Developing a community of practice in health professions education: reflections from the Africa HPE ECHO project

Introduction

There are many challenges to health professions education (HPE) in South Africa (SA), including an ongoing need to develop and retain health professionals who are contextually responsive, resilient, empathetic, and socially accountable.¹ Additional tensions arise between the imperatives of equity and redress, and the realities of training students within complex and often under-resourced healthcare environments where ethical dilemmas are often experienced.^2,3 Equally important are sustained efforts in faculty development to support this mission⁴ and to keep abreast with current educational advances alongside improvements in human resources, leadership, governance, infrastructure, and the financing of HPE as key strategies for health systems strengthening and developing future healthcare professionals (HP) to adapt to changing environments.^4–6

Health sciences programmes in South African higher education institutions are increasingly full, time-pressured and complicated, involving a blend of rigorous academic demands, the need to master extensive and interconnected knowledge, and the expectation to apply this understanding in unpredictable, real-world clinical settings. Educators are expected to deliver large volumes of content, oversee practical learning, facilitate clinical placements, and manage assessment demands, while ensuring that students are ready to function in the healthcare system upon graduation⁷ and equipped to be change agents in addressing the challenges of unequal health care in SA.⁸ Thus, curriculum time is tight, clinical placements are constrained, assessments are heavy, and the use of innovation or flexible pedagogies may be sidelined. At the same time, educators face high workloads and turnover, and often lack institutional support to revise teaching and learning models, so that HP graduates often feel underprepared for their roles in health care.^9,10 Consequently, space and opportunities for reflective, creative, and socially responsive professionals are diminishing. These all contribute to a sense of isolation and fragmentation among both students and educators. In addition, silos between health professions (nursing, medical, rehabilitation, and other professionals) and between academic and clinical worlds further impede collaborative practice, mutual learning and peer support. The Africa Health Professions Education Extension for Community Healthcare Outcomes (Africa HPE ECHO) project aims to develop a community of practice (CoP) to support transformative learning and cultivate change agents in HPE. This paper considers key themes that emerged from online discussions hosted by the Africa HPE ECHO and provides recommendations for development of an HPE CoP. While the Africa HPE ECHO is primarily concerned with health education during times of disruption such as the COVID-19 pandemic, floods, and other climate disasters, the focus of this paper is on the voices of South African HP educators and specifically, with regards to their need for a CoP, either institutionally or nationally.

Understanding the ECHO model of sharing experiences

A team of six HP educators from the University of KwaZulu-Natal and Stellenbosch University received financial support to implement a project titled: “The Africa ECHO Network for Health Professions Education in Times of Disruption” in response to the dual shocks of the COVID-19 pandemic and floods in KwaZulu-Natal. The team’s approach was built upon the internationally recognised Project ECHO model, an effective hub-and-spoke tele-education framework originally designed to support healthcare providers in rural, remote, and underserved communities.¹¹ The objective of the grant was to form a CoP for HP educators, enabling learning through both ‘ordinary’ and disruptive experiences, as a means of faculty development and mutual support towards facilitating greater transformative learning and the development of change agents in the healthcare system. This paper discusses the key themes that emerged from a series of online discussions hosted by the Africa HPE ECHO and provides recommendations for a CoP and for development of the HPE curriculum.

Method

Study design

A qualitative study was undertaken using dialogue in the form of reflective discussions as a tool to review and analyse themes that emerged from transcripts of the sessions hosted by the Africa HPE ECHO team. Dialogue is a well-recognised tool bringing people together to allow for exploration of different voices and experiences, as well as a space for clarifying issues and creating new understandings or solutions.¹² It allows for people to thoughtfully and reflectively move beyond their entrenched positions once they view others’ input and experiences.

Sampling of participants

Non-probability purposive sampling was used to recruit participants through the authors’ own networks and by snowballing. Health educators (HE) from various academic institutions and health sciences training backgrounds were recruited, representing a range of expertise and experience. Between 2024 and 2025, 36 60-minute sessions were held twice a month, with on average 24 HE participants attending each session, including the authors of this paper.

The sessions focussed on cases of disruptions in higher education teaching and learning, and were intended to encourage pro-active advocacy and mentoring, as well as authenticity and reflection. The number of participants was deliberately limited, to allow constructive and focussed input from all stakeholders. Each session started with a case from an invited presenter, to create a platform for discussion and debate, and to challenge and support, while remaining focussed on the broader concept of disruptions in teaching and learning in higher education. At the conclusion of each session, the recordings and transcripts were reviewed and a follow-up blog was developed that provided a brief overview of the session, together with key take-home messages and relevant resources. The content of each blog was reviewed and approved by scenario presenters and experienced peers prior to finalisation to ensure no bias from the authors before publication on the iECHO website (Project ECHO’s technology platform).

Study setting

Each session unfolded as follows: an experienced HP facilitator opened the meeting and introduced the day’s topic, which was drawn from the community’s needs, and reiterated the meeting process. Central to the session was the importance of creating a safe and supportive environment, while sustaining a spirit of curiosity. One of the community members then presented a real-world scenario drawn from their own practice or experience, illustrating a dilemma or uncertainty they faced, and raised questions for group discussion and reflection. Presenters were encouraged to be creative in how they delivered their scenario, using a range of formats including artwork, poetry, etc. Under the facilitator’s guidance, participants then explored the questions together, working to build a shared understanding of the underlying issues and drawing on each other’s similar experiences. There was no expectation of providing definitive answers or solutions. An HP educator, or ‘friend with experience’ in the topic area, was also invited to contribute further perspectives and/or resources in response to the discussion. Finally, each session concluded with reflections from the group on their shared learning and possible next steps.

Topics for discussion

Topics for discussion arose from the CoP, and were focused on actual experiences in teaching and learning where presenters had grappled with disruptions, dilemmas, or challenges that remained unresolved. The sessions were often grouped around topics, as ideas from one presenter would spark another person to offer a scenario on a similar issue. The thematic analysis for this study was carried out by reviewing the transcript summaries of each recorded session, without identifying any of the participants. The session blogs were also reviewed. FS, IC and JC repeatedly reviewed the data and collaboratively extracted themes inductively, with PB then providing an overall review of these. These practices align with widely accepted standards for rigorous thematic analysis, including the guidance of Virginia Braun and Victoria Clarke, whose framework emphasises systematic coding, reflexivity, and transparent reporting.¹³

Ethical considerations

This paper arose from research being undertaken under the title: “Exploring CoP: Lessons from the Africa ECHO Network for HPE”, for which ethics approval was received from the Social, Behavioural and Education Research Ethics Committee, Stellenbosch University as Project ID: 33257. No individuals were identified, and any quotations used were attributed only to the relevant topic rather than to specific participants; therefore, confidentiality was not considered a concern.

Findings

The authors reviewed the topics presented over the last two years and identified five themes, namely: caring; fit-for-purpose professionals; growth mindset; leading, and swimming upstream (see Table 1).

Caring

“We get into the space of education … and we’re so fixated on the learning outcomes, the objectives, the alignment of curriculum and assessments that we forget that life is also happening to the people who are in the room with us.”

As healthcare professionals, how we care and view patients, students, and colleagues reflects the principles of relationality as well as professional and empathetic learning (sessions 1.1–1.6).

Experiences of students in a distributed learning platform and clinically under-resourced environment, with high patient load and little time for reflection, was a disorienting dilemma relating to transformative learning theory (1.1). This discussion led to a subsequent session on the mental health of students in clinical spaces (1.2). There is a need for educators to listen and work to understand students’ experiences, for example during the floods in KZN early in 2024. The group then asked: In authentic learning, how do we as educators create learning spaces that support vulnerability in any disruption?

Sessions followed on how educators enable and equip students to relate to patients as human beings, as a whole person, and build relationships in clinical settings. Discussions centred around the skill of presence, in a clinically challenging environment and how students, as part of caring, deal with the suffering of patients (1.3–1.6). The practice of presence is about being present to what is happening, viewing the patient as a person and witnessing suffering. Multiple questions arose, including: How to assist students with processing experiences that are not ideal? How can HPs be present to ourselves when confronted with ethical issues in clinical practice and with the suffering of our patients, without disconnecting emotionally resulting in compassion fatigue? This raised discussions around professional and empathetic behaviour in various contexts and the role of educators in relationality and learning.

Fit-for-purpose professionals

These sessions discussed the challenge of training professionals who are fit-for-purpose and adaptable to function and offer health care in changing contexts that included the use of artificial intelligence (AI) and climate disruptions (sessions 2.1–2.6).

“Part of the of the educational space is almost guiding students in terms of responsible use of generative AI. Then we can use the advantages that artificial intelligence affords us to cut out on time that could be better used in terms of developing our inner muscle, which is developing those cognitive skills.”

Dilemmas were presented on the use of AI by students in assessment and the impact thereof on critical thinking and clinical reasoning (2.1). Generative AI can assist with eliminating mundane tasks, to allow for deeper thinking and learning (2.2). The dilemma on how to incorporate AI into learning and assessment while maintaining ethical educational practices remains. HP educators reported that using AI to assist with grading student submissions required significant time to train the system to apply the marking rubric accurately (2.3). Discussions raised questions around the ethical dilemmas of structuring learning activities for authentic reflections that are not AI generated. By using AI for assessment, are HP educators, like students, wanting AI to generate feedback? Providing formative feedback to students aids learning, but the number of students and submissions are overwhelming in big classes. HP educators need to include AI responsibly into assessment tools for authentic learning (2.4).

Disruption requires adapting to different possibilities. The impact of climate change and how to incorporate that in curricula to ensure students are prepared for the future was discussed (2.5). Group questions were: What cognitive processes and problem-solving skills do HPs require to adapt to the uncertainty of climate change or any other disruption? What is the core curriculum for being responsive and competent to a changing context and environment? What is the core curriculum for compassion for both patients and their environment for a healthy SA? HP educators require spaces for reflection and curiosity about what and how they learn together and within a context and environment that develops HPs for the future (2.6).

Growth mindset

At the core of HPE is a desire for students to develop and grow in knowledge and as humans caring for patients (sessions 3.1–3.9). Learning effective communication, empathy, and patient centredness are key. Students are often taught these skills separately from a clinical context (3.1); thus, they are disconnected from real clinical communication and lack the practice of communication and empathy, including having difficult conversations. Reflection on practice is also required.

“The students were really struggling with this dichotomy between doctor and patient-centred care … [with] accurate information giving, and trying to distinguish between giving information and actually being supportive in a situation … they really struggle to engage with an authentic situation and show empathy in that.”

Building reflective leadership practices in students requires educators to think differently. Students need critical thinking to solve problems, understand intended meaning, and to suggest change that acknowledges assumptions. This is connected to the practice of HP attributes in courses and assessments (3.5). It also suggests a role for mentorship.

Mentors influence students, with the experience influencing their present and future career trajectory. The presenters of this session were mentees and reflected on their mentors who had facilitated learning from patients, open discussions, and trusting the process of fluid and open learning experiences, which in turn had developed their inner resources, confidence, and competence, and had been invaluable in their careers. True mentorship and how it shapes leaders was discussed. The lessons learnt included being authentic to oneself, and showing vulnerability which creates a safe space to build trust and relationships. Added to this were setting expectations, learning to listen, and to appreciate the mentee’s current needs and identity. These allow space to grow and to become one’s best self (3.2, 3.3, 3.6).

Reflective spaces were raised again in the next scenario. Using the children’s game ‘stuck-in-the mud’ as a metaphor, a scenario explored the challenge of multiple students in a widely distributed learning environment (3.4). The group discussion led to the following question: To ensure ongoing personal transformation for students and educators, how are environments created that allow vulnerability for growth, while balancing the need for transformative experiences without the risk of transformational trauma? Seeing patients in a healthcare facility is different from understanding patients in their own environments; to achieve this, critical thinking in complex systems is encouraged. The question asked was: Who is stuck in the healthcare system - educators, students, or patients (3.4)?

Another session discussed how to address health systems’ challenges in managing diseases, including upskilling the nursing workforce for decentralised care (3.5). The question asked was: What constitutes effective workplace transformative education? The dilemma faced was how to learn in the workplace without sufficient resources for effectiveness and sustainability. A culture of learning within the clinical environment was suggested with supervision and opportunities for peer-learning. How can healthcare workers be encouraged to learn in their workplace, rather than travelling for face-to-face workshops? What leads to practice change, clinical confidence, and morale amongst healthcare workers (3.8)?

Practice change continued in the next scenario on innovation in experiential learning of first-year students using theatre (3.7). Experiences of postgraduate students and their families engaged in the healthcare system were drawn on. This exposed students to their health profession in the early years.

The gap between theory and practice was the focus of a scenario on ethical dilemmas that students encounter during their clinical experiences (3.9). The HP educators questioned how to support students to relate and help patients with a problem at a human level. Participants agreed that ethics needs to be more integrated into learning, as every clinical decision has an ethical component.

Leading

An important role of HP educators is to be a leader, which requires skills and insights into identity, as well as the courage to be authentic (sessions 4.1–4.7).

“I wonder if we need to not separate, but to embrace the idea that emotions are inseparable from our cognitive, practical, spiritual meaning of life aspects of being and belonging and becoming, and integrate all of this in our teaching and learning upfront.”

A session explored how to find a space and niche as a new academic within an established department. New academics experience vulnerability in asking for help from colleagues, in their role with students, and in mentoring relationships. Academic identity is a journey and is continually being constructed (4.1–4.2). This sparked a discussion on how personal identity shapes perceived responsibilities. The participants observed that language informs identity. Being aware of unconscious biases embedded within one’s identity, enables curiosity about others’ perspectives.

The complex interplay and blurred boundaries between friendship and professional relationships were discussed in the context of the clinical courage needed to navigate the dual roles of healer and fellow human. (4.3). This led to discussion on when to say “No” when trying to do more than is manageable, and how this can lead to conflict between commitments. Saying “No” can be part of a process of recognising that we are not as important as we think and to reflect on purpose and values (4.4). Intellectual courage was described as a custodial responsibility essential for nurturing and advancing a scholarly discipline. This requires educators to be open to learning and also to unlearn and relearn with a flexible mind as part of challenging norms. Knowledge emerges through processes of invention and reinvention, through a continuous, hopeful, and collaborative human inquiry conducted both within and alongside the world. A community of HP educators ensures ongoing academic courage.

“I think the challenge is knowing when to say ‘No’, and then, having the courage to do that. I think equally on the flip-side, we need the courage to say ‘Yes’; the courage to say ‘Yes’ to other people’s ideas, ‘Yes’ to other people’s opportunities.”

Women in academia requiring courage was the next session. The academic journey for women brings different challenges: juggling work and family, facing pressure of appearing strong and demonstrating vulnerability, and being ready to speak-up against something that is not right but was previously accepted as the norm (4.6). The theme of authenticity resonated in another session in the form of imposter phenomenon, for example taking on a mentoring role, when one is surrounded by experienced leaders (4.7).

Swimming upstream

“Are we trying to force square pegs into round holes, or the environment of round holes which is unpredictable and volatile and ambiguous into square pegs?”

Implementing transformative HPE requires educators to challenge established norms and structures, and to move in a different direction (sessions 5.1–5.8). Health professional educators need a space to play with ideas and experiences, and together find approaches and practices that support ongoing learning and innovation. Participants agreed that in order to change the way they teach and learn, they should be creating safe spaces or social learning spaces to practice listening to each other’s stories and to exchange ideas (5.1, 5.5).

A question posed was: Is our health workforce being trained for an ideal system, or for the current system? How can better ways be found to equip or foster resilience in students and provide them with essential and necessary skills for adaptation (5.2)? How should teaching and assessment tools, implemented in high-income settings, be adapted to a low-resourced setting (5.3)? Participants agreed that they need to rethink how they do things and to develop a programme of teaching and assessment that fits their needs. Relevance, resources and sustainability of programmes need to be considered.

A session expanded on evolving programmes and the intersection between the arts, humanities, and health sciences, which allow students to reflect on their experiences in clinical settings, their uncertainties and the emotional trauma they might have encountered (5.4, 5.6).

The landscape of learning is constantly changing in terms of needs, policies, tools, and roles (5.4). Health professional educators do not have all the answers; an important lesson is to be comfortable in the uncomfortable, to enable the team to engage openly, and to allow a way forward to emerge (5.7). A presentation considered how the academic expectation of ‘publish or perish’ is met while trying to undertake in-depth quality research, and that writing from what emerges from deep reflection can take time (5.8). Participants stated that they need an academic space where ideas and collaboration matter. It is important to remember that higher education requires critical reflection about the current state of the system and society, and to where one would like to see it move and improve. This requires HP educators to do the work of thinking and dreaming.

Common themes

The need for safe, reflective, and supportive spaces for deliberation ran through most sessions. Having a CoP that allows HP educators to express their thoughts, share ideas, and feel listened to and less isolated was a key recommendation. Participants valued a space in which to explore dilemmas, delights and discoveries, and appreciated the sense that they were not alone in tackling these issues. They reflected on the absence of such learning and practice communities in their institutions, and on the importance of the support offered by the Africa HPE ECHO community.

Discussion

According to Teeter et al.,¹⁴ CoPs are groups of people who share a concern, set of problems, or interest in a topic and seek to improve their practice by interacting regularly with others. They are based on the notion that learning is an integral part of social practice and cannot be separated from that.¹⁵ Although there have been many generations of the theory of CoP, all share the notion that learning is a participatory social process.¹⁶ The latter is evident in key themes that emerged from the discussion sessions and demonstrated by the fact that all participants wanted to share and participate in the sessions.

Since the Lancet Global Commission report on the Education of Health Professionals for the 21^st Century¹⁷ expressed the need to train doctors, nurses, midwives, and public health professionals to be change agents, the call has been taken up in the HPE literature and spaces, including in SA.⁶ No-one knows how best to go about training change agents, but it is clear that there needs to be a major shift from traditional educational approaches to more transformative methods.¹⁸ It emerged through the discussions that HP educators are very aware of the need for change agents in the healthcare system, but are struggling to know how best to do that in the context of the multiple challenges that they face. Included in their challenges, however, is the sense of frustration with an education system that is not creating the space and environment they need, given that institutional commitment is essential if prioritising community’s health is to be embedded in policies and curricula.¹⁹

The discussion sessions gave many participants a voice and explored various ways of thinking through issues together. It has been suggested, in the realm of physical education, that pedagogical change is possible when teachers are supported in their explorations and encouraged to dialogue with other teachers through a CoP.¹⁹ The current research suggests the same could be true in HPE. Some presenters have already implemented changes as a result of the process of presenting and being part of the sessions. The challenge is that measuring long-term impact requires changes to student training that will lead to them becoming agents of change, which in turn, will lead to changes to health care, representing a set of connecting pieces that are difficult to hold together.

If it is assumed that training change agents is the first step in that process, it is critical that those involved in HPE are nurtured, supported, and encouraged to think differently. This is particularly important given the substantial rate of burnout among mid-career medical faculty, especially women.²⁰ The authors are encouraged by suggestions that safe, reflective and shared learning spaces can be a way of regenerating learning and teaching practices and of building dynamic academic communities that can foster faculty development.¹⁴ Recognising that HP educators are not individuals but part of an educational and healthcare system that provides a critical cultural and community context,²¹ the Africa HPE ECHO CoP experience could be replicated beyond current participants and extended as a form of faculty development for those that need support and encouragement to take on the critical task of reorientating HPE to address the needs of HPs in an increasingly changing and disrupted world.

Recommendations

Based on the discussion sessions, the following recommendations were developed:

• Curricula should focus on areas of uncertainty, resilience, adaptability, responsiveness, and presence. Educators need to pay more deliberate attention to the positive hidden curriculum that should be made explicit in order to develop these essential skills in future healthcare professionals.

• HP educators need to work to create safe and supportive spaces for reflection, and to advocate for a different kind of engagement in healthcare education, so as to allow students to grow through their experiences, both traumatic and positive. Cross-disciplinary CoPs can address some of these aspects.

• HP educators need to emphasise the importance of critical thinking and, in terms of AI, to guide students on how to access, utilise and apply knowledge. HP educators should embrace new technology and co-create experiential and transformative learning spaces to empower their students. More research on the use and impact of AI on HPE is required.

• HP training institutions need to carefully consider the best ways to support educators to ensure their ongoing development as people and to retain them. This can be done by building safe environments (institutional or national CoPs) where reflection in professional and interdisciplinary groups is encouraged to optimise learning, and to reinforce their identities as HP educators. These will play a significant role in supporting HP educators as they explore ways to challenge both the education and healthcare systems, working alongside, and being role models for, their students. Best practice will need to be documented for replication across institutions and regionally.

Limitations

This study has several limitations. First, the researchers’ backgrounds in health professions education may have influenced data interpretation despite the use of reflexive practices, collaborative coding, and an audit trail to enhance confirmability. Second, the purposive sample, drawn from a limited number of participants, may not capture the full diversity of experiences among health professions educators, limiting the transferability of the findings. While these limitations should be considered when interpreting the findings, the use of rigorous thematic analysis, transparent reporting, and strategies to enhance trustworthiness strengthen confidence in the study’s conclusions.

Conclusion

There is a clear need for forums where all participants in HPE can engage in discussions about the current situation with regards to training health professionals within the challenges of existing healthcare realities, while also empowering them to work for ongoing systemic change. This space needs to be safe, authentic, and allow for diversity of views. Such open discussions can lead to incremental changes in training, which, in turn, can bring about significant system change.

Acknowledgements

We are grateful to the participants of the Africa HPE ECHO CoP with whom these ideas have been developed, explored and tested.

We are also grateful to the ECHO Institute, University of New Mexico for their support.

Abbreviations