http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, Early Online: 1–7 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2015.1004041
RESEARCH ARTICLE
International Classification of Functioning, Disability and Health: catalyst for interprofessional education and collaborative practice J Interprof Care Downloaded from informahealthcare.com by University of California San Francisco on 03/23/15 For personal use only.
Stefanus Snyman1, Klaus B. Von Pressentin2 and Marina Clarke1 1
Centre for Health Professions Education, Stellenbosch University, Tygerberg, Cape Town, South Africa and 2Division of Family Medicine and Primary Care, Stellenbosch University, Tygerberg, Cape Town, South Africa Abstract
Keywords
Patient-centred and community-based care is required for promotion of health equity. To enhance patient-centred interprofessional care, the World Health Organization recommends using the framework of the International Classification of Functioning, Disability and Health (ICF). Stellenbosch University’s Interprofessional Education and Collaborative Practice (IPECP) strategy has promoted using ICF since 2010. Undergraduate medical students on rural clinical placements are expected to use ICF in approaching and managing patients. Students’ ability to develop interprofessional care plans using ICF is assessed by a team of preceptors representing various health professions. This study explored the experiences of medical students and their preceptors using ICF in IPECP, and how patients perceived care received. Associative Group Analysis methodology was used to collect data for this study. In total, 68 study participants were enrolled of which 37 were medical students, 16 preceptors and 15 patients. Students found ICF enabled a patient-centred approach and reinforce the importance of context. Patients felt listened to and cared for. Preceptors, obliged to use ICF, came to appreciate the advantages of interprofessional care, promoting mutually beneficial teamwork and job satisfaction. The value of integrating IPECP as an authentic learning experience was demonstrated as was ICF as a catalyst in pushing boundaries for change.
Associative group analysis (AGA), health professions education, International Classification of Functioning, Disability and Health (ICF), interprofessional collaborative practice, interprofessional education
Introduction In 2001, the World Health Organization (WHO) launched the International Classification of Functioning, Disability and Health (ICF) as a comprehensive coding system for functioning and disability, a conceptual framework and ‘‘common language between all professions’’ (WHO, 2001, p. 3). In its first decade ICF was primarily used in international and national health and disability reporting, for clinical and epidemiological use, and for impact, intervention and application research (WHO, 2013a). In health professions education (HPE) ICF has not been widely taught as a conceptual framework in approaching and managing patients (Allan, Campbell, Guptill, Stephenson, & Campbell, 2006; WHO, 2013b). Rather, students are often taught numerous, potentially contradictory, frameworks in approaching patients and communities. These contradictions may serve as barrier to interprofessional communication and a bio-psycho-social-spiritual approach to patient-centred care (Fehrsen & Henbest, 1993). Currently, these barriers to interprofessional education and collaborative practice (IPECP) are being challenged by educators worldwide through institutional reform, which includes promotion of patient-centred IPECP (Barr, 2011; Frenk et al., 2010; Oandasan & Reeves, 2005; Thibault, Schoenbaum, & Josiah Macy Jr. Foundation, 2013; WHO, 2010). Dufour and
Correspondence: Dr Stefanus Snyman (MB, ChB, MPhil (Health ScEd), DOM), Centre for Health Professions Education, Stellenbosch University, PO Box 19063, Tygerberg, Cape Town 7505, South Africa. E-mail: [email protected]
History Received 27 January 2014 Revised 22 October 2014 Accepted 31 December 2014 Published online 23 January 2015
Lucy (2010) argue that solutions to these barriers necessitate moving away from the strong biomedical view of disease, which could neglect functional and contextual factors. They advocate for using ICF which ‘‘not only highlights the need for a diverse team of health care professionals, but also represents a paradigm shift in how to approach health and health care’’ (p. 668). A Global Independent Commission (Frenk et al., 2010) recommended HPE delivers graduates who strive for health equity through patient-centred and community-based care. This commission proposes instructional and institutional reform that, among others, fosters interdependence and promotes interprofessional learning. This could potentially ‘‘break down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams’’ (Barr, 2011, p. 319). Barr envisions this as an ‘‘iterative process between education and practice, as it generates commitment and competence for collaborative practice’’ (Barr, 2011, p. 319).
Background In 2010–2011 the IPECP strategy at the Faculty of Medicine and Health Sciences, Stellenbosch University (SU), South Africa, was revised by a group representing all undergraduate programmes (human nutrition, medicine, occupational therapy, physiotherapy and speech-language and hearing therapy), as well as postgraduate nursing (De Villiers, Conradie, Snyman, Van Heerden, & Van Schalkwyk, 2014). In keeping with findings of the Canadian Interprofessional Health Collaborative (2010), Frenk et al. (2010), Institute of Medicine (2011), Interprofessional Education
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Collaborative Expert Panel (2011) and WHO (2010), this revised strategy considered the pivotal role of IPECP in equipping students as change agents when addressing health needs of individuals and communities. The group chose to develop strategies integrating IPECP into current curricula, rather than designing a separate curriculum. To institutionalise this envisaged culture of IPECP, three focus areas were identified: (1) Development, integration and assessment of core competencies in curricula (Stephenson, Peloquin, Richmond, Hinman, & Christiansen, 2002), based on the CanMEDS competency framework (Frank, 2005) and competencies for interprofessional collaborative practice (Canadian Interprofessional Health Collaborative, 2010; Interprofessional Education Collaborative Expert Panel, 2011). (2) Promotion of an interprofessional care and collaboration framework, based on ICF as common language between professions at individual, institutional and societal levels (Figure 1) (Allan et al., 2006; Cahill, O’Donnell, Warren, Taylor, & Gowan, 2013; Dufour & Lucy, 2010; Tempest & McIntyre, 2006; WHO, 2001). (3) Harmonisation between two key stakeholders in HPE: higher education (university) and service providers (government health departments and community-based organisations). The aim was to build relationships and capacity among faculty and service providers in modelling interprofessional collaborative practice (Clark, 2004; Craddock, O’Halloran, McPherson, Hean, & Hammick, 2013; Global Consensus for Social Accountability of Medical Schools, 2010; Lawson, 2004; Steinert, 2005). (Figure 2). Figure 1. The interprofessional education and collaborative practice strategy at Stellenbosch University (adapted and used with permission of Talaat & Ladhani, 2014).
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The gradual implementation of this strategy commenced in undergraduate community-based modules at SU’s Ukwanda Rural Clinical School, where the educational environment was perceived as more open to creative innovation (Van Schalkwyk et al., 2012). These rural placements offered experiential learning of ICF-informed interprofessional collaborative practice. Typical challenges of IPE were prominent, e.g. short rotations, shift incompatibility, issues of profession-specific supervision and claims that accreditation requirements by professional boards are not flexible enough to allow for IPECP (Freeth, Hammick, Reeves, Koppel, & Barr, 2005; Jacobs et al., 2013; Lawson, 2004; Oandasan & Reeves, 2005; Thibault et al., 2013). There were logistic challenges: medical students were placed for a 2-week rural clinical rotation in one of nine sites in a 150-km radius from the medical school. Students from other afore-mentioned undergraduate programmes were only sporadically present at three of these sites, which were based at primary care facilities or district hospitals. A novel approach was adopted to address these challenges. At each site the university appointed a part-time health professional as facilitator modelling interprofessional collaborative practice to both medical students and local health professionals. In this study the term ‘‘preceptor’’ refers to IPECP facilitators and various health professionals guiding students (Mills, Francis, & Bonner, 2005). During their rural rotation, medical students worked alongside these preceptors in managing their patients interprofessionally. Visits to their patients’ homes were guided by the environmental factors of ICF. This demonstrated how context influenced patients’ participation in activities and life roles. Towards the end of the rotation preceptors used an ICF-informed
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Figure 2. The ICF as interprofessional care and collaboration framework (adapted from WHO, 2001 and used with permission of Talaat & Ladhani, 2014).
rubric to assess students presenting their patients (Stellenbosch University, 2014).
Methods This study explored how using ICF in IPECP was experienced by medical students, preceptors and how patients perceived their care. Research design The Associative Group Analysis (AGA) method developed by Szalay and Brent (1967) was used as study design. AGA is a technique that educes free association responses from participant groups to a stimulus word in open-ended questions. The process requires spontaneous responses to questions within a limited time, thereby ensuring that only what was uppermost in the minds of participants was presented. It is therefore highly likely to be their spontaneous opinion associated with a specific concept (stimulus word). Choosing AGA allowed the researchers to collect qualitative data in resource and time constraint environments, where conducting focus group or individual interviews would have been impractical. Though traditional survey instruments can highlight data from a large number of subjects and give a broader cross-sectional snapshot of opinions, these techniques often fail to achieve significant levels of depth in their analysis. AGA can be criticised for being less objective, because it is a qualitative data collection technique, not formally testing for statistical significance as
traditional questionnaires using the survey procedure, does. However, in using AGA it is argued that it is through subjective data that the brain structures meaning to makes sense of the world around us. Therefore, objective data alone cannot further our understanding of how much respondents value something or how salient it is in a particular context (Linowes, Mroczkowski, Uchida, & Komatsu, 2000). Two researchers formulated different open-ended questions for students, preceptors and patients, respectively. The wording of questions for students and preceptors (piloted among medical students and preceptors not included in the study cohort) were basically the same, some only differ slightly contextualising it for each cohort, for example: Think about an interprofessional approach to patient care. What comes to mind first? What else? And what else? (both groups) Think about the ICF framework used to approach and manage patients. What comes to mind first? What else? And what else? (both groups) Think about the ICF framework. Think how the ICF approach to patient care contributed (if any) to your development as a health professional (preceptors) or future health professional (students). What comes to mind first? What else? And what else? Think about students’ case presentations using the ICF framework and the impact (if any) this has had on the healthcare team at your clinic/hospital? What comes to mind first? What else? And what else? (preceptors)
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Figure 3. The Ukwanda Rural Clinical School of Stellenbosch University and the sites where students are placed (used with permission of Talaat & Ladhani, 2014).
Examples of questions asked to patients and/or their carers: Think about the students. What comes to your mind first? What else? And what else? Think about the contribution the students made to you. What comes to your mind first? What else? And what else? In your opinion, what did the students do for you that should be done better? What comes to your mind first? What else? And what else? Participants and sampling Participants comprised of all fourth-year SU medical students who had completed an integrated 2-week rural clinical rotation in family medicine, community health and rehabilitation on the Ukwanda Rural Clinical School platform during 2012 (Figure 3), their preceptors and patients (and/or their carers). The preceptors included medical doctors (seven), registered nurses (two), occupational therapists (two), physiotherapists (four) and a dietician (one) from the nine rural sites. Most preceptors worked at more than one site. The patients had received care from the medical students. All preceptors, students and patients and/or carers who met the inclusion criteria, were approached to participate voluntarily in this study. There were no self-exclusions.
Table I. Details of participants.
Gender: Female Male Age (average in years) Home language: Afrikaans English isiXhosa Unspecified/ withheld Total number
Students
Preceptors
Patients/ carers
Total
26 (70%) 11 (30%) 22.5
10 (62.5%) 6 (37.5%) 34
9 (60%) 6 (40%) –
45 (66%) 23 (34%) –
20 11 2 4
11 3 0 2
(54%) (30%) (5%) (11%)
(69.75%) 14 (93%) (19.75%) 0 (0%) (0%) 1 (7%) (12.5%) 0 (0%)
37 (100%) 16 (100%)
45 14 3 6
(66%) (21%) (4%) (9%)
15 (100%) 68 (100%)
Ethical approval Ethical approval for this study was granted by SU’s Health Research Ethics Committee. Written informed consent for voluntary participation was obtained before data collection.
Data collection and analysis
Findings
Each participant completed a questionnaire. The researcher read each question in turn giving both preceptors and students 3 min to write their initial cognitive associations before moving to the next question. Medical students gathered in a class room and preceptors at their workplaces to complete the questionnaire. Patients were approached individually as preceptors arranged that they (and their carers) were available to complete the questionnaire either at the health facility or in their homes. More time was allotted for initial responses from the functionally illiterate patients and/or carers, thus enabling the researcher to verify and capture these responses verbatim. These responses were in the form of short sentences. These narrative data were captured verbatim in an MS Excel spread sheet to form the data set. To ensure the rigour of findings, the data set was initially read, reread and coded by the three researchers individually using qualitative content data analysis methodology to develop themes (Ritchie & Lewis, 2003). After individual data analysis, the three researchers met to triangulate their findings.
This study enrolled 68 study participants: 37 medical students, 16 preceptors and 15 patients (Table I). Seven themes emerged. Preceptors: using the International Classification of Functioning, Disability and Health facilitates interprofessional patient care All preceptors indicated ICF enabled a more comprehensive and holistic understanding of patients. This was as a result of students involving various health professionals as part of the interprofessional team in caring for each patient. Preceptors reported that using ICF brought their health care team together and that valuable inputs from other team members were facilitated leading to comprehensive patient management. They also mentioned that their skills were improved and exchanged between colleagues and that using ICF reduced the tendency to work in silos. This provided more holistic insight, which in turn stimulated clinical reasoning.
DOI: 10.3109/13561820.2015.1004041
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Interprofessional assessment of students using the international Classification of Functioning, Disability and health enhances care Interprofessional patient care was particularly evident to preceptors when students presented their patient management plans for assessment. By assessing students using a rubric based on ICF, preceptors were indirectly challenged to better familiarise themselves with the framework and to improve their own interprofessional practice. During preparation for their assessments, students became more aware of the unique role of different professions as it relates to domains of ICF. Students indicated by using ICF they entered into ‘‘team collaboration, discussion and approach’’ with ‘‘less hierarchy’’ and ‘‘became aware of different health professionals’’. Mutual respect was promoted by working in a team with less hierarchy and discussing strategies to address health care needs of patients. Patients reported that they felt listened to and taken seriously, believing that they had received improved individual patient care. In some instances though, it has been reported that ‘‘there has not been an impact at hospital level’’. Preceptors were also ‘‘not sure if nursing staff are affected’’ as they were mostly not involved in student assessments. Students and preceptors reported excellent relationships with nursing staff and suggested nurses be more involved in interprofessional teams. Student experience of using the International Classification of Functioning, Disability and Health in IPECP Students and preceptors indicated IPECP activities during the rural clinical rotation using ICF contributed ‘‘significantly to students’ development as future healthcare professionals’’. In addition, students felt valued by patients, believing they had made a constructive contribution. Students also reported that prior to this rural clinical placement they had little exposure to IPECP, having been primarily exposed to uniprofessional, curative biomedical models of care. All students found ICF comprehensive and beneficial in obtaining effective and holistic insight into patient needs and context. Sixty-two percent of students were positive about using ICF in clinical practice, where others experienced ICF too time-consuming, unnecessarily detailed and not always practical given the clinical workload. Students need practise to apply the conceptual framework of the International Classification of Functioning, Disability and Health Although students reported it was a ‘‘challenge to implement’’ ICF in approaching a patient and developing an individual interprofessional management plan, they observed it is ‘‘best for [the] patient and [in] achieving common goals’’. Students not only requested more teaching and exposure on using ICF in clinical settings, but also more opportunities for IPECP. They suggested that they should be required to collaborate with other healthcare students and/or health professionals during their earlier years of study and clinical placements. Clear guidelines on when, why, and to which profession, patients should be referred, was a further request from students. Preceptors felt some students still struggled to apply ICF in approaching a patient and in developing an interprofessional management plan. Preceptors’ self-reflection on their practice Preceptors indicated their involvement with students using ICF challenged them to develop both as health professionals and educators. ICF brought about awareness of contextual factors
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influencing patients’ health and, as one preceptor reported, ‘‘it improved my practice especially regarding referral, health promotion, discharge and post-discharge planning and has definitely made me a better doctor’’. For some preceptors using ICF made them ‘‘open to see own [my] shortcomings’’, providing a comprehensive outline which allowed for ‘‘more input, less missed detail, better overall result’’ and the ‘‘patient feels more attended to’’. Preceptors felt that professional jealousy, shortage of health care personnel and logistical constraints are obstacles to IPECP and that successful implementation is largely dependent on individuals supporting this concept. Despite these challenges, both students and preceptors agreed that teamwork is ‘‘difficult to implement’’, but ‘‘worth the effort’’. Experience of patients and their carers Patients and their carers felt listened to and valued by students and the health system, and that they experienced receiving better care. They recognised change in the way students interacted with them as beneficial: ‘‘students sensed my frustration and dealt with it’’. Furthermore, patients and carers reported students took time to explain their condition and treatment in an understandable manner. One said: ‘‘I am a month here [in hospital] waiting for information – students explained better to me why I have been here for so long’’. Asking patients and/or their carers questions guided by ICF, can lead to ‘‘Doctors [that] will be more useful . . . if they ask me the questions these students did.’’ However, the perception was that ‘‘once you are a doctor you just run through things, but these students thought broader’’. Student interaction may challenge people to live a healthier lifestyle as ‘‘students influenced me how I can improve my health and what I must do to achieve it’’. Patient home visit particularly valuable Students and preceptors found visiting patient homes using ICF as guideline, as providing ‘‘especially important information about the patient’s health’’. Patients and carers experienced students’ home visits as ‘‘positive’’, ‘‘feeling respected and listened to’’; reporting that their needs were taken seriously. These visits provided an opportunity for students to conceptualise patient functioning as dynamic interaction between a person’s health condition, environmental and personal factors. One patient commented that the student’s ‘‘humanness was very helpful for me and my parents’’, lamenting that these visits only take place during training.
Discussion This study suggested how ICF – when situated in an authentic learning experience as offered on a rural clinical platform – can be introduced successfully at undergraduate level as a catalyst for IPECP. During a rural clinical placement, undergraduate medical students succeeded in delivering interprofessional patient-centred care, informed by ICF and supported by local preceptors. The data suggest that ICF provided a common language to involve different health professions in developing insight of patients’ needs beyond the immediate diagnosis (WHO, 2013b). Visiting patients’ homes was a paradigm-shifting experience in students’ journey towards discovering contextual factors influencing health. The environmental and personal domains of ICF guided this visit, by demonstrating how these factors are interlinked with the patient’s activity limitations and participation restrictions. Students’ appreciation of the comprehensive ICF approach is consistent with findings of Allan et al. (2006), Dufour and Lucy (2010) and Tempest and McIntyre (2006). Mirroring the
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findings of Hallin, Henriksson, Dale´n, and Kiessling (2011), patients and carers felt valued by students, resulting in an improved health system experience. This study provided some confirmation of the value of the ICF to facilitate clinical reasoning, to elicit the non-linear complexity of health and to serve as framework in the iterative ‘‘juggling’’ (Hugo & Cooper, 2006) during patient interactions. These findings are consistent with other studies (Allan et al., 2006; Jelsma & Scott, 2011; Tempest & McIntyre, 2006). During the assessment at the end of their rural rotation, students presented their patients’ interprofessional management plan to preceptors from various professions. Students unknowingly served as change agents during these assessments, primarily because they modelled an interprofessional patient-centred approach to preceptors. This approach challenged preceptors to reflect on their own practice. This highlights the transformative power of interprofessional learning in creating change and facilitating a cultural shift in practice (Cooper, 2010). Interprofessional collaboration, as also reported by Cahill et al. (2013) and Hammick, Olckers, and Campion-Smith (2009), enhanced students’ understanding of the benefits of working as a team. As in the case of Orchard, Curran, and Kabene (2005) and Steiner et al. (2002), students realised that doctors cannot solve health problems alone. An interprofessional approach by using ICF is suggested, as opposed to the tradition of uniprofessional or multiprofessional practice. As suggested by WHO (2013b), ICF provided a systematic, though non-mechanical means of engaging with patients, carers and interprofessional team members. Furthermore, it enhanced respect, collaborative leadership, job satisfaction, trust relationships and accountability between team members, as well as a culture of on-going learning. This process challenged the traditional hierarchy and professional silos prominent in preceptors’ healthcare teams, which links to the findings of Dufour and Lucy (2010), Lawson (2004), Hammick et al. (2009), and Tempest and McIntyre (2006). It is necessary to deflate the hierarchical system where one profession is regarded of greater value than another, and enable medical practitioners to know when and to which profession to refer, as well as which professional should lead each case (Allan et al., 2006; Cahill et al., 2013; Dufour & Lucy, 2010; Tempest & McIntyre, 2006). Preceptors and students referred to the strategic role of the nursing profession as part of IPECP: students value preceptorship by nurses, while existing preceptors are seeking formal opportunities to incorporate nurses in the interprofessional assessment of medical students. Mirroring the findings of Tempest and McIntyre (2006), some students experienced ICF too time-consuming, unnecessarily detailed and not always practical given the clinical workload. They were under the impression they should utilise the main ¨ stu¨n, Chatterji, and Kostanjsek (2004) volume of ICF. However, U found only a fraction of ICF domains is needed for any single patient. Furthermore, the need for instructional and institutional reform to facilitate IPECP and system-based learning was confirmed as students requested synchronisation of undergraduate health professions curricula, earlier exposure to IPECP and ICF, modelling of IPECP in all clinical rotations and longer placements in community-based settings. This study setting comprised mainly of rural community-based sites; future studies should explore the juxtaposition of rural and urban placements. Whether the learning will lead to the permanent use of ICF in practice (by students and preceptors) has not been established. It is also not established whether this learning is transferred back by students to the tertiary hospital context upon completion of the rural rotation. This study focused on students of a single rural rotation; future studies should consider a
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longitudinal study involving students from various professions learning and working together using ICF. Only medical students were included, mainly due to the current system of asynchronous undergraduate curricula. The study also did not explore the impact of an ICF approach on patient outcomes. In summary, it is a conventional assertion that ‘‘assessment drives learning’’ (Muijtjens, Hoogenbook, Verwijnen, & Van der Vleuten, 1998). Using ICF in assessment however has the potential not only to drive learning, but also interprofessional practice of both students and preceptors. ICF becomes a catalyst for IPECP when authentic patient-centred learning experiences are shared by different health professions.
Acknowledgements The authors acknowledge Proff. Susan van Schalkwyk, Hoffie Conradie, and De Wet Schutte for their support, as well as the students, preceptors and patients who participated in the study. The authors appreciate the encouragement of the Institute of Medicine’s Global Forum for the Innovation in Health Professions Education and the Functioning and Disability Reference Group of the WHO’s Family of International Classifications Network.
Declaration of interest The authors report no declaration of interest. The authors are responsible for the writing and contents of this article.
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Ritchie, J., & Lewis, J. (Eds.). (2003). Qualitative research practice. A guide for social science students and researchers. London: SAGE. Steiner, W., Ryser, L., Huber, E., Uebelhart, D., Aeschlimann, A., & Stucki, G. (2002). Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Physical Therapy, 82, 1098–1107. Steinert, Y. (2005). Learning together to teach together: Interprofessional education and faculty development. Journal of Interprofessional Care, 19, 60–75. Stellenbosch University. (2014). Rubric used as guideline for interprofessional case discussions and presentations. Retrieved from http:// tiny.cc/icfrubric. Stephenson, K., Peloquin, S., Richmond, S., Hinman, M., & Christiansen, C. (2002). Changing educational paradigms to prepare allied health professionals for the 21st century. Education in Health, 15, 37–49. Szalay, L.B., & Brent, J.E. (1967). The analysis of cultural meanings through free verbal associations. Journal of Psychology, 72, 161–187. Talaat, W., & Ladhani, Z. (Eds.). (2014). Community based education in health professions: Global perspectives. Cairo: World Health Organization Regional Office for the Eastern Mediterranean. Tempest, S., & McIntyre, A. (2006). Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation. Journal of Interprofessional Care, 28, 663–667. Thibault, G.E., Schoenbaum, S.C., & Josiah Macy Jr. Foundation. (2013). Forging collaboration within academia and between academia and health care delivery organizations: Importance, successes and future work. Commentary. Washington, D.C.: Institute of Medicine. ¨ stu¨n, B., Chatterji, S., & Kostanjsek, N. (2004). Comments from WHO U for the Journal of Rehabilitation Medicine special supplement on ICF core sets. Journal of Rehabilitation Medicine, Suppl., 44, 7–8. Van Schalkwyk, S., Bezuidenhout, J., Burch, V., Clarke, M., Conradie, H., Van Heerden, B., & De Villiers, M. (2012). Developing an educational research framework for evaluating rural training of health professionals: A case for innovation. Medical Teacher, 34, 1064–1069. World Health Organization. (2001). International Classification of Functioning, Disability and Health. Geneva: World Health Organization. World Health Organization. (2010). Framework for Action on Interprofessional Education and Collaborative Practice. Geneva: World Health Organization. World Health Organization. (2013a). ICF application areas. Retrieved from http://www.who.int/classifications/icf/appareas/en/index.html. World Health Organization. (2013b). How to use the ICF: A practical manual for using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment. October 2013. Geneva: World Health Organization.
RESEARCH ARTICLE
International Classification of Functioning, Disability and Health: catalyst for interprofessional education and collaborative practice J Interprof Care Downloaded from informahealthcare.com by University of California San Francisco on 03/23/15 For personal use only.
Stefanus Snyman1, Klaus B. Von Pressentin2 and Marina Clarke1 1
Centre for Health Professions Education, Stellenbosch University, Tygerberg, Cape Town, South Africa and 2Division of Family Medicine and Primary Care, Stellenbosch University, Tygerberg, Cape Town, South Africa Abstract
Keywords
Patient-centred and community-based care is required for promotion of health equity. To enhance patient-centred interprofessional care, the World Health Organization recommends using the framework of the International Classification of Functioning, Disability and Health (ICF). Stellenbosch University’s Interprofessional Education and Collaborative Practice (IPECP) strategy has promoted using ICF since 2010. Undergraduate medical students on rural clinical placements are expected to use ICF in approaching and managing patients. Students’ ability to develop interprofessional care plans using ICF is assessed by a team of preceptors representing various health professions. This study explored the experiences of medical students and their preceptors using ICF in IPECP, and how patients perceived care received. Associative Group Analysis methodology was used to collect data for this study. In total, 68 study participants were enrolled of which 37 were medical students, 16 preceptors and 15 patients. Students found ICF enabled a patient-centred approach and reinforce the importance of context. Patients felt listened to and cared for. Preceptors, obliged to use ICF, came to appreciate the advantages of interprofessional care, promoting mutually beneficial teamwork and job satisfaction. The value of integrating IPECP as an authentic learning experience was demonstrated as was ICF as a catalyst in pushing boundaries for change.
Associative group analysis (AGA), health professions education, International Classification of Functioning, Disability and Health (ICF), interprofessional collaborative practice, interprofessional education
Introduction In 2001, the World Health Organization (WHO) launched the International Classification of Functioning, Disability and Health (ICF) as a comprehensive coding system for functioning and disability, a conceptual framework and ‘‘common language between all professions’’ (WHO, 2001, p. 3). In its first decade ICF was primarily used in international and national health and disability reporting, for clinical and epidemiological use, and for impact, intervention and application research (WHO, 2013a). In health professions education (HPE) ICF has not been widely taught as a conceptual framework in approaching and managing patients (Allan, Campbell, Guptill, Stephenson, & Campbell, 2006; WHO, 2013b). Rather, students are often taught numerous, potentially contradictory, frameworks in approaching patients and communities. These contradictions may serve as barrier to interprofessional communication and a bio-psycho-social-spiritual approach to patient-centred care (Fehrsen & Henbest, 1993). Currently, these barriers to interprofessional education and collaborative practice (IPECP) are being challenged by educators worldwide through institutional reform, which includes promotion of patient-centred IPECP (Barr, 2011; Frenk et al., 2010; Oandasan & Reeves, 2005; Thibault, Schoenbaum, & Josiah Macy Jr. Foundation, 2013; WHO, 2010). Dufour and
Correspondence: Dr Stefanus Snyman (MB, ChB, MPhil (Health ScEd), DOM), Centre for Health Professions Education, Stellenbosch University, PO Box 19063, Tygerberg, Cape Town 7505, South Africa. E-mail: [email protected]
History Received 27 January 2014 Revised 22 October 2014 Accepted 31 December 2014 Published online 23 January 2015
Lucy (2010) argue that solutions to these barriers necessitate moving away from the strong biomedical view of disease, which could neglect functional and contextual factors. They advocate for using ICF which ‘‘not only highlights the need for a diverse team of health care professionals, but also represents a paradigm shift in how to approach health and health care’’ (p. 668). A Global Independent Commission (Frenk et al., 2010) recommended HPE delivers graduates who strive for health equity through patient-centred and community-based care. This commission proposes instructional and institutional reform that, among others, fosters interdependence and promotes interprofessional learning. This could potentially ‘‘break down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams’’ (Barr, 2011, p. 319). Barr envisions this as an ‘‘iterative process between education and practice, as it generates commitment and competence for collaborative practice’’ (Barr, 2011, p. 319).
Background In 2010–2011 the IPECP strategy at the Faculty of Medicine and Health Sciences, Stellenbosch University (SU), South Africa, was revised by a group representing all undergraduate programmes (human nutrition, medicine, occupational therapy, physiotherapy and speech-language and hearing therapy), as well as postgraduate nursing (De Villiers, Conradie, Snyman, Van Heerden, & Van Schalkwyk, 2014). In keeping with findings of the Canadian Interprofessional Health Collaborative (2010), Frenk et al. (2010), Institute of Medicine (2011), Interprofessional Education
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Collaborative Expert Panel (2011) and WHO (2010), this revised strategy considered the pivotal role of IPECP in equipping students as change agents when addressing health needs of individuals and communities. The group chose to develop strategies integrating IPECP into current curricula, rather than designing a separate curriculum. To institutionalise this envisaged culture of IPECP, three focus areas were identified: (1) Development, integration and assessment of core competencies in curricula (Stephenson, Peloquin, Richmond, Hinman, & Christiansen, 2002), based on the CanMEDS competency framework (Frank, 2005) and competencies for interprofessional collaborative practice (Canadian Interprofessional Health Collaborative, 2010; Interprofessional Education Collaborative Expert Panel, 2011). (2) Promotion of an interprofessional care and collaboration framework, based on ICF as common language between professions at individual, institutional and societal levels (Figure 1) (Allan et al., 2006; Cahill, O’Donnell, Warren, Taylor, & Gowan, 2013; Dufour & Lucy, 2010; Tempest & McIntyre, 2006; WHO, 2001). (3) Harmonisation between two key stakeholders in HPE: higher education (university) and service providers (government health departments and community-based organisations). The aim was to build relationships and capacity among faculty and service providers in modelling interprofessional collaborative practice (Clark, 2004; Craddock, O’Halloran, McPherson, Hean, & Hammick, 2013; Global Consensus for Social Accountability of Medical Schools, 2010; Lawson, 2004; Steinert, 2005). (Figure 2). Figure 1. The interprofessional education and collaborative practice strategy at Stellenbosch University (adapted and used with permission of Talaat & Ladhani, 2014).
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The gradual implementation of this strategy commenced in undergraduate community-based modules at SU’s Ukwanda Rural Clinical School, where the educational environment was perceived as more open to creative innovation (Van Schalkwyk et al., 2012). These rural placements offered experiential learning of ICF-informed interprofessional collaborative practice. Typical challenges of IPE were prominent, e.g. short rotations, shift incompatibility, issues of profession-specific supervision and claims that accreditation requirements by professional boards are not flexible enough to allow for IPECP (Freeth, Hammick, Reeves, Koppel, & Barr, 2005; Jacobs et al., 2013; Lawson, 2004; Oandasan & Reeves, 2005; Thibault et al., 2013). There were logistic challenges: medical students were placed for a 2-week rural clinical rotation in one of nine sites in a 150-km radius from the medical school. Students from other afore-mentioned undergraduate programmes were only sporadically present at three of these sites, which were based at primary care facilities or district hospitals. A novel approach was adopted to address these challenges. At each site the university appointed a part-time health professional as facilitator modelling interprofessional collaborative practice to both medical students and local health professionals. In this study the term ‘‘preceptor’’ refers to IPECP facilitators and various health professionals guiding students (Mills, Francis, & Bonner, 2005). During their rural rotation, medical students worked alongside these preceptors in managing their patients interprofessionally. Visits to their patients’ homes were guided by the environmental factors of ICF. This demonstrated how context influenced patients’ participation in activities and life roles. Towards the end of the rotation preceptors used an ICF-informed
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DOI: 10.3109/13561820.2015.1004041
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Figure 2. The ICF as interprofessional care and collaboration framework (adapted from WHO, 2001 and used with permission of Talaat & Ladhani, 2014).
rubric to assess students presenting their patients (Stellenbosch University, 2014).
Methods This study explored how using ICF in IPECP was experienced by medical students, preceptors and how patients perceived their care. Research design The Associative Group Analysis (AGA) method developed by Szalay and Brent (1967) was used as study design. AGA is a technique that educes free association responses from participant groups to a stimulus word in open-ended questions. The process requires spontaneous responses to questions within a limited time, thereby ensuring that only what was uppermost in the minds of participants was presented. It is therefore highly likely to be their spontaneous opinion associated with a specific concept (stimulus word). Choosing AGA allowed the researchers to collect qualitative data in resource and time constraint environments, where conducting focus group or individual interviews would have been impractical. Though traditional survey instruments can highlight data from a large number of subjects and give a broader cross-sectional snapshot of opinions, these techniques often fail to achieve significant levels of depth in their analysis. AGA can be criticised for being less objective, because it is a qualitative data collection technique, not formally testing for statistical significance as
traditional questionnaires using the survey procedure, does. However, in using AGA it is argued that it is through subjective data that the brain structures meaning to makes sense of the world around us. Therefore, objective data alone cannot further our understanding of how much respondents value something or how salient it is in a particular context (Linowes, Mroczkowski, Uchida, & Komatsu, 2000). Two researchers formulated different open-ended questions for students, preceptors and patients, respectively. The wording of questions for students and preceptors (piloted among medical students and preceptors not included in the study cohort) were basically the same, some only differ slightly contextualising it for each cohort, for example: Think about an interprofessional approach to patient care. What comes to mind first? What else? And what else? (both groups) Think about the ICF framework used to approach and manage patients. What comes to mind first? What else? And what else? (both groups) Think about the ICF framework. Think how the ICF approach to patient care contributed (if any) to your development as a health professional (preceptors) or future health professional (students). What comes to mind first? What else? And what else? Think about students’ case presentations using the ICF framework and the impact (if any) this has had on the healthcare team at your clinic/hospital? What comes to mind first? What else? And what else? (preceptors)
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Figure 3. The Ukwanda Rural Clinical School of Stellenbosch University and the sites where students are placed (used with permission of Talaat & Ladhani, 2014).
Examples of questions asked to patients and/or their carers: Think about the students. What comes to your mind first? What else? And what else? Think about the contribution the students made to you. What comes to your mind first? What else? And what else? In your opinion, what did the students do for you that should be done better? What comes to your mind first? What else? And what else? Participants and sampling Participants comprised of all fourth-year SU medical students who had completed an integrated 2-week rural clinical rotation in family medicine, community health and rehabilitation on the Ukwanda Rural Clinical School platform during 2012 (Figure 3), their preceptors and patients (and/or their carers). The preceptors included medical doctors (seven), registered nurses (two), occupational therapists (two), physiotherapists (four) and a dietician (one) from the nine rural sites. Most preceptors worked at more than one site. The patients had received care from the medical students. All preceptors, students and patients and/or carers who met the inclusion criteria, were approached to participate voluntarily in this study. There were no self-exclusions.
Table I. Details of participants.
Gender: Female Male Age (average in years) Home language: Afrikaans English isiXhosa Unspecified/ withheld Total number
Students
Preceptors
Patients/ carers
Total
26 (70%) 11 (30%) 22.5
10 (62.5%) 6 (37.5%) 34
9 (60%) 6 (40%) –
45 (66%) 23 (34%) –
20 11 2 4
11 3 0 2
(54%) (30%) (5%) (11%)
(69.75%) 14 (93%) (19.75%) 0 (0%) (0%) 1 (7%) (12.5%) 0 (0%)
37 (100%) 16 (100%)
45 14 3 6
(66%) (21%) (4%) (9%)
15 (100%) 68 (100%)
Ethical approval Ethical approval for this study was granted by SU’s Health Research Ethics Committee. Written informed consent for voluntary participation was obtained before data collection.
Data collection and analysis
Findings
Each participant completed a questionnaire. The researcher read each question in turn giving both preceptors and students 3 min to write their initial cognitive associations before moving to the next question. Medical students gathered in a class room and preceptors at their workplaces to complete the questionnaire. Patients were approached individually as preceptors arranged that they (and their carers) were available to complete the questionnaire either at the health facility or in their homes. More time was allotted for initial responses from the functionally illiterate patients and/or carers, thus enabling the researcher to verify and capture these responses verbatim. These responses were in the form of short sentences. These narrative data were captured verbatim in an MS Excel spread sheet to form the data set. To ensure the rigour of findings, the data set was initially read, reread and coded by the three researchers individually using qualitative content data analysis methodology to develop themes (Ritchie & Lewis, 2003). After individual data analysis, the three researchers met to triangulate their findings.
This study enrolled 68 study participants: 37 medical students, 16 preceptors and 15 patients (Table I). Seven themes emerged. Preceptors: using the International Classification of Functioning, Disability and Health facilitates interprofessional patient care All preceptors indicated ICF enabled a more comprehensive and holistic understanding of patients. This was as a result of students involving various health professionals as part of the interprofessional team in caring for each patient. Preceptors reported that using ICF brought their health care team together and that valuable inputs from other team members were facilitated leading to comprehensive patient management. They also mentioned that their skills were improved and exchanged between colleagues and that using ICF reduced the tendency to work in silos. This provided more holistic insight, which in turn stimulated clinical reasoning.
DOI: 10.3109/13561820.2015.1004041
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Interprofessional assessment of students using the international Classification of Functioning, Disability and health enhances care Interprofessional patient care was particularly evident to preceptors when students presented their patient management plans for assessment. By assessing students using a rubric based on ICF, preceptors were indirectly challenged to better familiarise themselves with the framework and to improve their own interprofessional practice. During preparation for their assessments, students became more aware of the unique role of different professions as it relates to domains of ICF. Students indicated by using ICF they entered into ‘‘team collaboration, discussion and approach’’ with ‘‘less hierarchy’’ and ‘‘became aware of different health professionals’’. Mutual respect was promoted by working in a team with less hierarchy and discussing strategies to address health care needs of patients. Patients reported that they felt listened to and taken seriously, believing that they had received improved individual patient care. In some instances though, it has been reported that ‘‘there has not been an impact at hospital level’’. Preceptors were also ‘‘not sure if nursing staff are affected’’ as they were mostly not involved in student assessments. Students and preceptors reported excellent relationships with nursing staff and suggested nurses be more involved in interprofessional teams. Student experience of using the International Classification of Functioning, Disability and Health in IPECP Students and preceptors indicated IPECP activities during the rural clinical rotation using ICF contributed ‘‘significantly to students’ development as future healthcare professionals’’. In addition, students felt valued by patients, believing they had made a constructive contribution. Students also reported that prior to this rural clinical placement they had little exposure to IPECP, having been primarily exposed to uniprofessional, curative biomedical models of care. All students found ICF comprehensive and beneficial in obtaining effective and holistic insight into patient needs and context. Sixty-two percent of students were positive about using ICF in clinical practice, where others experienced ICF too time-consuming, unnecessarily detailed and not always practical given the clinical workload. Students need practise to apply the conceptual framework of the International Classification of Functioning, Disability and Health Although students reported it was a ‘‘challenge to implement’’ ICF in approaching a patient and developing an individual interprofessional management plan, they observed it is ‘‘best for [the] patient and [in] achieving common goals’’. Students not only requested more teaching and exposure on using ICF in clinical settings, but also more opportunities for IPECP. They suggested that they should be required to collaborate with other healthcare students and/or health professionals during their earlier years of study and clinical placements. Clear guidelines on when, why, and to which profession, patients should be referred, was a further request from students. Preceptors felt some students still struggled to apply ICF in approaching a patient and in developing an interprofessional management plan. Preceptors’ self-reflection on their practice Preceptors indicated their involvement with students using ICF challenged them to develop both as health professionals and educators. ICF brought about awareness of contextual factors
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influencing patients’ health and, as one preceptor reported, ‘‘it improved my practice especially regarding referral, health promotion, discharge and post-discharge planning and has definitely made me a better doctor’’. For some preceptors using ICF made them ‘‘open to see own [my] shortcomings’’, providing a comprehensive outline which allowed for ‘‘more input, less missed detail, better overall result’’ and the ‘‘patient feels more attended to’’. Preceptors felt that professional jealousy, shortage of health care personnel and logistical constraints are obstacles to IPECP and that successful implementation is largely dependent on individuals supporting this concept. Despite these challenges, both students and preceptors agreed that teamwork is ‘‘difficult to implement’’, but ‘‘worth the effort’’. Experience of patients and their carers Patients and their carers felt listened to and valued by students and the health system, and that they experienced receiving better care. They recognised change in the way students interacted with them as beneficial: ‘‘students sensed my frustration and dealt with it’’. Furthermore, patients and carers reported students took time to explain their condition and treatment in an understandable manner. One said: ‘‘I am a month here [in hospital] waiting for information – students explained better to me why I have been here for so long’’. Asking patients and/or their carers questions guided by ICF, can lead to ‘‘Doctors [that] will be more useful . . . if they ask me the questions these students did.’’ However, the perception was that ‘‘once you are a doctor you just run through things, but these students thought broader’’. Student interaction may challenge people to live a healthier lifestyle as ‘‘students influenced me how I can improve my health and what I must do to achieve it’’. Patient home visit particularly valuable Students and preceptors found visiting patient homes using ICF as guideline, as providing ‘‘especially important information about the patient’s health’’. Patients and carers experienced students’ home visits as ‘‘positive’’, ‘‘feeling respected and listened to’’; reporting that their needs were taken seriously. These visits provided an opportunity for students to conceptualise patient functioning as dynamic interaction between a person’s health condition, environmental and personal factors. One patient commented that the student’s ‘‘humanness was very helpful for me and my parents’’, lamenting that these visits only take place during training.
Discussion This study suggested how ICF – when situated in an authentic learning experience as offered on a rural clinical platform – can be introduced successfully at undergraduate level as a catalyst for IPECP. During a rural clinical placement, undergraduate medical students succeeded in delivering interprofessional patient-centred care, informed by ICF and supported by local preceptors. The data suggest that ICF provided a common language to involve different health professions in developing insight of patients’ needs beyond the immediate diagnosis (WHO, 2013b). Visiting patients’ homes was a paradigm-shifting experience in students’ journey towards discovering contextual factors influencing health. The environmental and personal domains of ICF guided this visit, by demonstrating how these factors are interlinked with the patient’s activity limitations and participation restrictions. Students’ appreciation of the comprehensive ICF approach is consistent with findings of Allan et al. (2006), Dufour and Lucy (2010) and Tempest and McIntyre (2006). Mirroring the
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findings of Hallin, Henriksson, Dale´n, and Kiessling (2011), patients and carers felt valued by students, resulting in an improved health system experience. This study provided some confirmation of the value of the ICF to facilitate clinical reasoning, to elicit the non-linear complexity of health and to serve as framework in the iterative ‘‘juggling’’ (Hugo & Cooper, 2006) during patient interactions. These findings are consistent with other studies (Allan et al., 2006; Jelsma & Scott, 2011; Tempest & McIntyre, 2006). During the assessment at the end of their rural rotation, students presented their patients’ interprofessional management plan to preceptors from various professions. Students unknowingly served as change agents during these assessments, primarily because they modelled an interprofessional patient-centred approach to preceptors. This approach challenged preceptors to reflect on their own practice. This highlights the transformative power of interprofessional learning in creating change and facilitating a cultural shift in practice (Cooper, 2010). Interprofessional collaboration, as also reported by Cahill et al. (2013) and Hammick, Olckers, and Campion-Smith (2009), enhanced students’ understanding of the benefits of working as a team. As in the case of Orchard, Curran, and Kabene (2005) and Steiner et al. (2002), students realised that doctors cannot solve health problems alone. An interprofessional approach by using ICF is suggested, as opposed to the tradition of uniprofessional or multiprofessional practice. As suggested by WHO (2013b), ICF provided a systematic, though non-mechanical means of engaging with patients, carers and interprofessional team members. Furthermore, it enhanced respect, collaborative leadership, job satisfaction, trust relationships and accountability between team members, as well as a culture of on-going learning. This process challenged the traditional hierarchy and professional silos prominent in preceptors’ healthcare teams, which links to the findings of Dufour and Lucy (2010), Lawson (2004), Hammick et al. (2009), and Tempest and McIntyre (2006). It is necessary to deflate the hierarchical system where one profession is regarded of greater value than another, and enable medical practitioners to know when and to which profession to refer, as well as which professional should lead each case (Allan et al., 2006; Cahill et al., 2013; Dufour & Lucy, 2010; Tempest & McIntyre, 2006). Preceptors and students referred to the strategic role of the nursing profession as part of IPECP: students value preceptorship by nurses, while existing preceptors are seeking formal opportunities to incorporate nurses in the interprofessional assessment of medical students. Mirroring the findings of Tempest and McIntyre (2006), some students experienced ICF too time-consuming, unnecessarily detailed and not always practical given the clinical workload. They were under the impression they should utilise the main ¨ stu¨n, Chatterji, and Kostanjsek (2004) volume of ICF. However, U found only a fraction of ICF domains is needed for any single patient. Furthermore, the need for instructional and institutional reform to facilitate IPECP and system-based learning was confirmed as students requested synchronisation of undergraduate health professions curricula, earlier exposure to IPECP and ICF, modelling of IPECP in all clinical rotations and longer placements in community-based settings. This study setting comprised mainly of rural community-based sites; future studies should explore the juxtaposition of rural and urban placements. Whether the learning will lead to the permanent use of ICF in practice (by students and preceptors) has not been established. It is also not established whether this learning is transferred back by students to the tertiary hospital context upon completion of the rural rotation. This study focused on students of a single rural rotation; future studies should consider a
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longitudinal study involving students from various professions learning and working together using ICF. Only medical students were included, mainly due to the current system of asynchronous undergraduate curricula. The study also did not explore the impact of an ICF approach on patient outcomes. In summary, it is a conventional assertion that ‘‘assessment drives learning’’ (Muijtjens, Hoogenbook, Verwijnen, & Van der Vleuten, 1998). Using ICF in assessment however has the potential not only to drive learning, but also interprofessional practice of both students and preceptors. ICF becomes a catalyst for IPECP when authentic patient-centred learning experiences are shared by different health professions.
Acknowledgements The authors acknowledge Proff. Susan van Schalkwyk, Hoffie Conradie, and De Wet Schutte for their support, as well as the students, preceptors and patients who participated in the study. The authors appreciate the encouragement of the Institute of Medicine’s Global Forum for the Innovation in Health Professions Education and the Functioning and Disability Reference Group of the WHO’s Family of International Classifications Network.
Declaration of interest The authors report no declaration of interest. The authors are responsible for the writing and contents of this article.
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DOI: 10.3109/13561820.2015.1004041
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