Soda/ Vork Training of New Health Professionals MAUREEN J. HUTTER GLORIA E. ZAKUS CLAIBOURNE I. DUNGY, MD

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New health professionals are being trained to provide primary health-care services to lowincome and rural communities. A training program for child health associates found that social workers are uniquely qualified to teach these new professionals a variety of social work skins.

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N THE PAST DECADE the American health care system has been radically altered by the development of new training programs. The goal of these programs is the preparation of nonphysician health professionals who, by virtue of their training and role definition, are uniquely prepared to meet the increasing need for providers of primary care in rural and low-income communities. Examples of such projects include the nurse practitioner, physician assistant, and physician associate programs.' Medical social workers are experienced providers of primary care in the social and behavioral services and, as such, have the potential to make a unique and important contribution to the development of these health training programs. Their techniques in interviewing, their understanding of family and group dynamics, their abilHEALTH AND SOCIAL WORK,

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ity to diagnose and treat common emotional and developmental problems, and their awareness of available community resources—all skills of the social and behavioral sciences—will be important in the new training programs for primary-care providers. Coupled with the social worker's traditional association with other health professionals in the practice setting, these skills make the social work practitioner a logical member of the teaching teams that will be involved in these new programs. This article describes the way in which one new health training program has used social workers in an expanded and innovative role. The results of evaluative studies that have been made to measure the success of this utilization are also discussed. CHILD HEALTH ASSOCIATE PROGRAM

The Child Health Associate program, which was developed at the University of Colorado Medical School, trains pediatric practitioners to work in ambulatory settings under a physician's supervision. These new professionals are prepared to deliver comprehensive well child care and to diagnose accurately and manage appropriately the common diseases of childhood. Child health associates, as these new professionals are called, provide counseling to children and their families in the area of growth and development. In addition, they receive sufficient training in the social and behavioral sciences to be able to assess and manage the psychosocial aspects of pediatrie problems. The time required to train child health associates is considerably shorter than that required to train physicians. Not only that, most of the training of these professionals takes place in outpatient, primary-care settings, such as the offices of private practitioners and public health clinics. As a result, child health associates meet the need for well-trained pediatric personnel in primary-care settings where physicians' services are limited. In proof of this, Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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over half the graduates of this program are presently practicing in rural areas or in public facilities in inner cities. 2 Social workers have been active staff members of the Child Health Associate program since its inception in 1969. As members of the administrative staff they have participated in committees on curriculum planning, student admissions, and student-faculty advisers. Each of these committees has played an important role in shaping the kind and quality of health professional being trained. Social work input on the curriculum planning committee has been influential in emphasizing the need for a thorough, clearly defined curriculum in the behavioral sciences—one that seeks to present all material on a practical level which can then be used by child health associates in the outpatient setting. The use of medical social workers who have experience in pediatrics has resulted in the development of courses that are tailor-made to the problems and issues most relevant to these new practitioners. For example, one topic covered in the course "Social Aspects of Pediatrics" is early mother-child attachment. The social worker presented current theory and research findings in this area. This factual material was supplemented by case studies from the obstetrical clinic and ward and from the newborn nursery, which served to illustrate how such attachment occurs and the kinds of problems encountered most frequently. The students then interviewed expectant mothers and mothers of newborn babies to assess the nature of these mothers' early attachment to their children. Students visited child protection agencies and other agencies in the community that offer services to families having problems in this area. By the end of the learning experience, students had been exposed to both research and theoretical material on motherchild attachment. They had talked with women who had been successful in forming such attachments and with those who had not, and they had met and worked with the professionals who were involved in aiding families with Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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problems in this area. This practical experience provided the students with skills in recognizing, managing, and, when necessary, referring problems in mother-child attachment. The social worker has also functioned as a member of the Child Health Associate program's committee on admissions. By emphasizing such social work values as social consciousness, empathy, and respect for individual worth, social workers can attract students to the program who will be perceptive of and responsive to the emotional and social needs of parents and their families. During the first few years of the Child Health Associate program no formal student-faculty advisory program existed. Realizing that faculty awareness and responsiveness to the emotional and social needs of students would provide important role-modeling for the students in their contacts with patients, the staff social worker organized such a program. Each student was encouraged to select a faculty adviser who accepted the responsibility of meeting regularly with the student and offering whatever guidance might be needed. The students have taken advantage of these relationships in a variety of ways. Some have come for help with academie concerns and questions about their careers; others have focused on personal and family problems. Many of the women students with families requested the staff social workers as advisers and have focused on the severe problems of adjustment they and their families have experienced as their time and energies are directed awav from the home and into outsicle careers and resnonsibilities. Many of these advisers have referred students to appropriate therapy when this was needed. TEACHING ROLE

Although the administrative activities described are important and innovative, the direct teaching role of the social worker in the Child Health Associate program is Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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of even greater interest. Four areas of learning have been identified in which the social worker is the primary teacher: (1) interviewing skills, (2) the identification and management of common family problems, (3) variations in health care beliefs and practices of different cultural and ethnic groups, and (4) use of community resources. In each of these areas the social worker has developed a set of objectives that states briefly the specific behavioral tasks students will be expected to master in order to demonstrate their competence. These behavioral tasks are stated in positive and negative terras because it is sometimes easier to describe the negative behavior and to observe its negative consequences. A sample set of learning objectives follows, which was devised to help the child health associate organize an interview. Positive

Negative

1. Clarifying purpose of visit by asking why patient is there and telling patient what practitioner plans to do

1. Neglecting to clarify the purposes of the visit either by assuming the purpose or by assuming that the patient knows what practitioner will do 2. Skipping from topic to topic 3. Assuming that the patient recognizes the connections between topics

2. Discussing one topic at a time 3. Using transitional comments and explanations in proceeding from one topic to another 4. Ending interview appropriately by summarizing actions taken and explaining future steps

4. Ending the interview inappropriately, either by doing so abruptly or by failing to explain what comes next

At regular intervals—usually every three months—the students receive a list of the learning objectives. Thus, they are alwao aware of what is expected of them. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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"One student remarked that his extended contact with social work professionals throughout the training program had enabled him to incorporate social work values in his own role definition."

The social workers are responsible for developing the core classes and clinics that provide the knowledge base and practical experiences needed by students to meet the behavioral objectives. For example, in the teaching of interviewing skills, a five-quarter-long lecture series has been developed that combines the theoretical material in required readings with demonstration interviews, role-playing, and home-visit assignments. In conjunction with the lecture series, the students have experience in direct patient contact in the obstetrical clinic, hospital nursery, and wellbaby clinic. Students are encouraged to practice their interviewing skills with each patient. Social workers on the teaching team are available for formal and informal consultation on how to handle certain problems in interviewing patients, thus reinforcing the practical relevante of the skills being taught in the classroom. Social workers give written examinations at quarterly intervals and require the students to audiotape actual interviews with their patients one or more times each quarter. These taped interviews are reviewed according to the criteria of the behavioral objectives. The students' level of performance is then measured and graded. EVALUATION OF SOCIAL WORK PARTICIPATION

The effectiveness of social work participation in administration, teaching, and evaluation within the Child Health Associate program has been documented by both formal and informal means. One nonscientific but direct and forceful measurement is its acceptance by students. At the end Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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of each quarter students are asked to evaluate the content and teaching of each course. Those courses taught by social workers have received consistently high ratings, and students have noted in particular the relevante and practicality of the material presented. Students frequently comment on the value of close personal contact with social workers during their training as child health associates. One student remarked that his extended contact with social work professionals throughout the training period had increased his ability to work effectively with these professionals in team delivery of comprehensive care and had enabled him to incorporate many social work values into his own rol e d efinition. Another informal means of assessing the success of social work involvement in the Child Health Associate program is the impact of such involvement on other training programs. Staff social workers have been asked to serve as curriculum consultants in planning courses in interviewing and social medicine for medical students, nurse practitioners, and house officers in family practice programs. They have given presentations at several nationwide medical meetings and at a training program for community health professionals working with adolescents. Objective assessment In addition to these informal measures of effectiveness, two formal research projects have been completed that assess the impact of social work teaching in the areas of interviewing and crisis management. As described earlier, all learning in the area of interviewing was defined in behavioral units. These units were presented to the students at regular intervals during their training, making use of such forms as the Interview Skills Check Sheet and the Data Base Check Sheet. The six categories contained in the Interview Skills Check Sheet are (1) organization of the interview, (2) general attitude conveyed in the interview. (3) communication skills, (4) responsiveness to feelings, Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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"Those students who took part in the formal program of teaching skills in interviewing gathered an average of 72 percent of all available data. . . . The untrtiined group only gathered an average of 47 percent of all available data."

(5) treatment planning in medical areas, and (6) treatment planning in psychosocial areas. The Data Base Check Sheet varied depending on the information relevant to a given interview. For example, a well-child visit might list such information as prenatal history, physical development, patterns of eating, sleeping, and elimination, as well as family relationships and the medical history of other family members. A visit for an acute illness would list the nature of the illness, its effect on the child an: family, past medical history, relevant medical and social history of the family After completing the five-quarter-long teaching program in interviewing skills, the students participated in a standardized simulated clinical interview. The format of such an interview is similar to that developed by Helfer and Hess for use in the pediatric training of medical students. 3 It involved training the mother of a young child to give a complete history of the child's physical and emotional development and to discuss a current medical or psychosocial problem. The students interviewed the mother in private sessions for a maximum of thirty minutes. The interviews, which were videotaped, were then broken down into two main areas—content (the data gathered) and process (the units of interaction). A social worker and pediatrician, acting as team observers and tested for interobserver reliability and accuracy, reviewed the tapes using the Interview Skills Check Sheet and the Data Base Check Sheet. This process of evaluation enabled a statement to be made Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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on how each individual student, as well as the group as a whole, performed in a standardized interview. An earlier class of child health associate students, who had not taken part in the Interview Skills Teaching program, served as a control group. Both groups of students took part in the standardized interviews after completing five quarters of child health associate training. Both groups had participated in two or more videotaped interviews. The results of the study show that those students who took part in the formal program of teaching skills in interviewing gathered an average of 72 percent of all available data and used an average of 84 percent of the skills defined as necessary for positive interview interaction. The untrained group only gathered an average of 47 percent of all available data and used an average of 62 percent necessary skills. The standardized simulated clinical interview was also used to measure the student's ability to manage a family crisis. A woman was trained to role-play a depressed mother who was experiencing difficulty in handling a marital crisis. The students interviewed the woman individually for a maximum of twenty minutes, and the interviews were videotaped. A team of social worker and pediatrician observers, trained for interobserver reliability and accuracy, reviewed these tapes using a score sheet that listed the kinds of data and types of interaction in crisis management. One group of medical students and one of graduate social work students served as controls. Findings indicated that the child health associate students were able to recognize the presence of the family crisis and could gather sufficient data to measure its severity, but had difficulty in dealing with certain aspects of the mother's feelings. There was no significant difference in the performance of the medcal or social work students. 4 SUMMARY

The Child Health Associate program provides a model for using social workers in the training of new health profesDownloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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sionals. Administratively, social workers have contributed to curriculum development in the behavioral sciences. They have influenced decisions regarding student selection and have developed and implemented a faculty adviser program. Because of their practical experience as primary care practitioners, social workers have been able to define effectively the skills needed by the new professionals to meet the social and emotional needs of their patients. Social workers have made use of their contacts in hospitals and communities to design and implement courses and clinics that combine in a meaningful manner theoretical material and practical experiences in patient contact. Evaluative research in the area of interviewing skills and crisis management demonstrates that the teaching methods applied by the social work profession are effective in increasing the level of students' interviewing skills in clinical practice and help prepare them to recognize family crises.

About the Authors Maureen J. Hutter, MA, and Gloria E. Zakus, MSW, are clinical social workers, University of Colorado Medical Center, Denver. Claibourne I. Dungy, MD, is phy sician, Department of Pediatrics, University of California at Irvine. At the time of writing he was associate professor of pediatrics, University of Colorado Medical School at Denver. The authors wish to thank Virgina Moore, MD, and John E. Ott, MD, who were active in developing the Social Work Component of the Child Health Associate program. A portion of this article was Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/125/765779 by Rutgers University user on 12 January 2018

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presented at the annual meeting of the American Public Health Association, New Orleans, Louisiana, October 15, 1974.

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Notes and Re erences .

1. Henry K. Silver, "A Blueprint for Pediatric Health Manpower for the 1970's," Journal of Pediatrics, 82 (January 1973), pp. 149-156. 2. Henry K. Silver, and John E. Ott, "The Child Health Associate: A New Health Professional to Provide Comprehensive Health Care to Children," Pediatrics, 51 (January 1973), pp. 107; and Claibourne J. Dungy, "The Child Health Associate in a Rural Setting," Journal of the National Medical Association, 66 (January 1974), pp. 32 44. 3. Ray Helfer, and Joseph Hess, "An Experimental Model for Making Objective Measurement of Interviewing Skills," Journal of Clinical Psychology, 26 (July 1970), pp. 327-331. 4. Maureen Hutter et al., "The Second Problem: The Assessment of Psychosocial Problems by Allied Health Professionals." Presented at the Fourteenth Annual Meeting of the Ambulatory Pediatrics Association, Washington, D.C., April 28, 1974.



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Social work training of new health professionals.

Soda/ Vork Training of New Health Professionals MAUREEN J. HUTTER GLORIA E. ZAKUS CLAIBOURNE I. DUNGY, MD Downloaded from https://academic.oup.com/hs...
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