The development of clinical reasoning and interprofessional behaviors: service-learning at a student-run free clinic

Abstract

This article examines the benefits of a student run free clinic (SRFC) as a service learning experience for students in medicine, pharmacy, occupational therapy, physical therapy and physician assistant programs. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional health care teams and clinical reasoning skills compared to students who did not participate. Three assessments were administered to an experimental and control group of pre-clinical students from medical, occupational therapy, physical therapy, pharmacy and physician assistant programs before and after participation in an interprofessional service-learning course and volunteering at the SRFC. The tools were the Interdisciplinary Education Perception Scale (IEPS), Readiness for Interprofessional Learning Scale (RIPLS) and the Self-Assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course had improvements in interprofessional perceptions and attitudes (p?=?0.03) and perceptions of clinical reasoning skills when compared to the control group (p?=?0.002). This study is novel as it examined students’ perceptions of interprofessional attitudes and clinical reasoning following participation in an interprofessional service-learning course and participation in a SRFC.     

Adherence to clinical guidelines in heart failure (HF) outpatients: Impact of an interprofessional HF team on evidence-based medication use

Abstract

Clinical systolic heart failure (HF) guidelines specify recommendations for ACE inhibitors (ACEI), angiotensin receptor blockers (ARB), and beta blockers according to doses used in clinical trials. However, many HF patients remain suboptimally treated. We sought to determine which provider type, between an interprofessional HF team, non-HF cardiologists, and primary care physicians (PCP), most optimally manages HF medications and doses. A retrospective chart review was performed on adult patients at an academic county hospital with an ejection fraction ≤40% and a diagnosis of HF, seen by a single provider type (HF team, cardiologist, or PCP) at least twice within a 12-month period. Utilization rates of any ACEI/ARB and any beta blocker were robust across provider types, though evidence-based ACEI/ARB and beta blocker were greatest from the HF team. Doses of evidence-based therapies dropped markedly in the non-HF team groups. The percent of patients prescribed optimal doses of an evidence-based ACEI/ARB AND beta blocker was 69%, 33%, and 25% for the HF team, cardiologists and PCPs, respectively (p?<?0.0167). Patients followed by the HF team were more frequently prescribed evidence-based medications at optimal doses. This supports using specialized interprofessional HF teams to attain greater adherence to evidence-based recommendations in treating systolic HF.     

Integrated care coordination by an interprofessional team reduces emergency department visits and hospitalisations at an academic health centre

People with chronic behavioural and physical health conditions have higher healthcare costs and mortality rates than patients with chronic physical conditions alone. As a result, there has been promotion of integrated care for this group. It is important to train primary care residents to practice in integrated models of care with interprofessional teams and to evaluate the effectiveness of integrated care models to promote high-quality care for this at-risk group. We implemented an integrated, interprofessional care management programme for adults with chronic mental and physical health needs as part of a curriculum for family medicine and family medicine psychiatry residents. We then evaluated the clinical effectiveness of this programme by describing participants’ healthcare utilisation patterns pre- and post-enrolment. Patients enrolled in the programme were approximately 60–70% less likely to utilise the emergency room and 50% less likely to be admitted to the hospital after enrolment in the programme compared to before enrolment. The odds of individual attendance at outpatient primary care and mental health visits improved after enrolment. In the context of the implementation of integrated behavioural and physical healthcare in primary care, this interprofessional care management programme reduced emergency department utilisation and hospitalisations while improving utilisation of primary care and psychiatry outpatient care. Further studies should focus on replication of this model to further discern the model’s cost-savings and health promotion effects.     

Treating diabetes in underserved populations using an interprofessional care team

Abstract

Community Health Centers that provide diabetic care for underserved patients have unique challenges. This study describes how interprofessional care improves outcomes and results in cost savings. Interprofessional diabetes education and structured team building are discussed. The team consisted of a physician, nurse practitioner, clinical pharmacist, and a number of pre-medicinal, nursing, and pharmacy students. The outcomes were measured at one year intervals for a total of three years. During the two year period with the interprofessional care team, the diabetic patients in this study achieved a 10% improvement in HgA1c, and 9% improvement in systolic blood pressure, a 5% improvement in diastolic blood pressure, and a 62.6% reduction in triglycerides. These findings suggest that this interprofessional care model in a free clinic significantly improved the HgA1c, triglycerides, and blood pressure.     

Development and evaluation of an interprofessional seminar pilot course to enhance collaboration between health professions at a student-run clinic for underserved populations

ABSTRACT

This report describes the development and evaluation of an interprofessional pilot course aimed at health science students. The course was developed through collaboration of three health professions: Dentistry, Kinesiology, and Pharmacy. The coursework comprised of traditional lecture-based learning, interprofessional experiential education through four on-site visits at two area clinics that participate in team-based care, four student self-reflections following each site visit, and demonstration of interprofessional education and collaboration (IPEC) competencies through student evaluation of current interprofessional care at those existing clinics with a component for key improvement intervention. The study aims include evaluating both the course’s effectiveness and quality in increasing student preparedness for interprofessional practice and its ability to enhance collaboration between health professions at two area clinics. Methods of evaluation include the Interprofessional Collaborative Competency Attainment Survey (ICCAS) instrument, pre- and post- course surveys, and course evaluation survey. The results show that students felt their knowledge and skills increased across the four IPEC core competency domains: interprofessional communication, values and ethics, roles and responsibilities, and team and teamwork. We suggest that using an integrated course framework is an effective measure in enhancing interprofessional education (IPE) outcomes.     

Best practice interprofessional stroke care collaboration and simulation: The student perspective

Interprofessional practice (IPP) is the accepted standard of care for clients following a stroke. A brief, embedded and evidence-based IPP team simulation was designed to address stroke care knowledge and IPP competencies for students within limited curriculum space. Each team was required to construct a collaborative care plan for their patient during the simulation and submit the care plan for evaluation of best practice stroke care knowledge and implementation with evidence of interprofessional collaboration (IPC). A total of 302 students (274 on-site, 28 by distance technology) representing four professions comprised of 55 teams took part in this experience. Post-simulation, voluntary and anonymous programme evaluations were completed using the standardised interprofessional collaborative competency assessment scale (ICCAS) and open-ended free-text responses to five questions. There was a significant improvement for all pre–post ratings on the ICCAS regardless of profession or previous interprofessional experience. Additionally, the open-ended responses indicated perceived changes to role clarification, communication, and teamwork. The combined interpretation of the programme evaluation results supports interprofessional team simulation as an effective and efficient learning experience for students regardless of previous interprofessional experience, and demonstrated positive changes in stroke best-practice knowledge and IPC competencies.     

A team approach to an undergraduate interprofessional communication course

Interprofessional communication is a team-taught upper-level undergraduate course for Nursing and Health Sciences students. In addition to teaching fundamental communication skills, this course weaves interprofessional competencies into weekly learning activities and assignments. The utilization of the principles and practices of team-based learning in the classroom enhances the attainment and practice of communication and interprofessional collaboration skills. Lessons learned from conducting informal course evaluations and delivering the course multiple times are presented.     

A survey of Canadian interprofessional student-run free clinics

Student-run free clinics (SRFCs) have existed in Canada since 1971, providing interprofessional healthcare to underserved populations. SRFCs are seen as vehicles for socially accountable health professional education. Literature on how Canadian SRFC function is lacking. Web-based surveys were sent to student leaders from Canadian SRFCs regarding their 2014 activities. All six fully-functioning SRFCs responded reporting on the following: services provided, professions involved, governing structure, funding sources, clients seen, types of care sought, students and preceptors involved, as well as perceived strengths, weaknesses, opportunities and threats. In 2014, 2,159 clients were provided clinical care at Canadian SRFCs. The most common reasons for visiting included pain and infection. Strengths identified include autonomy, ability to adapt to client needs, serving the underserved, and real-world interprofessional teamwork. Weaknesses reported include high student and preceptor turnover. Threats include securing funding and liability coverage. Since there is little literature on Canadian SRFCs, we compared our results with United States (US) based SRFCs. Canadian SRFCs share core values with US-based SRFCs and report similar strengths and challenges. However, Canadian SRFCs differ in scope and appear to provide care for more acute concerns. Data from studies of US-based SRFCs may not be immediately applicable to Canadian SRFCs. Studies evaluating Canadian SRFCs are needed.     

Assessing quality of care through client satisfaction at an interprofessional student-run free clinic

Student-run free clinics (SRFCs) have become important contributors not only to improve access to primary-care services for homeless and uninsured populations but also to enhance health sciences student education. In order for SRFCs to reliably provide high quality healthcare services and educationally benefit students, it is imperative to assess client perceptions of the quality of care provided. The objective of this study was to evaluate the delivery of healthcare services through a client satisfaction questionnaire at the University of California, Los Angeles Mobile Clinic Project (UCLA MCP). From 2012 to 2015, 194 questionnaires that addressed demographic information, satisfaction with services and client outcomes were analysed. Satisfaction scores were evaluated on a four-point scale and differences in the composite satisfaction scores were assessed using Mann–Whitney U-tests. Half (50%) of the client respondents report that UCLA MCP is their primary source of health care (MCP primary care clients), while 81.3% reported that the clinic improved access to other healthcare resources. Overall, clients are highly satisfied with their experiences (Range: 3.5–3.9) and 62% have recommended our services to others. While MCP primary-care clients report significantly higher satisfaction scores than non-primary-care clients on average (p < 0.01), the mean composite scores for all subgroups are consistently high. The UCLA MCP clients perceive the clinic to provide high-quality healthcare services. This article presents a framework that may help other SRFCs evaluate clients’ perception of the quality of their care, an essential building block for effective physician–client relationships.     

Examining student perceptions of an inter-institutional interprofessional stroke simulation activity

Integration of interprofessional educational (IPE) activities into health professions’ curricula aims to promote collaborative practice with a goal of improving patient care. An interprofessional stroke simulation involving standardised patients was organised for IPE student learners from a number of different health professions programmes based across several different institutions. In this article, we describe the development of an inter-institutional IPE activity and examine the outcomes of this activity on student interprofessional growth. Using a pre-post-study design, all participants were invited to anonymously respond to the 16-question IPEC Competency Self-Assessment tool to examine self-assessed interprofessional interactions and values as a result of the simulation. The questionnaire was available to the students using an online platform, and paired t-tests were used to analyse the responses. Quantitative data revealed significant positive changes in both the values and interaction domains of the assessment from pre- to post-simulation experience (p < 0.0001 and p = 0.0003, respectively). Student reflections identified new realisations around the concepts of leadership and team member roles in the context of patient care. Results of this endeavour support the effectiveness of this activity for developing interprofessional competencies among students, suggest that the self-assessment tool may be used as a means to detect these changes, and lend support to our methods for establishing inter-institutional IPE partnerships.     

Toward better care of delirious patients at the end of life: A pilot study of an interprofessional educational intervention

Symptom distress with end-of-life delirium (EOLD) is complex and multidimensional, and interprofessional (IP) teams require knowledge and skill to effectively care for these patients and their families. The purpose of this pilot study was to test an educational intervention about EOLD for IP teams at a long-term care facility and a hospice. The intervention included a comprehensive self-learning module (SLM) on EOLD and IP teamwork; a modified McMaster–Ottawa team objective structured clinical encounter (TOSCE) and a didactic “theory burst” on the principles of delirium assessment, diagnosis and management. Evaluation tools completed by participants included the interprofessional collaborative competencies attainment survey (ICCAS) and the W(e) Learn. Two groups at each site participated in 1-hour sessions, repeated 2 weeks later. Only one group from each site received the SLM after the first session. Researchers scored EOLD knowledge and IP team functioning in both sessions. Results suggest that the intervention improved EOLD knowledge and perceptions of IP competence and supports the value of the TOSCE as an IP teaching method. The module does not appear responsible for the changes. Future studies are required to evaluate the effectiveness of the individual components used in this study, and to tailor the intervention to individual care contexts.     

Different perceptions of interprofessional collaboration and factors influencing the one-stop service for sexual assault victims in Taiwan

The purpose of interprofessional collaboration is to bring better services for sexual assault victims. In order to avoid secondary victimisation and improve the quality of forensic examination and prosecution rate, a one-stop service has been developed recently in Taiwan. However, whether the collaboration is successful may depend on participants’ professional backgrounds and personal experiences and can be influenced by a number of factors. This study used the Index of Interdisciplinary Collaboration to examine the different perceptions of collaboration in team members and the related influences on collaboration. Surveys were conducted in 140 team members including social workers, doctors, nurses, and police officers. The result indicated that collaboration was perceived differently in different professionals and significantly lower by social workers in the domain of interdependence and reflection on process. Factors such as professional roles, structural characteristics, personal characteristics, and history of collaboration were positively associated with the overall perception of collaboration. Only structural and personal characteristics predicted the type of profession. This study highlights the importance to acknowledge different experiences. Additional efforts and investments for improving mutual help and trust by the organisations are recommended.     

Changing student attitudes through interaction: Findings from an interprofessional workshop

Healthcare professionals are increasingly expected to work in interprofessional teams. Students therefore need opportunities to learn and practise skills that will allow them to be effective team members when they enter the workforce. This article summarises an interprofessional learning experience for 289 undergraduate and graduate students representing 13 programmes in a College of Health Professions (CHP) at a US public university. The half-day workshop provided an opportunity for participants with no prior interprofessional education to collaborate in a problem-solving case study and to inform students of other professions about their professions. Faculty members from all CHP programmes collaborated in writing the case study and facilitating student discussions during the event. Attitudes related to interprofessional collaboration and professional roles were assessed prior to and after workshop participation. A paired t test showed a statistically significant difference in four attitude questions. Participants reported a significant increase in understanding the roles of other professionals in healthcare and community situations. They also reported an increased understanding of the benefits and challenges of working in interprofessional teams. This event successfully introduced participants to interprofessional collaboration and provided them the opportunity to share their professional expertise and understand the expertise of others.     

Students in the community: An interprofessional student-run free clinic

Students in the Community (SITC) is an interprofessional collaboration of health science students at the University of Washington. SITC runs a weekly free clinic at the Aloha Inn, a transitional housing facility for 70 homeless men and women in downtown Seattle. The focus of this clinic is on health education, chronic disease management, and re-integration of patients into the healthcare infrastructure. SITC serves as a valuable service learning opportunity for students. In addition to direct clinical services, students gain experience in planning health education strategies, community collaboration, and evaluating intervention outcomes. SITC also oversees a lecture and discussion-based elective course at the University of Washington focused on health issues of the homeless community and provides formal teaching which complements the service-learning component of the endeavor.     

Oral health care and smoking cessation practices of interprofessional home care providers for their patients with HIV

The need for oral health services among patients with HIV, especially those in advanced stages of disease and those who smoke, has been well documented. Patients receiving HIV-related home care services provide an opportunity for assessment of oral health and smoking cessation needs; however, the majority of home care providers lack formal training to provide these services, thus interprofessional collaborations may be of value. This study assessed the oral health and smoking cessation practices of a random sample of 81 HIV home care providers. Results showed very favorable attitudes toward providing these services with some differences across disciplines. More than 70% of nurses would like to receive additional training in comprehensive oral health assessment by dental professionals. The study provides evidence for the potential of expanding these services for patients with HIV through interprofessional collaboration, in particular with nurses and dentists.     

Nursing and medical students teaming up: Results of an interprofessional project

Health professions programmes are increasing the number of interprofessional events in their curricula. Many of these programmes are grounded in case study or simulation events in order to prepare students for eventual practice. We designed an interprofessional education collaborative practice (IPECP) that provides direct interprofessional practice experience while students are still in their health profession programmes. In our programme, teams of senior baccalaureate nursing and third-year medical students provided health coaching to patients in need of chronic disease management. The purpose of the project and study was to determine whether repeated exposure to opportunities for interprofessional communication would lead to improvement in the individual and team communication skills. Teams met with their assigned patients monthly to provide coaching and had follow-up conversations with the patients between meetings. Faculty were present at each meeting to review the healthcare and coaching plans, observe the teams’ interactions, and provide a debriefing after each meeting. Results demonstrated that both individual and team communication skills significantly increased over time. The IPECP project was successful in providing a context where students could develop and improve upon key interprofessional communication skills.     

Observation of interprofessional collaboration in primary care practice: A multiple case study

Interprofessional collaboration (IPC) is known to improve and enhance care for people with complex healthcare and social care needs and is ideally anchored in primary care. Such care is complex, challenging, and often poorly undertaken. In countries such as Canada, the United Kingdom, the Netherlands, Australia, and New Zealand, primary care is provided predominantly via general practices, where groups of general practitioners and nurses typically work. Using a case study design, direct observations were made of interprofessional activity in three diverse general practices in New Zealand to determine how collaboration is achieved and maintained. Non-participant observation of health professional interaction was undertaken and recorded using field notes and video recordings. Observational data were subject to analysis prior to collection of interview data, subsequently gathered independently at each site. Case-specific themes were developed before determining cross-case themes. Cross-case themes revealed five key elements to IPC: the built environment, practice demographics and location, practice business models, shared goals, and team structure and climate. The combination of elements at each practice site indicated that strengths in one area helped offset challenges in others. The three practices (cases) collectively demonstrated the importance of an “all of practice” commitment to collaborative practice so that shared decision-making can occur.