Realist approach to evaluating an interprofessional education program for medical students in clinical practice at a community hospital

Figures & data

Table 1. One-week clinical practice schedule in a course of IPE program in a community hospital.

	Monday	Tuesday	Wednesday	Thursday	Friday
Morning	-Orientation -S: Nurse and rehabilitation therapist in hospital wards	-O: Medical services at a special elderly nursing home	-O: Home rehabilitation services	-O: Outpatient medical services	-Presentation on the student’s assigned patient -S: Pharmacist
Lunch time	-S: Registered dietician
Afternoon	-O: Home medical services	-S: Home nursing services	-S: Medical social worker (MSW)	-Writing report	Reflection on training

The student attended case conferences held for patients with multiple professions when they had time.

S: Shadowing; O: Observation.

Table 2. Representative data used to develop the working hypothesis.

Confident professional role

Occupational therapist: “I always try to determine the reasoning behind patients’ movements and activities through communication with the patients. For example, a lady had difficulties walking after developing cerebral infarction. However, she wanted to bring a plateful of offerings to the family altar every morning. For rehabilitation, I suggested that she walk holding an empty plate. I think that occupational therapists have to identify the reasoning behind patients’ activities and help them attain their purpose.” Pharmacist: “Pharmacists’ work is not only to fill prescriptions. I try to learn what patients think of drugs and how they use drugs through ordinary conversations with them. I am enjoying working in the primary care field.” The pharmacist provided an explanation to a patient about the prescribed drugs and asked about the patient’s daily life. Both the pharmacist and patient spoke with smiles on their faces. Nurse: “I think patients look down on nurses. But it’s ok. Our work is to help patients live their lives. I feel I am helping patients when I see they are increasingly able to do more things or are discharged from the hospital.” Despite receiving many calls, the nurse was well-organized and capably cared for each patient.

Readiness to teaching medical students

Speech therapist: “I think that people who become physicians have special brains. They are different from us. I do not know what I can teach them.” Nurse: “I recently noticed that some students did not neatly line up their shoes at the home entrance when they visited patients. I advised the students to arrange their shoes tidily because their behavior was rude to the patients and their families.” Registered dietician: “I notice when students’ interest is low. They are reluctant even to thicken soup, acting like they are being forced to do it.” Nurse: “We have to look after medical students because there is a possibility that we might work with them in the future.” Community general support center: “We want medical students to come to our center and observe the work of care managers and other community healthcare staff.

Table 3. Four patterns of configuration of CMOs.

CMOs	Context	Mechanism (intervention)	Mechanism (assumption)	Outcome
I. Comparisons between the university hospital and community hospital and self-managed learning based on the comparisons	Field training at the university hospital where medical students have fewer chances to meet professionals other than physicians	Shadowing of other professionals at the community hospital and preparation of reports	Learning of contexts due to structural unreasonableness	Awareness of the roles of various professions for life healthcare services
			Self-managed learning	Awareness of physician-centered thinking
II. Legitimate peripheral participation, empirical learning and contact hypotheses based on the learning characteristics of medical students and contexts of the community hospital	Medical students are likely to prioritize efficiency and perform intergroup comparisons (learning characteristics)	Participatory clinical practice and hospital-stay clinical practice, review and reporting	Legitimate peripheral participation	Legitimacy of community-oriented primary care and the roles of other professions
	Support for field training from skilled and knowledgeable professionals		Empirical learning
	Patient-centered information sharing and cooperation based on close interprofessional relationships		Contact hypothesis/observational learning	Increased affinity with various professionals
III. Observational learning among other professionals and awareness of the social structure to deepen understanding of the contexts of observational learning	Roles of other professions at the community hospital, which had limited resources	Shadowing of many professionals	Observational learning	Understanding of the special roles and comprehensive patient-centered roles of each profession
	Environments in which healthcare professionals have greater knowledge about community healthcare services	Field training outside the community hospital	Awareness of the social structure (Freire)	Understanding of the roles of each profession in supporting patients
IV. Learning effects of free discussions with other professionals that increased cognitive empathy in medical students	Preparation and free discussions with other professionals	Other professionals’ expectations of medical students and advice regarding the roles of physicians	Cognitive empathy	Awareness of the roles of physicians and motivations for contribution

Table 4. Representative data extracted CMOs based on the medical students’ reports, various professionals’ 360-degree assessment reports, and field notes.

I. Comparisons between the university hospital and community hospital and self-managed learning based on the comparisons	Report from Student A: “During field training at the university hospital, some physicians instructed the staff members to prepare soupy or paste-like meals for patients who had difficulties swallowing. I tried these meals. The taste and flavor were totally different from ordinary meals. I have to try to remember the reason behind the need for soupy or paste-like meals when I give such instructions.” Report from Student B: “During the clinical practice at the community, I observed comprehensive and holistic medical services that differed from medical services provided at the university hospital. Because I am studying diseases, I am more likely to pay attention to diseases than to patients. This tendency increases when I am busy working. I will never forget the experiences I had during the clinical practice and want to provide patients with holistic medical services.”
II. Legitimate peripheral participation, empirical learning and contact hypotheses based on the learning characteristics of medical students and contexts of the community hospital	Report from Student C: “Efficiency is important to me. I thought the clinical practice would be a waste of time and useless if it was unclear to me what I would learn. For the first three days of the community clinical practice, I thought the training was a waste of time and useless, and I wanted it to stop. However, on the last day, I realized the significance of the training. Upon review, I realized that there was something I could learn from it. I continued the training because the staff had a sense of responsibility as humans rather than as professionals and were gentle and kind to me. If I had discontinued the clinical practice, I would have felt bad. I don’t think you would want to attend clinical practice if you were being ignored.” Report from Student D: “I thought that the occupational therapist and speech therapist were mentally mature and were always thinking of the patients and their families. When the occupational therapist and I visited a patient for rehabilitation, the occupational therapist checked whether or not the patient had bedsores or rashes by referring to the visiting histories and materials of various professionals. This taught me about interprofessional cooperation.” Statement from Student E: “Because the community hospital was small, I had the chance to meet other professionals. I enjoyed having friendly conversations with them at the cafeteria and established close relationships with them: when one staff member referred to “that person,” all the staff members knew who “that person” was.” This student spoke about the atmosphere of the hospital with smile. 360-degree assessment: “He asked many questions about my profession (OT), and he seemed to understand the role of therapists” “Please continue to be a doctor who is humble and collaborates with nurses.”
III. Observational learning among other professionals and awareness of the social structure to deepen understanding of the contexts of observational learning	Report from Student F: “The speech therapist massaged the salivary glands and mimetic muscles of patients with global aphasia and the four limbs of patients with hemispatial neglect. The speech therapist prepared rehabilitation programs from the broad perspective of various professions. During home rehabilitation, the speech therapist tried to resolve every one of the patients’ problems: when a patient with COPD said they felt sick when lying on the bed, the speech therapist suggested that the patient use cushions to adjust the height or to change the position of the cushions.” Report from Student G: “I received training in home healthcare, nursing and rehabilitation services. When I noticed that the medical staff were providing support to the patients as humans rather than as professionals, I vaguely understood the significance of home medical services. Considering the demographics of this region, I think home medical services are necessary in this region.”
IV. Learning effects of free discussions with other professionals that increased cognitive empathy in medical students	Report from Student H: “The clinical practice taught me that I should write as much information on patients as possible and the reasons for selecting drugs in the notes section of a prescription. I want to establish close relationships with other professionals so that they will feel free to ask me any questions.” Report from Student I: “Because the physiotherapist, occupational therapist and speech therapist were always positive about helping patients regain the life they had before, the patients felt free to express their emotions. The physiotherapist, occupational therapist and speech therapist accepted them as they were. Therefore, the physiotherapist, occupational therapist and speech therapist seemed to have knowledge that only they knew. I want to be a physician who can communicate well with other professionals and take advantage of information from other professionals for treatment.” Report from Student J: “Assessment, improvement and maintenance of swallowing function and activities of daily life are essential for treatment during hospital admission. I want to exchange opinions and ideas with occupational therapists, speech therapists and other professionals to determine the most optimal treatment. I want to create an environment/relationship whereby all professionals understand each other and can work smoothly together.” Report from Student K: “It is concerning that other professionals hesitate to speak to physicians.” Report from Student L: “Until this clinical practice, we thought that doctors only had doctors’ specialties; we had a narrow perspective of a doctor. However, in the same way, we thought nurses had nurses’ specialties and rehabilitation therapists had specialties that doctors did not have. If rehabilitation therapists are involved with my patients, I would love to listen to their opinions and refer to their evaluation to provide higher quality medical care.”