learning about age Learning to care for older patients: hospitals and nursing homes as learning environments Marije Huls,1 Sophia E de Rooij,2 Annemie Diepstraten,3 Raymond Koopmans4,5 & Esther Helmich6

CONTEXT A significant challenge facing health care is the ageing of the population, which calls for a major response in medical education. Most clinical learning takes place within hospitals, but nursing homes may also represent suitable learning environments in which students can gain competencies in geriatric medicine. OBJECTIVES This study explores what students perceive as the main learning outcomes of a geriatric medicine clerkship in a hospital or a nursing home, and explicitly addresses factors that may stimulate or hamper the learning process. METHODS This qualitative study falls within a constructivist paradigm: it draws on socio-cultural learning theory and is guided by the principles of constructivist grounded theory. There were two phases of data collection. Firstly, a maximum variation sample of 68 students completed a worksheet, giving brief written answers on questions regarding their geriatric medicine clerkships. Secondly, focus group discussions were conducted with 19 purposively sampled students. We used template analysis, iteratively cycling between data collection and analysis, using a constant comparative process.

RESULTS Students described a broad range of learning outcomes and formative experiences that were largely distinct from their learning in previous clerkships with regard to specific geriatric knowledge, deliberate decision making, endof-life care, interprofessional collaboration and communication. According to students, the nursing home differed from the hospital in three aspects: interprofessional collaboration was more prominent; the lower resources available in nursing homes stimulated students to be creative, and students reported having greater autonomy in nursing homes compared with the more extensive educational guidance provided in hospitals. CONCLUSIONS In both hospitals and nursing homes, students not only learn to care for older patients, but also describe various broader learning outcomes necessary to become good doctors. The results of our study, in particular the specific benefits and challenges associated with learning in the nursing home, may further inform the implementation of geriatric medicine clerkships in hospitals and nursing homes.

Medical Education 2015: 49: 332–339 doi: 10.1111/medu.12646 Discuss ideas arising from the article at “www.mededuc.com discuss”.

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Nursing Home Heijendaal, Arnhem, the Netherlands Section of Geriatrics, Department of Internal Medicine, Amsterdam Medical Centre, University of Amsterdam, Amsterdam, the Netherlands 3 Department of Geriatrics, Radboud University Medical Centre, Nijmegen, the Netherlands 4 Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands 2

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5 Joachim en Anna Centre for Specialised Geriatric Care, Nijmegen, the Netherlands 6 Center for Evidence-Based Education, Amsterdam Medical Center, University of Amsterdam, Amsterdam, the Netherlands Correspondence: Esther Helmich, Center for Evidence-Based Education, Amsterdam Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands. Tel: 00 31 20 566 1278; E-mail: [email protected]

© 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 332–339

Workplace learning in hospitals and nursing homes

INTRODUCTION

One of the main challenges in current health care refers to the increasing ageing of the population, which calls for a major response in the education of medical doctors. Future doctors need to be able to care for older patients, who often have multiple acute and chronic diseases, disabilities and geriatric conditions, necessitating an interdisciplinary approach.1–3 The most prominent educational initiatives for reaching this goal share a common reliance on the gaining of authentic experience in caring for elderly patients.4 Traditionally, most experience-based learning has been situated in hospitals or, to a lesser extent, in primary care settings.5 It might be assumed that students encounter older patients everywhere during clerkships, but previous research has shown that a dedicated clerkship in geriatric hospital wards was more effective than traditional clerkships in preparing students to care for elderly patients.6 Although largely unrecognised and underused,7,8 nursing homes may also offer learning environments suitable for gaining geriatric competencies. The nursing home was previously described as an excellent location in which to practise the medical interview and physical examination.9 It offers medical students opportunities to actively participate in patient care, to develop patient-centred attitudes,10–12 and to learn to collaborate in an interprofessional environment.13 Further, utilising the nursing home as a clinical environment may alleviate the pressure imposed on traditional clinical teaching sites, which have high numbers of students. This study builds upon the literature on authentic learning experiences and workplace-based learning5 with the aim of adding specific knowledge about geriatric medicine and undergraduate clinical medical education. In the clinical workplace, in addition to the formal processes, informal and implicit processes may impact on the learning of students.14 Learning environments are complex socio-cultural contexts and the characteristics of a specific sociocultural environment are often not self-evident. Comparing and contrasting two different learning environments may therefore help us to gain more insight into the relative affordances of each. In this study, we contrast two learning environments in which students learn to care for older people: the nursing home, and the in-hospital geriatric service. We explore, from the perspective of medical

students, what and how they learn during a geriatric medicine clerkship, and explicitly address factors that may stimulate or hamper the learning process in the nursing home in comparison with that in the hospital.

METHODS

Context In the Netherlands, two of the eight medical schools provide mandatory clerkships in geriatric medicine.15 We carried out this study in one of those medical schools, the Radboud University Medical Centre Nijmegen, which, as is common in the Netherlands, offers an undergraduate-entry, 6-year medical school curriculum. By the end of the fifth year, medical students have completed their core clerkships (including those in medical and surgical specialties, neurology and psychiatry, paediatrics, ear, nose and throat, ophthalmology, dermatology, public health and general practice). They then enter a geriatric medicine clerkship, which is the final mandatory clinical placement before they undertake the scientific and clinical electives required for graduation. This geriatric clerkship at the Radboud University Medical Centre Nijmegen is facilitated by 15 different nursing homes and nine hospitals, located in the southeast of the Netherlands. In the Netherlands, nursing homes or nursing home organisations typically provide both psychogeriatric and long-term somatic care for frail elderly patients and often offer a rehabilitation service. The number of patients ranges from around 20 in small (psycho-geriatric) living units to more than 200 in larger facilities. The main difference with other countries may be that, in the Netherlands, medical care is delivered by specifically trained elderly care physicians, who are employed by the nursing home, from which they may also provide care for people in small residential units that are part of the same large organisation, and who engage in both home visits and in-hospital consultations. Allied health professionals (including psychologists, speech therapists, dieticians, occupational therapists, physiotherapists, art therapists and spiritual counsellors) are also primarily employed by the nursing home. Whereas most nursing care in hospitals is delivered by registered nurses with a higher education background, the nursing staff in nursing homes typically consists of nurse assistants, who have completed a

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M Huls et al vocational training programme of 2 or 3 years at maximum. Nursing homes offer learning opportunities for trainees within nursing, allied health professions and medical education. Medical students are usually supervised by elderly care physicians, but may also be given some supervision by postgraduate medical trainees in elderly care medicine. Study design As workplace learning in medicine takes place in interaction with patients, doctors, nurses and other health care professionals in a given social context, we adopted a socio-cultural perspective, conceptualising learning as situated in a particular social practice.16,17 All members of the research team had backgrounds in geriatric or elderly care medicine, which inevitably influenced our perceptions of the subject under study. Moreover, our and the participants’ perceptions of nursing homes or in-hospital geriatric services as learning environments can be subject to the particular cultural and geographic contexts of our place in time, which implies that finding one sole ‘truth’ regarding the nursing home or in-hospital geriatric services will never be possible. Our epistemology therefore was constructivist: we consider knowledge to be actively constructed in human interactions and acknowledge the roles of the researchers in shaping research outcomes.18 Within this paradigm, particular attention is paid to reflexivity.19 Researchers must be conscious and transparent about their own backgrounds and assumptions, and about how they may influence the data collection and analysis process. At the time of the study, the lead researcher (MH) was a senior medical student with particular interest in elderly care medicine; her collaborators were (hospital-based) geriatricians (SEdR, AD) and (nursing home-based) elderly care physicians (RK, EH). We were interested in how medical students perceived their learning in nursing homes and in-hospital geriatric services. In order to gain insight into students’ perceptions, we applied a self-report method in which we used both free-text questionnaires and focus group interviews addressing students’ experiences. We used a generic qualitative approach,20 largely guided by the principles of constructivist grounded theory. In deviation from one of the premises of grounded theory (i.e. the development of a substantive theory), we aimed to achieve a careful description of perceived benefits, learning opportunities and challenges associated with the two different learning environments.

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Data collection Data collection and data analysis represented an iterative process comprising two phases. Firstly, we asked 68 students who had just finished their geriatric medicine clerkships to give brief written answers to the following questions: what did you learn during the geriatric medicine clerkship? What was your most formative learning experience and why? These questions, chosen to elicit students’ perceptions of the learning experiences most relevant to their professional development, were printed on a worksheet on which students were also asked to provide some background information on age, gender and clerkship location. The worksheets were introduced and handed out to students by faculty teachers at the end of small-group reflection sessions shortly after students had finished their geriatric medicine clerkships. This resulted in maximum variation sampling so that the sample included students who differed in age, gender, prior experience, future career perspectives and clerkship location; we considered these factors to be important in allowing us to obtain broad insight into students’ geriatric clerkship experiences. After analysis of these data, we used focus group interviews to deepen our understanding and further inform the themes derived from the analysis of the worksheet data. We purposively sampled 19 students for participation in focus group interviews. Students were invited to participate in a focus group interview via e-mail or in person by MH. We sampled students who were able to express themselves and critically reflect on their learning experiences, again striving for differences in age, gender, prior experience, future career perspectives and clerkship location. Focus group interviews are suitable for gaining a thorough overview of what is happening within a specific domain.21 We preferred focus groups over individual interviews because discussion encourages the exchange of ideas and experiences.21,22 A certain amount of homogeneity among group members is desirable to increase mutual understanding.22 Therefore, we conducted a first focus group interview with students who had followed the clerkship in nursing homes and a second focus group interview with students who had been placed in hospitals. However, if an active discussion is to be achieved, some heterogeneity should also be sought.22 For this reason, we mixed students from both settings in a third focus group.

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Workplace learning in hospitals and nursing homes The interviews were facilitated by a skilled moderator (EH). During the discussions, an assistant moderator (MH) took notes to capture non-verbal behaviour and any particular group processes. The moderator started each focus group interview by asking what had been the most formative learning experience during the clerkship. Other prompts during the interviews followed the themes derived from the analysis of the worksheets.

them that results would be presented anonymously and at group levels. For the first part of the study, we considered the return of a completed worksheet as representative of the granting of informed consent. At the start of each focus group interview, the students in the group confirmed their participation by signing an informed consent sheet.

RESULTS

Data analysis To organise the data into themes, we used template analysis.23 This involves the construction of a coding template that is applied to the data and further revised as necessary. The process starts with the careful reading and rereading of the data, with the application of open codes that represent salient themes in the text, and results in a coding list or preliminary template. This coding structure is applied to the text, revised and reapplied until the template provides a clear representation of the data. In our study, a senior medical student (MH) coded the data from the worksheets and developed an initial template. She discussed her coding approach and the initial template with an elderly care physician and medical educator (EH), and together they further developed and refined the template in an iterative process of applying, revising and reapplying. Subsequent versions of the template were discussed with the other members of the research team. To analyse the focus group interviews, we used the template derived from the worksheets and complemented and further developed this into a final template. Analysis occurred alongside and informed data collection, shaping the approach during subsequent focus group interviews.24 Each interview was transcribed verbatim and analysed before the next interview was carried out.

In their worksheets, students described a broad range of learning outcomes and formative experiences, which were largely distinct from their learning in previous clerkships. During the focus group interviews, students elaborated more extensively on the differences between their experiences in nursing homes and those in in-hospital geriatric services. In this report, we will address both the most salient differences between medical students’ learning in a geriatric medicine clerkship and their previous learning experiences, and differences between nursing homes and in-hospital geriatric services, as perceived by medical students. What is different in geriatric medicine? In both the nursing home and the hospital context, medical students described several factors that challenged their previously developed clinical reasoning skills, such as the need to deal with concomitant medical conditions and atypical presentations of disease. Students perceived treatment considerations as an important feature of care for elderly people in both learning environments. They recognised the central role of quality of life and described this clerkship as representing an excellent opportunity to become more aware of the differences between cure and care. They described the need to critically consider possible advantages and disadvantages of treatment or withdrawal before asking for additional diagnostic or therapeutic procedures, which stimulated deliberate decision making:

Ethics Educational research is exempt from requirements for formal ethical approval under Dutch law. At the start of this project, the possibilities in the Netherlands for the ethical review of medical education research were limited. To ensure the well-being of our participants, we took several precautions. We informed students verbally and by providing a written information form. Participation was fully voluntary and participants knew they were able to withdraw from the study at any moment. We assured

‘They did not blindly ask for a computed tomography or something like that. First it was argued. . . what the consequences were for the patient and so on.’ (Hospital clerkship student) Students talked about various aspects of palliative care and witnessed the final stages of life. The provision of support to patients and their families during this process is extremely important and, according to students, ways of doing this could be learned during this clerkship in both nursing homes and geriatric

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M Huls et al hospital departments. Students in both learning environments indicated that they had been stimulated to look beyond a single biomedical diagnosis and to include psychological and social aspects of care. They became aware of the impact of disease on the lives of patients and the need to anticipate problems that might arise after discharge: ‘You gained a nice picture about how somebody lived his life and all the kind of things that could go wrong at home. Not just looking at the medical aspects. So yes, that was an eye-opener.’ (Hospital clerkship student) By contrast with previous clerkship experiences, students reported that they had collaborated more often with other health care professionals, such as physiotherapists, occupational therapists, psychologists and social workers. They had participated in multidisciplinary team meetings and recognised the added value of interprofessional collaboration: ‘You could notice that everybody saw the added value of each other and appreciated it. That it really became a collaboration.’ (Nursing home clerkship student) Students in both learning environments reported that they had further developed their communication skills. More specifically, they indicated that they had learned to communicate with older patients, in particular those with dementia, and their relatives: ‘Well, regarding communication with patients, it is obvious that you have to adapt your way of communicating to someone with less cognitive capacity. Sometimes you witnessed this during previous clerkships, but not on such a large scale.’ (Nursing home clerkship student) What is different in the nursing home? Teamwork Interprofessional teamwork was omnipresent, especially in nursing homes. Although very instructive, working in an interprofessional team in a nursing home posed its own challenges to students, particularly in terms of collaborating with nurses who had significantly different educational backgrounds. Students described their need to learn how to distil relevant information from that given to them by nurses, and how to explain medical orders clearly to prevent misunderstandings. However, students stated that they gained specific knowledge and skills

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from working together with nurses, such as of how to deal with older patients with cognitive impairments: ‘They just have more knowledge of other things. For instance I really learned [about] dealing with difficult patients from the nurses.’ (Nursing home clerkship student) The low resource–high yield paradox Students in nursing homes described important limitations in terms of the availability of advanced diagnostic procedures and treatment options, which differed hugely from their experiences in previous clerkships in hospitals. Most nursing homes had facilities to order blood tests on certain days or investigate urine samples, but if further diagnostic procedures were required, patients had to be referred to a hospital. Dealing with this low level of resources was challenging and students were stimulated to be creative and deliberate in their clinical reasoning and decision making. They indicated that they had learned to rely strongly on findings obtained from history taking and physical examination: ‘You really learn that one must make do with what one’s got.’ (Nursing home clerkship student) Autonomy and educational guidance Differences in the balance between the gaining of medical knowledge through extensive guidance and independent participation in patient care were indicated by students in the focus groups as representing the main distinction between the two learning environments. Students who were allocated to inhospital geriatric services reported that they usually had more interaction with their supervisors. Students in hospitals reported an increase in specific medical knowledge and stated that they had learned most from formal educational sessions, direct observation and feedback: ‘Compared to other clerkships, there was much more time for feedback.’ (Hospital clerkship student) In nursing homes, students reported that they had been offered excellent opportunities to work independently and to learn to practise patient care on their own. Formal supervision and teaching sessions were less prominent in the accounts of these

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Workplace learning in hospitals and nursing homes students because elderly care physicians tended to work across multiple geographically dispersed workplaces and were not always physically present in the same building as the medical student. However, students stressed that they had felt adequately supported by their supervisors, who were always available and approachable, at least by telephone: ‘I believe I certainly would have gained more knowledge if my elderly care physician had been more around, but then I would have learned much less about practising patient care on my own.’ (Nursing home clerkship student)

DISCUSSION

Given the growing demographic imperative to develop competence in caring for older patients, geriatric medicine clerkships in both nursing homes and in-hospital geriatric services may provide important learning opportunities for medical students. Students in our study described improvements in geriatric medical knowledge, clinical reasoning skills, deliberate decision making, communication and patient-centred attitudes. In both hospitals and nursing homes, students reported that they had actively engaged in interprofessional teamwork and end-of-life care. In order to provide all medical students with these learning opportunities, it may be helpful to consider nursing homes as additional sites for medical learning. In doing so, medical educators and curriculum developers may want to address at least three issues that were prominent in the present study. Firstly, interprofessional teamwork seems to be more pronounced in nursing homes than in hospitals, which might help students to gain more insight into the non-medical aspects of patient care. Secondly, the nursing home as a learning environment offers particular challenges compared with the hospital, which we term ‘the low resource–high yield paradox’. Thirdly, according to students, hospitals and nursing homes may differ in the levels of autonomy and educational guidance they allow; students described, respectively, their gaining of medical knowledge through extensive guidance in hospitals and their independent participation in patient care in nursing homes. According to a recent landmark report in The Lancet, educational reforms should focus on competency-driven approaches, promote interprofessional education, and take into account demographic

transitions.25 The influential CanMEDS project created a framework which represents the general competencies required in all medical specialists.26 Although our methodology does not permit the assessment of competencies, our study reveals perceived benefits and learning opportunities, especially regarding autonomy and social learning. Our results suggest that geriatric medicine clerkships in nursing homes or in-hospital geriatric services might offer excellent opportunities for students to learn to care for older patients and to develop general competencies, particularly regarding the roles that are less addressed in the traditional clinical clerkships, such as those of the communicator, the manager, the professional and the collaborator. Ford et al.27 previously described the nursing home as a suitable learning environment in which students can experience an interprofessional team approach. Medical students who followed a 2-week geriatric rotation at a post-acute rehabilitative care facility also rated their rotation as useful for interdisciplinary care training.28 Our results also indicate that nursing homes may be particularly suitable for learning to collaborate in interprofessional teams. Students in nursing homes described many instances of the low resource–high yield paradox related to the paucity of diagnostic and medical opportunities and the differing educational backgrounds of nursing home staff. This clearly shows how a particular socio-cultural environment impacts on students’ learning processes. In a recent study among postgraduate medical trainees in nursing homes, we identified five areas in which the need to ‘deal with less’ is relevant: organisational issues; medical opportunities; communication; teamwork, and supervision.29 For postgraduate trainees, this process of ‘dealing with less’ ultimately seemed to result in ‘learning more’. The undergraduate students in the current study also mentioned that they had felt stimulated to be creative by working in a low-resource environment and emphasised that they had developed more confidence in the value of the medical interview and physical examination. However, for undergraduate medical education, further research might be necessary to clarify the potential pitfalls of confronting medical students with a particular low-recourse learning environment. A central tenet of medical education is that, in the course of training, students or trainees progressively develop and demonstrate competence, gradually taking on more autonomy and responsibility in the care of patients, and ultimately becoming independent practitioners.30 The supervision of trainees

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M Huls et al during this process must maintain an appropriate balance between ensuring patient safety and quality of care, and promoting professional development in the learner.31 Our study suggests that in nursing homes students are offered ample opportunity to work independently, but that this may be at the cost of increasing their specific medical knowledge to a lesser extent. The current study may stimulate debate about the optimal balance between autonomy and educational guidance in different stages of medical education. Our study is limited by its single-centre, specific local context. The Netherlands is one of the few countries with strong university-affiliated nursing home networks, which provide a specific infrastructure for medical education.7,32 Although this may limit transferability, we think that our description of the main benefits and challenges of the nursing home has the potential to inform discussion about the inclusion of nursing homes or other new learning environments as additional sites for medical learning. Another limitation of the study refers to our use of self-reports. An advantage of asking students to provide written self-reports is that this method ensures the anonymity of participants to researchers, which enables the former to answer openly and to share negative experiences or thoughts about the clerkship. The use of focus groups allowed us to compare different groups of students who had followed the clerkship in different environments. Observations typical of ethnographic research, allowing for direct observations in the workplace, would have offered additional dimensions to our view of the different learning environments.

CONCLUSIONS

In this study, we aimed to add specific knowledge about geriatric medicine and undergraduate clinical medical education. Our results support those of previous studies on the importance of specific clerkships dedicated to geriatric medicine in helping medical students learn to care for older people. Moreover, we aimed to further explore the viability of nursing homes as possible sites for medical education. According to the students in our study, the nursing home differs from the hospital in three ways: (i) interprofessional collaboration is more prominent in the nursing home; (ii) low resources in nursing homes stimulate students to be creative, and (iii) students report that they are given more autonomy in nursing homes compared with the extensive educational guidance provided in

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hospitals. We hope that the specific benefits and challenges described for the nursing home may further inform the implementation of geriatric clerkships in hospitals and nursing homes in the Netherlands and abroad. Contributors: MH, AD, RK and EH contributed to the conception and design of the study, and to the acquisition of data. MH took responsibility for data analysis and drafted the manuscript. SEdR and EH made important contributions to data analysis and interpretation, and to the writing of the manuscript. AD and RK contributed to data analysis and to the critical revision of the manuscript. All authors approved the final manuscript for publication and have agreed to be accountable for all aspects of the work. Acknowledgements: None. Funding: None. Conflicts of interest: None. Ethical approval: Educational research is exempt from requirements for formal ethical approval in the Netherlands. In the manuscript, we have clarified the precautions taken to ensure the well-being of our participants.

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Learning to care for older patients: hospitals and nursing homes as learning environments.

A significant challenge facing health care is the ageing of the population, which calls for a major response in medical education. Most clinical learn...
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