Students’ satisfaction with their health and social care educational programmes: qualitative findings from the UK

Satisfaction des étudiants vis-à-vis de leurs programmes d'enseignement médico-social : résultats qualitatifs au Royaume-Uni

رضا الطلاب عن برامج تثقيفهم في مجال الرعاية الصحية والاجتماعية: نتائج كيفية من المملكة المتحدة

وليد الأنصاري، ترنس دافيز، دايان بيرسن

^IFaculty of Sport, Health & Social Care, University of Gloucestershire, Gloucester, United Kingdom (Correspondence to W. El Ansari: walidansari@glos.ac.uk)
^IIWestminster Institute of Education;
^IIISchool of Health and Social Care, Oxford Brookes University, Oxford, United Kingdom

ABSTRACT

This article reports a qualitative assessment of students’ satisfaction with their health and social care educational programmes. The responses of 66 students who completed an open-ended “comments” section at the end of a survey to assess students’ satisfaction were coded and analysed using the constant comparative method. Respondents commented on: course organization, module organization, workload, module content, course delivery, personnel delivering modules, course workload and assessment, and resources available. The findings suggest that 3 interrelated factors are imperative for “educationally effective” modules: 1) module administration, content and assessment; 2) module teams and university resources; and 3) module relevance.

RÉSUMÉ

الخلاصـة

تـتناول هذه الورقة البحثية تقيـيماً كيفياً لمدى رضا الطلاب عن البرامج التثقيفية التي تقدَّم إليهم في مجال الرعاية الصحية والاجتماعية. وقد تم في إطار الدراسة جمع إجابات من 66 طالباً، قاموا بملء قسم مفتوح للتعليقات، في نهاية مسح أُجري لتقيـيم مدى رضا الطلاب، ثم تم ترميز وتحليل هذه الإجابات باستخدام طريقة المقارنة المستمرة. وتناولت تعليقات الطلاب: تنظيم المقرَّر الدراسي، وتنظيم الوحدات النموذجية التدريبية، وعبء العمل، ومحتوى الوحدات التدريبية، وطريقة التدريس، والقائمين بالتدريس، وعبء العمل في المقرَّر وتقيـيمه، والموارد المتاحة. وتشير النتائج إلى ضرورة توافر ثلاثة عوامل متـرابطة لكي تحقِّق الوحدات التدريبية فعالية تثقيفية، وهي: (1) تنظيم الوحدة التدريبية. ومحتواها وتقيـيمها، (2) الفِرَق المشاركة في الوحدة التدريبية، والموارد الجامعية، (3) مدى صلة الوحدة التدريبية بالغرض منها.

Introduction

In the United Kingdom, the responsibility for both academic and practice-based health and social care education now rests with the higher education sector and universities [1]. Such developments have brought about significant changes in the organization and content of educational programmes [2], along with the recognition of the need to enhance and monitor the quality of learning and teaching. Quality education in health and social care is a complex subject and has traditionally been assessed by student evaluations that include a variety of factors [3]. These factors comprise the learning environment that involves interconnected components such as teaching methods and assessment, course structure, curriculum and teacher effectiveness. For instance, the way a module is delivered, its content and theoretical level, as well as the detail of administration and other factors all have an impact on students’ evaluations. Preparing health and social care students to deal with the complex aspects of future health care systems requires cultivating independence and critical thinking [4]. This raises important questions as regards students’ satisfaction with their education and how their professional preparation will be undertaken. Hence a range of factors collectively interplay to shape a satisfying learning and teaching experience. These include the module characteristics, organization, planning, workload, content, relevance, the theory-practice balance, lecture and seminar delivery, class size in terms of student numbers and accommodation, module teams, support systems and mechanisms, and university resources [5-13].

This paper is part of a study to assess the satisfaction of health and social care students with their educational programme which used an 18-item questionnaire to examine the factors affecting student satisfaction [14,15]. The paper focuses on the responses of students who provided open comments on their educational experience at the end of the questionnaire. The specific aims were to:

·   Assess whether the demographic and educational profiles as well as the satisfaction and achieved grades of students who volunteered to comment were different from those who did not comment.

]]> ·   Assess whether the participants who commented originated from a particular cluster of achieved grades.

·   Explore the different themes and factors of the learning and teaching encounter that may affect student satisfaction with their educational experience.

Methods

A questionnaire was used to survey the students. Details of the subjects, setting and questionnaire are detailed elsewhere [14,15]. An open “comments” section was included at the end of the survey questionnaire where students commented on any aspect of the teaching and learning experience that they wished. This section, which is the focus of this paper, explored qualitatively the facets of the educational process, and was employed to expand on issues critical to the effectiveness of students’ learning. Open-ended questions permit the participants to respond in their own words, use their own frame of reference, and express private thoughts and feelings [16]. After permission from the module coordinators, the open-ended “comments” section of the questionnaire was administered at the end of a teaching session (by the author to students who wished to participate).

This investigation used a “case study” approach [17] of students’ experience of learning and teaching. Whereas, the case study is singular, it has subsections (e.g. course organization and general satisfaction; module organisation and planning; module characteristics; lecture and seminar delivery; module teams) which comprise complex domains. Holistic case study calls for the examination of these complexities [18].

The comments were analysed using the constant comparative method [19]. Transcripts of students’ comments were initially read through and indexed to form provisional headings, which were confirmed or rejected in subsequent readings. Categories were developed and applied to all comments until theoretical saturation was achieved. There was no attempt to impute meaning or impose pre-formed categories, hence preventing any preconceived ideas held by the researcher from obscuring the respondents’ meanings. As the comments were analysed, themes emerged from these categories. The theme of educational satisfaction and effectiveness was followed through the whole data set. The study captured the respondents’ own words, as their descriptive immediacy means they are seldom forgotten.

The objectivity or neutrality of the data (confirmability) was accomplished by compiling an audit trail for the inquiry: a collection of materials and documentation, raw data, and data reduction, analysis and reconstruction products. An educational expert at the institution examined the data in the manner of an independent financial auditor. The trustworthiness of the data and the meanings attached to them were observed and were judged worthy of confidence. The generalizability of the data, the extent to which findings can be transferred to other groups, was attained by providing a description of the setting, subjects and context where the study was conducted, hence providing information for judging the external validity of the enquiry [20].

Results

The first 2 aims of the study were to assess the generalizability of the results to the wider student population at the institution. Table 1 shows the demographic and educational characteristics of students who did and did not comment. There were no significant group differences as regards their gender, level of disability, academic level or the nature of modules. In relation to the groups’ entry qualifications, there were insufficient numbers to be able to judge confidently whether there were any differences. The findings also suggested that being a part-time student aged < 21 years of “non-white” ethnicity was associated with commenting, while being on a Bachelor of Arts degree was less associated with commenting.

Participants who commented were slightly (but not significantly) more satisfied as regards 60% of the survey’s satisfaction items (data not presented). Those who commented had a slightly higher mean grade (1.05% higher) than those who did not, but the difference was not significant. Hence commenting did not indicate dissatisfaction or substandard student performance on the module assessment.

Table 1 also shows the relation between the students’ performance and the probability of commenting, by computing the percentages of students from each grade bracket who commented. Nearly equal percentages of students from the various grade brackets volunteered to comment. Although the highest percentage (18.8%) of students who commented were those who failed their modules, the differences were not significant. Hence, the qualitative narratives quoted below are from a sample of students with module performance scores representing the whole continuum.

The emerging categories and themes are shown in Table 2. The students’ comments are presented below, organized into the different categories that emerged from the analysis. In order to indicate that the comments came from different students, a semi-colon separates the comments every time a different student’s views are reported. The term “module” is used below to indicate a specific unit of under- and postgraduate study (e.g. epidemiology module or research methods module). Each programme of study is composed of a specific number of modules that are required to be successfully completed by the students.

Course organization and general satisfaction

Many informants found the experience enjoyable, interesting and “user-friendly”: Very enjoyable module; Very interesting module; Module very user friendly; Module has given confidence to address research at social and professional level that will enable me to use the research in an informed choice basis.

On the other hand, others reported some challenges: Found this module difficult: Modulewas much harder than I expected; It caused me extreme stress and anxiety; Was very stressful.

Module organization and planning

Students reported positively on the design, organization and planning: Module has been well designed; Module was well organized; The module set-up was planned; Helpful to have all the reading list handed out, thanks.

But some informants felt the need for more continuity, timely module materials, and a better use of some sessions: There seemed to be a lack of continuity; Module could have been organized differently;Would have liked the reading list earlier; Would have been useful if the seminar groups could have done a session each week on a section of the research proposal.

Module workload

As regards workload intensity and time frames: Work load and intensity was much higher than expected; A lot of work to do in such a short time made it very difficult; A large amount of extra study is needed outside the lectures; The intensity and volume of work is at times very difficult to cope with; Course work was very time-consuming and left little revision time; Quite a large number of topics covered, makes it difficult to remember everything.

Module content

Most participants reported that the modules were stimulating and informative, resulting in high levels of learning: Found it [module] challenging; Module was very interesting; Module team presented interesting information; Module is very intellectually stimulating; Lectures and seminars were informative; Module has been very stimulating, resulted in high levels of learning and new interest.

However, time constraints meant that overloaded modules, short time frames and long sessions were concerns, especially for part-time students with full-time jobs who attend the university in the evening: Unfortunately with 4 modules to contend with this term, would have liked more time to spend on the actual academic work; The time we had for the module is not enough to take all the information in as much as I would like to; Six [pm] to 9 [pm] is a long day.

Some respondents reported that there was a theory-practice gap which needed to be avoided: More lectures need to be devoted to practising practical techniques more with more clinical reasoning; Practical group work [is] insufficient.

Conversely, some students found their modules useful to their clinical practice: The things learnt are useful to clinical practice on a practical [level]

Lecture and seminar delivery

Informants perceived the teaching on their programmes to be of a high standard: Module delivered in clear and precise manner; Module was well taught; Module was well run; Have really enjoyed the lectures and group seminars; Quality of teaching was excellent.

Although providing students with handouts and reading material is helpful, the amount, timing and circulation method of the material might require consideration: Very useful to be given the readings, would have been useful to have had this prior to week 1 or ready for students to collect in one batch; Too many articles given out which seemed to distract from the lectures and assignment; Appreciated the informative and useful handouts but distribution was difficult and availability variable, caused some alarm at the time.

Participants gave mixed messages regarding the actual lectures and seminars: Time given by the seminar leader was good; Many of the lectures were unhelpful and boring; The seminar delivery was brilliant; Seminars useful, [but] never sure which articles were to be discussed; Did not find seminar sessions useful; Did not enjoy practical sessions.

Some students felt that the group size and accommodation might benefit from adjustment: If the groups had been smaller this may have been easier; I personally felt the group was very large and therefore was difficult to interact; The only suggestion I could make would be for smaller groups; Rooms too small for group.

Module teams

They also applauded their professional competence: The module team were well prepared; Excellent teaching styles adopted by lecturers; The module team was knowledgeable and skilled; The module [had] good staff; Very good visiting lecturers;Outside speakers were not always as good.

Course work and assessment

The appropriateness of assessment methods was questioned: Don’t know if the amount of learning can [be] clearly expressed through the assignment, whether marked assignment is a fair way to judge learning.

But it would seem assessment guidelines and module information can inadvertently send conflicting messages: Different groups within the same module were given different guidelines from tutors, this will cause problems; Might help to incorporate the assessment strategy information from the [assignment] guide into the handbook or reduce the diversity of the key principles.

Time constraints were another factor: Due to constraints in time in submitting the assignment, knowledge may not have been sufficiently developed; the pressure of completing the written assessment by the deadline, with the other modules, detracted from the learning experience; Would have helped to have longer period to develop the assignment; ordering [references] takes 2 weeks, considering the term is only 8 weeks, have only 3-4 weeks to prepare and write essay.

In spite of these challenges, some respondents reported good support systems and mechanisms: Students are offered support; Good support from staff and students; The level of educational and personal support is outstanding.

While others indicated poor facilitation and communication: The assignment was difficult and relied strongly on the lecture notes and reading lists; Would have liked more input on the assignment, perhaps with opportunity to go through my drafts, although with lots of students this is difficult.

Hence some informants indicated that more tutorial support would have been appreciated: Felt a bit lost and unsupported, I did not know who to appeal to for reassurance and guidance; Would have been useful to have some feedback on what we had begun to write; All work done on my own back; They just threw you into the deep end really and did not help you; I do not feel we were guided through the assignment enough; Would be useful to have more help from lecturers.

University resources

For instance, some books and periodicals were only for short loan, and access to a well-stocked nearby library was not feasible due to lack of a contractual agreement: Library books difficult to get hold of. I tended to use my local hospital library; One very important book was only available in short-term loans for 24 hours, with 70 people on module, not adequate; there was not enough journal resources made readily available, e.g. no access to [nearby] library which is available to other health care students; we are not allowed to use [nearby]library which had implications on amount of literature we can draw upon and reflect for our essay assignment.

Discussion

Quality has become a key issue everywhere: within the World Health Organization [[21], in the National Health Service [22], in the caring professions [23], and in higher education [24,25]. Further, teaching today is treated as a technology [26], with repeated calls for it to be “evidenced based” [27]. This focus on quality that is evidence based as well as the relevance of the teaching programmes [28] and the required improvements in quality performance [29] have collectively contributed to the monitoring of students’ satisfaction of their learning as a critical source of course evaluation [30].

The first aim of the study was to assess whether the demographic and educational profiles of students who volunteered to comment were different from those who did not comment. To that extent commenting was not related to a wide range of students’ demographic and educational characteristics [except being a part-time, traditionally-aged student (< 21 years) or of “non-white” ethnicity].

The first aim was also to assess whether the satisfaction and achieved grades of students who commented were higher or lower than those who chose not to comment. The findings suggested that commenting was not associated with low satisfaction or low achievement in terms of the grades the students accomplished in their final assignments.

The second aim of the study was to assess whether the participants who commented originated from a particular cluster of achieved grades. In this regard, comments did not come mainly from respondents within a certain grade bracket.

The third aim of the study was to explore collectively how a range of factors of the learning and teaching experience affect student satisfaction. The results of the current study are in agreement with those of Kinsella et al., who reported that a majority of UK student nurses felt that their course could have been better organized [31]. Educators might need strategies to accommodate the changes in educational objectives, processes and contents [32]. Students embark on their first term without knowing what to expect [33]. Only after attending are they able to judge their modules. For instance, other researchers [31] have reported that students rated 30% of their nursing modules between fair and good, whereas the rest achieved lower ratings. Hence, anticipatory anxiety and stress [34] are not uncommon for nursing students, with the possible consequences of decrease in morale and performance [35]. Similarly, exhaustive training [36] is a problem in health and social care education and an unnecessarily high academic level is sometimes a concern [37]. Intensive workloads do little to encourage learning, and rather, educational systems need to emphasise the learning of skills, how to learn and relearn, and how to apply new knowledge in the workplace.

To foster competencies, a course must adapt to the influx of new knowledge and to the service needs [38-40] found that that only half their sample of student nurses found the lectures interesting. As regards relevance, learning is motivated when practice problems are identified, or if the knowledge is of use in task performance. Effective courses must focus on delivering relevant knowledge, demonstrate fitness for purpose [41], and relate learning to the practice areas. However, “fitness-for-academic-award” and “fitness-for-professional-purpose” remain uneasy bedfellows [1]. Thus, the extent to which nursing courses are related to the students’ requirements remains a major consideration [16]. Different learning styles and approaches [42] have an impact on time and may act as barriers to reflective practice development [43].

As regards lecture and seminar delivery, this study concurs with the finding that student nurses perceive teaching and learning on their programmes to be of a high standard [46]. For instance, providing student handouts is helpful [47] but there is no single best time to distribute them [48]. Such aspects can cause student dissatisfaction, where the amount, timing and circulation method of material need consideration [49]. Other factors include group size and accommodation. These are also important factors: group dynamics may influence resistance to shared learning and commitment [50], but group processes encourage critical thinking, promote reflective practice and change behaviour and attitude [51]. As dominant members could block other students [50], small tutorial groups better allow students to reflect and meaningfully relate theory to practice.

In connection with the module teams, this study is in agreement with Smith [52], who reported that faculty configuration influences the shape and content of nursing curricula. The teaching skills necessitated in a clinical area or classroom are different, and various skill requirements of nurse teachers are necessary [53]. Openness to and positive interpersonal relationships with students are important characteristics of teacher effectiveness. Conveying knowledge, intellectual excitement and professional competence [54] are similarly critical qualities of an effective teacher. Nurse teachers need to be knowledgeable, experts in the field, credible and clinically and academically competent.

As regards course work and assessment, changes in education might require abandoning traditional student evaluation tools [32]. This investigation casts doubt on whether learning can be adequately assessed through the methods currently employed. For instance, in agreement with another study [38], the implementation of guidelines sometimes varies. Inadvertently, assignment guides and module information can send conflicting messages and participants might feel they had not been given sufficient information on what is expected from them [31]. Further, there is scant literature on nurse teacher’s professional training needs in relation to their tutorial functions, in spite of its apparent importance in maintaining student morale and in achieving academic standards [55]. This study showed that some respondents reported good support systems, but some felt there was poor facilitation and communication between teacher and student. This study found that more tutorial support would have been appreciated.

In connection with university resources, although educational reforms have led to a greater amount of classroom learning, this needs to be paralleled by adequate library support of reading resources and materials. Library and information services may sometimes be an afterthought, and consequently books and periodicals might be unavailable to support learning needs [56]. In this study, students complained that some books and periodicals were only for short loan and access to a nearby library was not feasible due to lack of a contractual agreement. This is in agreement with Bird and Roberts [57], who highlighted the value of library and information services, and their role in the facilitating student learning.

Whereas teaching departments may be able to do little in preventing students’ social problems, educators should address student satisfaction when it stems from poor course organization, mismanagement or lack of support. Research is needed to learn more about what makes an effectively organized course. How can modules bestimulating and relevant to a diverse student population of different ages, ethnicities, experiences and learning needs? The findings of this study suggest that there is room for improvement in the health and social care education programmes to increase student satisfaction. But such information will have an impact on the development of quality education only if it is acted upon. The university where the study was conducted holds student satisfaction as important to the organization, and the findings of this study have been reported to the institution in order to formulate and implement strategies that address student satisfaction and guide lecturers to enhancing the quality of learning and teaching.

Acknowledgements

The author would like to thank all those at the institution where the study was conducted: the faculty and staff, and the health and social care students who generously contributed information about the modules. Special thanks go to Julie Poulton of the Systems Unit for data retrieval and linkage.

1. Wheeler HH, Cross V, Anthony D. Limitations, frustrations and opportunities: a follow-up study of nursing graduates from the University of Birmingham, England. Journal of advanced nursing, 2000, 32(4):842-56.        [ Links ]

2.   Day C. Researching professional education. The role of the teacher/lecturer in practice. London, English National Board for Nursing, Midwifery and Health, 1998 (ENB Research Reports Series, No. 8. Chapter 1).

3.   Brennan J, Kogan M, Teichler U. Higher education and work: a conceptual framework. In: Brennan J, Kogan M, Teichler U, eds. Higher education and work. London, Jessica Kingsley, 1996.

4.   Walton JC. The changing environment: new challenges for nursing education. Journal of nursing education, 1996, 35:400-5.

5.   Kerridge JB, Mathews BP. Student rating of courses in HE: further challenges and opportunities. Assessment and evaluation in higher education, 1998, 23:71-82.

6.   Cash K. The pure and the applied in nursing education. Nurse education today, 2000, 20:73-7.

7.   Jowett S, Walton I, Payne S. The introduction of Project 2000; early perspectives from the students, Interim Paper no. 5. Slough, National Foundation for Educational Research, 1992.

8.   Wilson KL, Lizzio A, Ramsden P. The development, validation, and application of the course experience questionnaire. Studies in higher education, 1997, 22:33-53.

9.   Corlett J. The perceptions of nurse teachers, student nurses and preceptors of the theory-practice gap in nurse education. Nurse education today, 2000, 20:499-505.

11.  Davies C et al. Did Project 2000 nurse training change recruitment patterns or career expectations? Nurse education today, 2000, 20:408-17.

12.  Ofori R. Age and “type” of domain- specific entry qualifications as predictors of student nurses’ performance in biological, social and behavioural sciences in nursing assessments. Nurse education today, 2000, 20:298-310.

13.  Hounsell D, Trait H, Day K. Feedback on courses and programmes of study: a handbook. Edinburgh, University of Edinburgh, Centre for Teaching, Learning and Assessment, 1997.

14.  El Ansari W. Student nurse satisfaction levels with their courses: Part I − Effects of demographic variables. Nurse education today, 2002, 22(2):159-70.

15.  El Ansari W. Student nurse satisfaction levels with their courses: Part II ^{.. Effects of demographic variables.Nurse education today, 2002, 22(2):159-70.}

16.  Gould D et al. Students’ expectations of post-registration degree programmes. Journal of advanced nursing, 1999, 29(6):1308-17.

17.  Yin R. Case study research: design and methods. Thousand Oaks, California, Sage, 1994 (Applied Social Research Methods Series 5).

18.  Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park, Sage, 1985.

19.  Strauss A, Corbin J. Grounded theory methodology: an overview. In Denzin N, Lincoln Y, eds . Hanbook of qualitative research.Thousand Oaks, California, Sage, 1994.

21.  The principle of quality assurance. Copenhagen, World Health Organization Regional Office for Europe, 1983 (European Reports and Studies 94.)

22.  Griffiths R. NHS management inquiry. London, Department of Health and Social Services, 1983..

23.  Ellis R, ed. Professional competence and quality assurance in the caring professions. London, Chapman and Hall, 1988.

24.  Chapple M, Murphy R. The nominal group technique: extending the evaluation of students’ teaching and learning experiences. Assessment and evaluation in higher education, 1996, 21:147-58.

25.  Harris LM, Adamson BJ, Hunt AE. Assessing quality in higher education: criteria for evaluating programmes for allied health professions. Assessment and evaluation in higher education, 1998, 23:273-81.

26.  Bassey M. Creating education through research. Newark, NJ, Kinklington Moor Press, 1995.

27.  Davies P. What is evidence-based teaching? British journal of educational studies, 1999, 47(2):108-21.

28.  Lim D. Quality assurance in higher education in developing countries. Assessment and evaluation in higher education, 1999, 24(4):379-90.

29.  Ho SK, Wearn K. A higher education TQM excellence model: HETQMEX. Quality assurance in education, 1996, 4(2):35-42.

31.  Kinsella FE, Willaims WR, Green BF, Student nurse satisfaction: implications for the common foundation programme. Nurse education today, 1999, 19:323-33.

32.  Ben-Zur H, Yagil D, Spitzer A. Evaluation of an innovative curriculum: nursing education in the next century. Journal of advanced nursing, 1999, 30(6):1432-40.

33.  Gray M, Smith LN.The professional socialisation of Diploma of Higher Education in nursing students (Project 2000): a longitudinal qualitative study. Journal of advanced nursing, 2000, 29(3): 639-47.

34.  Parker TJ, Carlisle C. Project 2000 students’ perceptions of their training. Journal of advanced nursing, 1996, 24(4):771-8.

35.  Brown H, Edelmann R. Project 2000: a study of expected and experienced stressors and support reported by students and qualified nurses. Journal of advanced nursing, 2000, 31(4):857-64.

36.  Orr JG. Traditional V Project 2000 - something old, something new. Nurse education today, 1990, 10:58-62.

37.  Jowett S. Added value. Nursing times, 1995, 91(1):55-7.

38.  Jordan S et al. Assessing educational effectiveness: the impact of a specialist course on the delivery of care. Journal of advanced nursing, 1999, 30(4):796-807.

39.  El Ansari W, Pearson D, Davis T. Satisfaction with interprofessional multidisciplinary education? Influences of learners’ demographic and academic characteristics. Journal of interprofessional care, 2002, 16(2):174-5.

41.  Humphreys J. Educational commissioning by consortia: some theoretical and practical issues relating to qualitative aspects of British nurse education. Journal of advanced nursing, 1996, 24:1288-99.

42.  Carnwell R. Pedagogical implications of approaches to study in distance learning: developing models through qualitative and quantitative analysis. Journal of advanced nursing, 2000, 31:1018-28.

43.  Burton AJ. Reflection: nursing practice and education panacea? Journal of advanced nursing, 2000, 31:1009-17.

44.  Hislop S et al. Situating theory in practice: student views of theory-practice in Project 2000 nursing programmes. Journal of advanced nursing, 1996, 23(1):171-7.

45.  Lee DTF. The clinical role of the nurse teacher: a review of the dispute. Journal of advanced nursing, 1996, 22:1127-34.

46.  Phillips T et al. Experience of learning in higher education. In: The evaluation of pre-registration undergraduate degrees in nursing and midwifery programmes. London, English National Board for Nursing, Midwifery and Health, 1996:113-24.

47.  Bligh D. What’s the use of lectures?, 5th ed. Exeter, Intellect, 1998.

48.  Quinn FM. The principles and practice of nurse education, 4th ed. Cheltnham, Stanley Thornes, 2000.

49.  El Ansari W. Appraisal skills as a public health competency for evidence-based care: Student satisfaction with their research education. Journal of public health management and practice, 2004, 10(4):354-65.

51.  Platzer H, Blake D, Ashford D. An evaluation of process and outcomes from learning through reflective practice groups on a post-registration nursing course. Journal of advanced nursing, 2000, 31:689-95.

52.  Smith L. A follow-up study of nursing graduates, 1982-90. University of Glasgow. Journal of advanced nursing, 1993, 18:1840-8.

53.  Camiah S. New skills required for nurse tutors in the UK: a study within Project 2000 pilot schemes for pre-registration nursing courses. Nurse education today, 1998, 18:93-100.

54.  Nahas VL, Nour V, Al-Nobani M. Jordanian undergraduate nursing students’ perceptions of effective clinical teachers. Nurse education today, 1999, 19:639-48.

55.  Kevern J, Ricketts C, Webb C. Pre-registration diploma students: a quantitative study of entry characteristics and course outcomes. Journal of advanced nursing, 1999, 30(4):785-95.

56.  Trevelyan J. Live issues: libraries could do better. Nursing times, 1992, 88:69-71.

57.  Bird D, Roberts PM. The role of library and information services in the modular curriculum. Nurse education today, 1998, 18:583-91.

Climate and health: the effects of climate change on health

To a large extent, public health depends on safe drinking water, sufficient food, secure shelter, and good social conditions. A changing climate is likely to affect all of these. Overall, the health effects are likely to be overwhelmingly negative, particularly in the poorest communities. The effects include increasing frequency of heatwaves and more variable precipitation patterns (likely to compromise the supply of fresh water, increasing risks of water-borne disease).

Rising sea levels increase the risk of coastal flooding, and may necessitate population displacement: over half the world’s population lives within 60 km of the sea. Two of the most vulnerable regions are the Nile delta in Egypt and the Ganges–Brahmaputra delta in Bangladesh.

Climate change is likely to increase the transmission seasons of important vector-borne diseases such as malaria and leishmaniasis, and to alter their geographic range, potentially bringing them to regions which lack either population immunity or a strong public health infrastructure.

A WHO quantitative assessment, taking into account a subset of the possible health impacts, concluded that the effects of the changes in climate since the mid-1970s may have caused over 150 000 deaths in 2000. It also concluded that these impacts are likely to increase in the future. http://www.who.int/mediacentre/factsheets/fs266/en/index.htm ]]> 1 2000 32 4 4 842-56