidence on the effectiveness of in-class note taking and if this benefits students understanding or is a distraction. Though it would seem appropriate, given the lack of other reference material available, that the MCH Aide students should be allowed to take notes or have these provided by their tutors [28, 29]. Where students have limited or no access to learning materials or libraries the information provided within the classroom may take on a higher importance. The provision of learning resources is particularly important for this group of students who additionally reported finding time for self-study outside of the MCHA School difficult.

This study has important findings which need to be considered by countries looking at task shifting health care and introducing new cadres of nursing. The increase in numbers of healthcare workers in formal education programmes is not necessarily enough to meet the health needs of a country. The quality of the education programme and standards of teaching need to be addressed if such programmes are to successfully bridge the human resource shortages.

Strengths and limitations

The study involved both tutors and students and therefore obtained a comprehensive view of teaching and learning within the schools. Observation of teaching was new to the MCHA tutors but appropriate within the context of the study to determine the styles of teaching used and was, in fact, welcomed by the tutors. The use of peer review of teaching (on which the observations were based) is well established in many academic institutions, the aim of which is to provide constructive feedback to tutors on their practice [30]. The presence of the observers may have altered the dynamics within the classroom [31].

A planned final follow-up visit at 12 months and focus groups with the tutors following tutor training could not be completed due to the Ebola epidemic which occurred from May 2014 to November 2015. This is unfortunate as it would have provided self-evaluation of the tutors and information on the sustainability of the observed changes within the schools. The researchers also planned to conduct student focus groups to explore their perceptions and experiences in more detail than can be done via a questionnaire, but again the Ebola epidemic prevented this.