Promoting interprofessional learning with medical students in home care settings

Abstract

Background: The home care setting is ideal for medical students to learn about the importance of interprofessional collaboration in the community.

Aims: This project examined the impact of a unique program designed to facilitate medical students’ knowledge and awareness of the challenges of interprofessional care in the home.

Methods: In pairs, medical students participated in two community visits with preceptors from different professions. Students completed a structured personal reflection after their first visit. Students and preceptors participated in focus groups or interviews to identify strengths and challenges of the experiences. The structured reflections and the focus group and interview transcripts were analyzed qualitatively.

Results: 164 medical students and 36 preceptors participated in 326 visits. There were high ratings of satisfaction from students and preceptors. Students developed unexpected insights into peoples’ lives, developed a greater understanding of the patient's perspective and determinants of health, learned about others’ scope of practice, and developed an appreciation of the limitations of their own scope of practice. Preceptors had high expectations for student performance and engagement and enjoyed the opportunity to impart their knowledge to future physicians.

Conclusion: Although organizationally complex, the program evaluation suggestions that students and preceptors benefit from interprofessional experiences in the home.

Introduction

With the aging demographic, increase in chronic diseases and shift to community-based care has come the necessity to train medical students beyond hospital, clinic, and office settings. Today's graduates require competency in navigating a variety of health care settings and the ability to respond to changing landscapes of care (Halpern et al. 2001).

While not a new phenomenon, the importance of developing competency in interprofessional collaboration has also been reinforced in recent years (World Health Organization 2010). There is growing evidence that suggests that health outcomes are improved when care is delivered by collaborative teams (Zwarenstein et al. 2009). Increasingly interprofessional education activities have been shown to promote the development of competencies that enable students to practice collaboratively when they enter the workforce (Hammick et al. 2007).

A number of authors have promoted the home care setting as an ideal learning experience for health professional students. Over 20 years ago, Laguillo (1988) recommended home care as a preferred site for teaching geriatrics in family medicine residencies. Although arguably outdated and with findings based on an invalidated survey instrument, his recommendations highlighted the role of home care in understanding the principles of teamwork and a multidisciplinary approach to health care. Lapidos et al. (2002) argued that home care settings are particularly valuable for promoting interprofessional education. They developed a novel program in which learners from seven programs participated in home visits, team meetings, patient assessment and counseling, and in-service training. McWilliams et al. (2008) described an extracurricular service learning experience in which interprofessional teams of students participated in monthly home visits with older adults over a 1-year period. Students reported high levels of satisfaction with the experience, were able to appreciate the changes they observed in patients over time, and valued their interactions with other students. This project was voluntary, thus students may have been predisposed to evaluating the experience positively. Silk and Weber (2008) found that medical students who participated in a half-day home visit during their family medicine clerkship enhanced their understanding of how cultural diversity affects patients’ health. Although authors asked open-ended questions as part of a self-designed 10 question survey they did not analyze these in a systematic way.

Clinical experiences in the home care setting have the potential to reinforce interprofessional learning, highlight the importance of accessing and facilitating community resources, and increase learners’ awareness of the social determinants of health. This article presents the evaluation of a unique mandatory program designed to facilitate medical students’ knowledge and awareness of the challenges of interprofessional care in the community and home care settings. This project aimed to build on previous work by using more rigorous qualitative methods and through study of both student and clinical preceptor perspectives. The aim of the evaluation was to (1) identify strengths and challenges associated with the program and (2) identify participants’ perceptions of key learning that occurred through the experience.

Table

Practice points

Home care settings provide an ideal interprofessional learning opportunity for medical students. Observing patients in their homes helps medical students understand patient centered care and the social determinants of health. Clinical preceptors need to understand the limitations of a brief exposure of medical students to interprofessional home care practice.

Methods

The model

Students from the undergraduate Medical Doctor (MD) program at McMaster University collaborated with Community Rehab on this project. Community Rehab has been a leading provider of community-based rehabilitation services since 1985 and currently has over 340 clinicians, including occupational therapists, physiotherapists, registered dieticians, speech language pathologists, and social workers, providing services at various location throughout Ontario, Canada. Those clinical preceptors who had previous experience as educators through supervision of students from their own profession, and who volunteered to participate, were chosen for this experience. Prior to implementing the visits we conducted a half-day workshop to describe the objectives of the experience, familiarize the clinicians with the medical school curriculum, and provide specific strategies for facilitation of interprofessional education.

The student placements were anchored within a course of the medical program entitled “Professional Competencies.” The Professional Competencies Course runs from the first day of medical school until the start of clerkship and consists of weekly 3 h sessions including a brief large group didactic session followed by more extensive small group sessions. Groups of 10 students are co-facilitated by interprofessional pairs: one an MD and the other from a relevant clinical discipline. The dimensions of Professional Competencies teaching and skills practice include communication skills, professionalism, self awareness, community health, ethics, and clinical reasoning. As professionalism is an important component of the course, the community clinical preceptors were asked to comment on professionalism issues so that they could be addressed as part of student's overall performance.

This was a mandatory experience which took place in the final term of the first year of study and the first term of the second year of study in a 3-year curriculum. In teams of two, students were required to participate in two community-based visits with preceptors from different professions. Students traveled with their preceptors and interacted with patients in a variety of settings primarily the patients’ homes. Following the visits, students participated in a 2 h tutorial in groups of 10 along with a faculty facilitator and one of the clinical preceptors. In the tutorials, they reflected on issues related to determinants of health, the scope of practice of other health professionals, the centrality of patient, and family centered care and the need to collaborate when complex and chronically ill are cared for in their homes. In keeping with the curriculum philosophy, students were not given formal grades for this experience. To track any issues around professionalism, preceptors completed an online feedback form commenting on the student's respectful listening, accountability, ability to balance inquiry, and advocacy and the degree to which they took experiential learning seriously.

Evaluation

A mixed methods approach to evaluation of the project was conducted incorporating both student and clinician perceptions as outlined below. A mixed methods approach combines qualitative and quantitative methods so that the strength of the study is greater than using either method alone and to promote a broader understanding of the issue being studied (Cresswell 2009).

Student evaluation

As part of the mandatory experience, students ranked their overall satisfaction with the experience on an online evaluation form on a five-point scale ranging from very dissatisfied to very satisfied following each visit. Students were also asked to complete several open-ended questions that asked them what they most liked about the experience, how the experience could be improved, and whether they would recommend the experience to others. The open-ended questions were intentionally brief to promote completion of the entire form. In addition, following the first visit students were required to complete a structured personal reflection commenting on insights into the role of a health professional they accompanied in the community, the determinants of health that they observed and how their experience would change their approach to patient care.

In keeping with the ethics board procedures, program evaluation methods that are considered to be in addition to expected assignments and procedures cannot be mandatory. Therefore as an optional component of the evaluation, all students were invited to participate in face-to-face interviews or focus groups to gather in-depth data on their perceptions of the value of the clinical experience.

Clinician evaluation

A group of eight clinicians was randomly selected to participate in a focus group to share views on their experiences. Focus groups of students and preceptors were audiotaped and transcribed verbatim.

Both student and preceptor interviews and focus groups were conducted by a research assistant who was not known to the students or the preceptors. Student interviews and focus groups occurred following completion of the Professional Competencies Course. Interviews and focus groups were semi-structured in nature. This project received approval from the research ethics board at McMaster University.

Analyses

The open-ended questions were analyzed with a qualitative content analysis in which an initial coding scheme for each question was developed by a research assistant and verified by one of the study investigators (Hsieh & Shannon 2005). Codes similar in focus were grouped to form themes related to each question. A more in-depth content analysis was used for the analysis of the focus group, interviews, and structured reflections (Hsieh & Shannon 2005). This consisted of a line-by-line review of the forms and transcriptions to identify a key word or phrase that represented the students’ words. Initial codes for these analyses were also developed by the research assistant and verified by one of the study investigators. Codes similar in focus were grouped to form themes that emerged from the data.

Results

Participants included 164 medical students and 43 clinicians who participated in 164 visits in the summer session and 162 visits in the fall session for a total of 326 visits. The clinicians consisted of 16 physiotherapists, 15 occupational therapists, 6 speech and language pathologists, 3 dieticians, and 3 social workers.

Student findings

Online questionnaire

To determine the overall satisfaction with the experience responses indicating very satisfied or satisfied were combined. Following the first visit, 81.7% (n = 134) of students were satisfied; 81.7% (n = 134) of the students were satisfied after the fall visit. In response to the question about what they like most about the experience three themes arose: (1) learning the challenges faced by patients in the home; (2) learning about the scope of practice of other health professionals; and (3) going to patients’ homes. To improve the experience, students felt that (1) the time to travel should be minimized, (2) there should be a wider variety of health professionals available to them, and (3) the visits be incorporated into the curricula at a time that was less busy. Most of the students (78.5%; n = 129) would recommend the experience to others; 9.2% (n = 15) stated that they would recommend this experience to others but that the second visit should be optional and 12.3% (n = 20) would not recommend the experience as they felt it was too time-consuming and that too much time was spent driving to patients’ homes.

Student reflective summaries and interviews

Only six students volunteered to be interviewed following their experiences. As the themes that emerged from the analyses of the interviews coincided with those generated from the content analysis of the students’ reflective summaries, the results are combined in this section. Five themes emerged from these analyses: (1) unexpected insights into people's lives; (2) understanding the patient's perspective; (3) contribution of determinants of health; (4) learning about others’ scope of practice; and (5) appreciating the limitations of own scope of practice. These are described below.

Unexpected insights into people's lives

Many students described situations impossible to observe outside the home that provided valuable input about the patient's health status and functioning. Students noted that these situations would not be apparent if the patient presented in their office and that the patients’ and families’ behaviors within their home environment was often surprising, and in some cases, alarming. As one student described, “our first case, where the patient was believed to be depressed, presented a 60-year-old woman in her pajamas in the middle of the afternoon in a house with the window blinds shut and no lights on.” Another student described her insight into what she had considered to be a relatively minor ailment, “dizziness sounds like a relatively benign complaint, but it was very interesting to see the degree to which someone's life – outside a 10 min office visit – is affected. Furniture becomes an obstacle, carpets a hazard and cupboards become difficult to access if they involve bending or reaching. All of these make activities of daily living – most of us take for granted – both challenging and dangerous affecting a patient's ability to exercise, to get adequate nutrition and even to travel to their physician's office for appointments.”

Understanding the patient's perspective

Students described gaining a deeper understanding of the impact of the home environment and the need to understand health concerns from a patient's perspective. As one student described, “one of the patients commented that her family physician was ‘useless’. When I asked her to explain her comment, she replied that he rarely sees her and when he does he is unable to offer any solutions for her problems. Rather than being heard she feels as if she is ignored and shuffled off to other professionals. These comments make it clear that more time is to be given to patients and they have to be given an active role planning their care. Otherwise they feel burdensome and are relegated to the role of a passive bystander in management of their own health.”

Another student reflected on how the full picture is often missed when seeing the patient in the office setting, “seeing patients in their homes is a little humbling, you have to adapt your thinking to what you are seeing. You could see a patient in the office and be frustrated about their weight and bad dietary habits, but when you are in their homes you can understand it is very difficult to get around with crutches in a small kitchen and so the only option is ready prepared meals that are not high in nutritional value.”

Contribution of determinants of health

Students identified a wide variety of situations in which the determinants of health directly contributed to the patient's quality of life. Being in the home setting highlighted many determinants including access to health services, educational level, socioeconomic status, employment status, culture, and personal health practices. The complexity of caring for patients with chronic and long-term illnesses became more apparent within the context of a patient's home as described by one student, “we visited an elderly woman with multiple health problems who lived by herself in her ancestral home. Lacking a family, she was responsible for her own well-being. Being morbidly obese with diabetic foot ulcers she was highly immobile. She complained of ‘not being out all winter except for the doctors office’ since her medical illness prevented her from doing so. In addition, the house she was living in was deteriorating, with multiple health hazards (dysfunctional toilet, broken ceiling, etc.).”

Learning of others’ scope of practice

The primary interprofessional learning described by the students was related to learning about others’ scope of practice. By observing and interacting with a variety of professional students described how they had a much greater appreciation for the roles of others. As described by one student following a visit with a social worker, “what struck me most was their breadth of practice, from conducting medical appraisals related to mental capacity, hygiene, mobility and diet, to assessing living conditions, signs of neglect and abuse.” Students were surprised at the breadth of the scope of practice of others. As one student remarked after a visit to a speech language pathologist, “I found it very interesting in how (she) observed the patient through a holistic lens, not necessarily focusing on a specific task. Not only did (she) assess the physical but also the social and psychological well-being of the patient. I learned how often the social and psychological self could manifest into issues that the speech pathologists may be referred for.” For many students increased awareness of others reinforced that the physician does not work alone. “… there is a lot of work to be done that's not done by doctors. Just the ongoing support and diagnosis and sort of health teaching that is done – like just an appreciation for that work and the contribution it makes to other people's health.” Other students became aware of the importance of patient advocacy when working in the community. As stated by one student, “I was amazed at the way in which the physiotherapist's role with the patients seemed to extend far beyond the nuts and bolts of the profession. She became the patient's advocate. She did everything she could to ensure that the patient would receive all services that would help her. She spent much time making phone calls after the visit, for example, the patient's family physician to let him know the patient's difficulty coping.”

Appreciating the limitations of own scope of practice

This increased awareness of others prompted some to think about the limitations of their professional role and the need to involve others, “The medical doctor or surgeon has profound impact on people's life but he/she can’t provide complete care. Without the efforts of other allied health professionals the efforts of many doctors would be incompletely fulfilled.” There was a sense of surprise expressed by some students, “it is easy to get caught up in self and the role we play in people's lives. It was enlightening to see that patients cannot receive complete care without hard work from other healthcare providers.”

Clinician findings

Focus group

Eight clinicians participated in the focus group including three physiotherapists, two occupational therapists, a dietitian, a social worker, and a speech language pathologist. Three themes emerged from the qualitative analysis of the clinicians’ focus group transcripts: (1) importance of student engagement; (2) clinician expectations, and (3) enjoyment. These are described below with representative quotes.

Importance of student engagement

For the most part, clinicians enjoyed their participation and the opportunity to demonstrate their professional role to the students. Although often they were unable to see the same number of patients and that meant they were not fully compensated, if the students demonstrated that they were interested and respectful, the clinicians did not perceive this as a disadvantage. However, the occasional student who showed unprofessional behavior made a lasting impression. One clinician described how two of the students were talking about trivialities related to their upcoming summer elective while she was performing a treatment. Another clinician noted, “they were more interested in suturing.”

Clinician expectations

The clinicians had high expectations for the experiences. One had read all the articles that had been distributed to the students and when she went to question the students were surprised that they had not. “They had not put any prep thought into what [the home care experience] meant.” Others expected that the students would arrive with a greater understanding of the home care industry, “it would be nice if they came with some preconceived idea of what home care is and where it comes from and private services – like the whole sort of private industry versus public industry and that kind of stuff.” Still others felt that the students would get more out of the experience if they had background knowledge related to the clients they were going to see.

Other clinicians suggested that even a small insight and greater appreciation of the challenges experienced by both patients and the clinicians while undergoing treatment in the home would be a positive outcome. “I just wanted them to get a really good experience and learn something of their position in a team. So that when they referred their patients to us, they will listen to what we say, because they know we are knowledgeable, we've done full assessments.” Another clinician described how important it was for her that the students understood the daily reality of many patients. “… most of my clients have mobility issues that mean they cannot get out of the house. And yet, if they have major needs, we call the family physician and they are like ‘send them to the office’ and we are saying ‘they can't get (there) – that's the whole reason I'm going in’ and I tried to really talk to students about that and make them aware how much effort it is for them to find a driver to get out, to take their oxygen or you know these high needs … . And, I think most of them got that and if I could get them to get that, and know that home care physiotherapy existed, then I felt I was successful.”

Enjoyment

While clinicians recognized that there was variation in the level of student engagement and preparation, generally there was a sense that the experience was worthwhile for both themselves and the students. One clinician described the enthusiasm of two of her students, “… they were bouncing ideas while we were driving to the next client asking what they would've done in this situation and engaged each other for their opinion.” For another clinician, the fact that the students seem to understand the nature of home care and contributions of the determinants of health was a source of satisfaction, “I was blown away by how professional they were, how respectful they were, how they seemed, in my mind, to get it. Money makes a difference, where they live makes a difference, all these factors make a difference, not just that they've got an illness. It's all the other stuff – they really got it.”

One clinician summarized the experience, “I told all of them when they left that I was just so impressed with the future of the medical profession, because if they were a sampling of what was coming up, that it was looking really good. Like really it was so positive.”

Discussion

Students and clinicians were generally satisfied with the home care experiences and students were able to reflect on important learning for their future careers. However, this project was not without its challenges. The visits were complex to organize given the numbers of students and clinicians to coordinate. Therefore, it is important that this is perceived as a worthwhile educational experience from both student and clinician perspectives. In a fee for service environment clinicians need to feel that their efforts are appreciated. Many clinicians valued the intangible benefits related to helping future physicians understand the importance of collaboration in the community. Students need to understand the broader implications of their learning and the relevance no matter what their future specialty aspirations.

Although the clinicians had participated in a workshop that outlined the objectives for the experiences, some had unrealistic expectations about the learning that could occur during a short visit. Clinicians who wanted the students to come prepared with clinical knowledge (e.g., post up management of total knee replacements) need to be reminded to focus on the unique learning that can only be experienced in their setting and not the pathophysiology and medical management that could be learned elsewhere. Similarly, this needs to be viewed as an opportunity to introduce students to a health delivery setting outside of the hospital or clinic; thus expecting the students to come prepared with in-depth knowledge about the home care sector is not realistic. This highlights the importance of prior preparation of the clinicians and the need for feedback and dialogue about expectations following experiences so that the clinicians can continue to learn how to be more effective preceptors. Most clinicians had never supervised a medical student and were excited about the possibility to impart their knowledge to future physicians. While we presented strategies to the clinicians about how to facilitate “teachable moments” with the students, it was apparent that they need additional guidance on what learning is most feasible and important.

We were pleased with the depth of the students’ reflections. From our perspective, the experience was considered to be a success if the students gained an appreciation of the need for patient centered care and an understanding of how important it is to coordinate resources in the community. We were heartened by the students’ descriptions of their insights into the impact of the home environment and the social determinants of health. We were also encouraged that many students were able to appreciate the limitations of their profession and that they needed to work as a team to provide best care.

One challenge encountered relates to the students’ busy schedules and their ongoing need to prioritize learning. Competencies related to interprofessional collaboration, while recognized as important, can be perceived as more easily attainable than those related to diagnostic and medical management. Students’ anxieties about the time taken to travel to patient's homes and to participate in two visits were attributable to their sense of urgency to prepare for their upcoming clerkships. In order for students to see the relevance of any interprofessional activity is important that the curriculum reinforce the value of participation both implicitly and explicitly.

While on the surface, the initiative was designed to facilitate student learning, we believe that the project also had benefits for the clinicians involved. Our philosophy for interprofessional education at McMaster University is that in order to facilitate collaboration one must have an understanding of what this entails and be able to role model and practice this in his/her environment. We believe collaboration is a skill that must be taught and practiced. The concepts of interprofessional collaboration were furthered in the home care setting by developing the skills of the clinicians so that they can continue to facilitate collaboration with colleagues and students. The training opportunities, in conjunction with the expectation of role modeling and promoting interprofessional education with students, promoted a collaborative culture within the setting.

Key to the success of this project has been the support of the Community Rehab. The management's willingness to provide staff time for training, to commit to strategies to facilitate organization of the experience and to encourage clinicians to participate ensured the success of this project. Others have noted the importance of a positive partnership between academic institutions and home care organizations to ensure successful interprofessional training in the home (Lapidos et al. 2002). Developing placements in partnership with a private health care organization can present financial challenges. In our project, some clinicians were concerned about the additional time required to accommodate the students and the impact this had on their bottom line. Other clinicians were less concerned about this and valued the intangible benefits related to helping future physicians understand the importance of collaboration and the complexities of home care. However, the fiscal realities means that the benefits of the home care experience need to be clear, students need to demonstrate appreciation and understand that the experience might not meet all their learning needs and the overall process is required to be streamlined.

Most of the interprofessional learning related to increasing awareness of others’ scope of practice and knowing how to make appropriate referrals. Clearly a limitation of this project is the fact that we do not know whether there is a long-term impact on future practice behavior. In addition, we did not directly measure increase in knowledge or skills. An interprofessional experience such as this needs to be a component of an overall curricular approach to interprofessional education. Ultimately, students need the opportunity to develop competencies related to interprofessional collaboration that will enable them to work effectively and in partnership with other healthcare professionals.

Conclusion

While physicians seldom work in the home, they are involved in decisions related to discharge and coordinating care in the community. Thus, the learning acquired through these initiatives has the potential for broad applicability across medical disciplines. This project also promotes patient centered care early in the students’ careers and thus incorporates this into their socialization at a formative stage.

It is our hope that future clinicians who know how to access community supports, have an awareness of the system and the varied professional roles within the system and who understand the importance of patient centered care, will be able to collaborate more effectively to promote a seamless transition of care between and within community and home care settings. Additionally, there is the potential for clinical preceptors to learn strategies to enhance their collaboration with other health professionals in their current practice and help them develop strategies to promote interprofessional collaboration with a variety of learners.

This project was deemed a success and has been integrated into the MD Program curriculum at McMaster University. Future directions include enhancing the interprofessional learning education of the experience by having nursing and medical student pairs accompany the clinicians in the community.

Acknowledgments

The authors would like to acknowledge the ongoing commitment and support of Lynn Corbey, Kristen Parise, Diana Bellfountaine, Gissele Damiani-Taraba, Nicole Gervais, and the clinicians at Community Rehab whose participation made this project possible. This project was funded by the Interprofessional Care Education Fund through Health Force Ontario.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.