2014, 36: 495–504

Students improve patient care and prepare for professional practice: An interprofessional community-based study ELIZABETH SUSAN ANDERSON & LUCY NICHOLA THORPE University of Leicester, UK

Abstract Background: We report on an education model that enables students to contribute to practice while experiencing the realities of complex team-working in the community. Aims: The study considers how interprofessional learning impacts on patient care and service delivery. Method: A qualitative study using a realist approach. The views of practice-staff, patients and facilitators on how student team learning impacted on practice was obtained through focus groups, interviews and an e-questionnaire and compared to student analysis as feedback forms. Results: Staff from six Primary Health Care Teams (n ¼ 23) stated that the student teams had offered solutions to improve the quality of patient care and on organisational systems. The positive value of the student work was confirmed by the course facilitators (n ¼ 8). In addition, practitioners were propelled to maintain high professional standards. Patients (n ¼ 23) recalled benefits directly attributable to the student work confirmed by the 434 student feedback forms. Conclusion: Undergraduate interprofessional student teams in mid-training can support and help practice teams, and this subsequently benefits patient care. This practice-based interprofessional learning model offers learning, which is theory-based, and supports positive student contributions. This learning fits today’s requirements for positive outcomes from education when mapped against the Kirkpatrick or the NHS (UK) education outcomes framework.

Introduction

Practice points

Healthcare curriculum have been criticised for failing to prepare tomorrow’s graduates for team-based patient-centred care (Ham 2008; World Health Organisation 2010; Moore 2012; Thistlethwaite 2012). The Lancet Commission has referred to today’s health and social care curricula as ‘‘outdated and static’’ (Frenk et al. 2010). The UK General Medical Council has reflected that students are not fully prepared for the transition into their first two years as junior doctors and have asked for undergraduate curriculum to include ‘‘student assistantships’’ for this purpose (General Medical Council 2009). Furthermore, learning must assure practitioners who are mindful of the patient experience and strive for high quality care (Department of Health 2013). The common assent is that students need training, which provides interprofessional practice closely aligned to their future working responsibilities that combines profession-specific competence with interprofessional competence (World Health Organisation 2010; Thistlethwaite 2012; Wilhelmsson et al. 2012). There is now growing evidence that IPE is producing students whose attitudes are better primed for interprofessional working (Zwarenstein et al. 2005; Hammick et al. 2007; Pollard & Miers 2008; Reeves et al. 2008, 2010). However,



 





Realist approaches to educational research can help us understand how educational input contributes to patient care. Interprofessional student teams in mid-training can help to analyse patient care in the community. Front-line practitioners can gain professionally from allowing interprofessional student teams to assess and analyse their patient management plans. Student interprofessional teams offer invaluable insights on how to advance patient care and change organisational structures. Further research, on the impact of interprofessional student team learning in practice areas, is required.

there are still many hurdles and challenges to implementing interprofessional learning (IPL) as the norm within health and social care clinical placements (Jackson & Bluteau 2007). Generally, students in clinical settings remain under the supervision of their own profession, allocated through systems that cannot compute which students are in a clinical area at any one time. As such, they learn in parallel often unaware of

Correspondence: Elizabeth Susan Anderson, PhD, University of Leicester, Medical and Social Care Education, 107, Princess Road East, Leicester LE1 7LA, United Kingdom. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/60495–504 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.890703

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Adapted Kirkpatrick Framework

The Educaon Outcomes Framework

Hammick et al 2007

Department of Health 2013

A method for appraising the outcomes of interprofessional educaonal intervenons in health and social care educaon

A method for measuring the quality of health and social care educaon on quality and safety for paents

1.

2a

2b

3

Learners’ views on the educaonal experience are posive.

Domain 1

Learners demonstrate a change in reciprocal atudes or percepons.

Domain 2.

Acquision of knowledge and skills

Learners gain new knowledge and understandings linked to interprofessional collaboraon.

Domain 3.

Behavioural change

Learners transfer IPL to their pracce seng.

Domain 4.

Reacon

Modificaon of atudes

Excellent Educaon

Competent and Capable staff

Flexible workforce recepve to research and innovaon

NHS Values and behaviours 4a

4b

Changes in organisaonal pracce

Learning supports wider changes in the organisaon and delivery of care.

Benefits to Paents

The learning advances improvements in health or wellbeing of paents.

Domain 5. Widening parcipaon

Commissioning educaon where learners have a good experience and the teaching is delivered in a safe environment for paent staff and learners. Educaon which ensures praconers with the skills and knowledge to do the job and work effecvely in a team.

Educaon which ensures praconer who can be responsive to change, use the best pracce to assure high quality care.

Praconers who understand human kindness, compassion and assure a good paent experience.

Opportunies for all to fully parcipate and be supported to reach their potenal valuing diversity posively.

Figure 1. Frameworks to understand educational inputs on patient and organisational outcomes.

each other and can make little collective impact on practice delivery and patient care. We could postulate that should students be primed to learn together, their impact might be extremely beneficial to clinical teams, especially at a time of stretched clinical resources. There is little understanding of how educational input, in this study we consider IPL, influences patient care and or organisational outcomes. Attempts have been made to consider the value of IPL against a modified Kirkpatrick learning outcomes framework and the Department of Health (UK) has recently published an educational outcomes framework, which incorporates interprofessional aspirations for education that can improve the quality of patient care (Figure 1) (Kirkpatrick 1967; Freeth et al. 2002; Department of Health 2013). However, to our knowledge, no undergraduate study has considered the highest levels of the Kirkpatrick model (Barr et al. 2005; Hammick et al. 2007; Carpenter & Dickinson 2008). Substantive evidence of the benefits of IPL to improve patient outcomes would ensure wider availability in healthcare curricula (Thistlethwaite 2012). Calls for more empirical research of IPE in this regard continue (Reeves et al. 2010). Integration of practice-based IPE remains limited internationally and rarely sustained with some notable exceptions such as the training 496

wards in Sweden, a model of student assistantship at its very best (Wilhelmsson et al. 2009). The Leicester Model of practice-based Interprofessional Education (LMIPE), underpinned by theory, was designed through educational research involving patients, practitioners and students and has been used in community and hospital areas (Lennox & Anderson 2007; Anderson & Lennox 2009; Anderson & Thorpe 2010). The model of collaborative learning is built on the Kolb learning cycle considering constructivist learning principles and reflection (Vygostsky 1978; Kolb 1984; Lennox & Anderson 2012). Students work alongside clinical teams and from this vantage point are allocated patients/service users1 and carers along their care pathway consented following ethical principles. The student teams are tasked with assessing the suitability of patient care offered by practitioners and agencies directly involved in order to prepare new solutions to the management plan. In some adaptations of the model, students assist in care while in others they analyse one aspect such as the discharge plan or the shared assessment (Anderson et al. 2010; Kinnair et al. 2012). The learning enables interprofessional student teams (n ¼ 2–4) to both experience and observe team working in action gaining insights into the realities of clinical practice.

Student groups improve patient care

Our research has begun to demonstrate that using this IPL model supports front-line practice and can advance the quality of service delivery (Lennox & Anderson 2012; Anderson & Thorpe 2010). In this study, we prospectively follow interprofessional student teams in mid-training using this IPL model to assess how learning contributes to patient and service outcomes where the model is used in inner city primary care.

Context of the study The learning was repeated in cycles to accommodate the student numbers, annually, from Spring through to Autumn. The students, in mid-training, were allocated to small teams, which included students from medicine, nursing, social work, pharmacy and speech and language therapy (S & LT). Cohorts of 24 were sent to one of six Primary Health Care Teams (PHCTs) in inner city areas where many patients experience socio-economic disadvantage. In this study, they were sub-divided into interprofessional teams of three to five students. The students were briefed prior to the course (a multi-professional introductory lecture and workbook distribution) and worked together for two days. Each site had facilitators (educators from academia or practice) to support the student teams. The facilitators had prepared the PHCT and consented the patients. The student team organised their own work visiting their patient-case at home and subsequently the professionals involved, unaccompanied, to analyse the care plan of a complex patient with comorbidities. The students presented their findings to the practice team and facilitators in an organised presentation session and they completed a written feedback form concerning

their case recommendations. The cycle of learning is shown in Figure 2.

Methods The exploratory qualitative study was underpinned by a realist approach to understand the social impact of IPL using this model (Sayer 1992; Carter & New 2004). This is because the study sought to understand ‘‘how’’ this IPL input impacted on patients and the PHCTs. In particular, we wished to listen to patients, practice staff and the facilitators, working alongside the students, to consider how the student learning had influenced them. The prospective study was conducted following IPE events from 2008 to 2010.

Sampling and data collection The study used purposeful sampling to include those who worked with the students; the patients, the PHCTs practitioners and the locality IPE facilitators (Silverman 2011). Patients were secondarily referred to the researcher by the local PHCT and received invitation letters. Practitioners and facilitators were approached (by the researcher L. N. T.) at PHCT meetings and invited to take part. In order to understand in more detail the impact of the educational input, the experiences of the participants were collected using one-to-one semi-structured audio-taped interviews or focus groups (audio-taped) (Table 1). As some busy practitioners wished to contribute, an e-questionnaire containing open questions was developed after the outcome of the first interviews. All patients completed home interviews (conducted in 2009), which focused on their participation in

1. Immersion into the patient/service users, carers and professional experiences. Students together experience the complexity of front-line practice

4. Become change agents through feedback Students present their insights to practitioners in the form of recommendations-verbally

Although students complete this cycle of learning for themselves and as team members, facilitators are available to help them reflect and analyse

2. Analysis relating professional perspectives, theories and policies Students make sense of their observations through reflection

3. Consider solutions to problems identified Students merge their uni professional assessments and make new interprofessional appraisals for enhancing patient outcomes

Figure 2.

The learning cycle of the Leicester model of practice-based interprofessional education.

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Table 1. Questions (topic guide).

Themes for interviews and focus groups and use in e-questionnaire (Questions adopted for conversations patients or practitioners)  Introduction * Is this the first time you have been involved with student’s education? Done anything like this before? * Why and how did you get involved? * What did you think you would achieve by getting involved? * Can you tell me about your role in the course? How did you find being involved?  Participation (costs and benefits) * Good and bad things associated with this involvement? Were there any problems you encountered? * Did you receive any feedback from the students about what they got out of it? If yes, did you like receiving feedback? If no, would you have liked feedback? * Do you know which students came to see you/worked with the PHCT?  Outcomes (so does anything change?) * Do you feel you gained anything personally (or as PHCT) from being involved? * Have there been any benefits to you (or your agency/PHCT) as a result of being involved with this course? * Have you faced any personal challenges as a result of being involved? Any personal concerns you may have about your involvement? * Were there any problems for you (or your agency, the PHCT) faced as a result of being involved? * Have you received any feedback from your doctor’s nurses or other professionals (or from the patient/carers) regarding their involvement with this course? * Have the students brought about any changes to your care (or issues you have dealt with to help patients)? Are you aware of any issues that could be followed up to make a difference to you (or your patients’ lives) as a result of student feedback on this course? * How do you hope these students will do things differently in the future, as a result being on this course? * Do you feel that combining practice with interprofessional education is worthwhile?  Other * Do you anticipate being involved again in the future? If so what support do you feel you would require? * Did you enjoy participating? * Anything else?

the teaching programme and what happened to them as a result of the students having worked with them. It was possible to compare the experiences of practitioners and patients to student learning outcomes in the form of their student team feedback forms for the PHCTs. These were photocopied and anonymised. With 6 PHCT’s each working with six student teams repeated in 10 annual cycles, there were a possible 360 forms in any one year (variable according to number of sites running and student numbers). The form had three sections: (i) student summary of key patient issues; (ii) a student ideal management plan; and (iii) three recommendations for addressing any identified unmet needs.

Data analysis The interviews and focus group data were transcribed into Microsoft Word and analysed by two researchers (L. N. T. and E. S. A) using inductive thematic analysis (Braun & Clarke 2006). The data were analysed with flexibility for patterns, and these findings were coded and themes agreed. Throughout the process, the researchers acknowledged their stance and enabled reflective dialogue to assure that the data were searched for responses that informed how students had impacted on practice. The data were triangulated during analysis to consider how different participants working alongside the students viewed their engagement (Hammersley & Atkinson 1983). The student written reports were analysed using content analysis selecting extracts where students claimed to offer new insights to change practice using as overarching codes the Kirkpatrick framework 4a and 4b (Joffe & Yardley 2004; Hammick et al. 2007). The analysis divided the patients into age ranges (children, mid-life and elderly). 498

Table 2. Study participants.

Study participants Patients Practice staff*

Data collection method One-to-one home interviews One-to-one interviews Focus group Questionnaires

Facilitators Students

One-to-one interviews Feedback forms

Number 23 7 (included a doctor or nurse from all six PHCTs) One large practice (with five participants) 15 (completed by practitioners from all PHCTs) 8 434

*The one-to-one interviews were from two General Practitioners [family doctors], three practice managers and one nursing sisters and one social worker. The focus group comprised staff from one practice of three family doctors, one practice nurse and one practice manager. The questionnaires were from seven family doctors, two practice managers, four practice nurses and two administrators/managers.

Ethical permission to engage practice staff, patients and student learning materials was obtained from COREC (Regional ethics committee 05/Q2502/104) 2005 as part of a long-term regional analysis of IPE.

Results From a possible 54 patients in 2009, 23 patients (43%) were able to host a home interview. Twenty-seven practice staff participated (from a possible 35 (77%)) and eight (66%) facilitators (from a possible n ¼ 12). The sample included staff from all six PHCTs. Only one practice met as a focus group as interviews or e-questionnaires were easier to organise (Table 2). From the student learning, a total of 641 forms were collected, but some were mislaid and 207 were

Student groups improve patient care

discounted from the research as they were incomplete leaving 434 (74%) for analysis. The dominant theme was that the student teams had helped to improve patient care and had influenced the PHCTs to consider organisational practice changes. In addition, the students had forced the practitioners to keep up to date in their practice. The themes and sub-themes are reported with supportive data extracts.

Practitioners (PHCT members) Themes from the practice staff confirmed that the student learning offered the potential to improve patient care for several reasons. Students’ home visits were timely and offered feedback and new data; they had spent time analysing the care packages and identified gaps or errors and had helped the staff to re-consider their actions and advance referral possibilities. Occasionally the information they bring we are not aware of which is quite fantastic . . . the patients tells the students what they have never told us, focus group extract. It’s an odd thing when you’ve got a patient who you’ve probably seen so many times and you feel you’re banging your head against a brick wall, because whatever you suggest, they don’t do, and then a fresh pair of eyes goes in [the students], and they discuss it with the patients, and things happen, practice manager. For ourselves we have definitely found problems with the care we were giving. The first was an elderly gentleman who had a stroke . . . and we had been told speech and language therapy were involved . . . it was only when we used that case [student IPE visit] we identified that . . . he wasn’t and it was a really important part of his rehabilitation, Family Doctor. The data across all sites showed how the student team working alongside the PHCT challenged the professionals to keep up to date. Two practitioners from different PHCTs stated the students were ‘‘Keeping us on our toes’’ (Doctor and Nurse). In this way, the students were forcing and assuring high professional standards. This was because the students questioned the practitioners and held them to account: Sometimes they give you a question, and it sort of like makes you think are we doing this, are we doing that? Then you think, I must do that in the future, focus group extract. Some people have rare conditions that you wouldn’t really bother about it, but because you have got to speak to a student group you have got to go and look it up and research, and it improves our outlook, focus group extract. I thought about aspects of care I don’t normally think about, Family Doctor. Over the years, the students had become welcomed because the practitioners perceived them as helpers.

The students had highlighted other networks and possibilities for different approaches to the patient’s problems. As a result, many PHCTs had made connections with local agencies for the first time because of the IPL. The practice staff often referred to the students as ‘‘a fresh pair of eyes’’ or as a conduit for thinking to be transferred from the family to the practice team. Yes, because I think students go into the patients’ homes and sometimes we don’t really need to go to some people’s homes, especially children. We have had feedback from the students that has highlighted a few points, focus group extract. Sometimes when the students come back they also tell us about the family situation down there, so it gives us an idea of the family situation when we talk to them . . . it gives us a bit more idea and a better picture, so it is quite beneficial, focus group extract. A frequent theme was the value of the group being interprofessional. They perceived how, for example, social worker students picked up unmet social needs and pharmacy students highlighted drug issues: The social workers, nurses etc that have gone in and had a look, they have had a different outlook on the whole opinion. It is good, questionnaire comment. its stuff like knowing that everything is being looked at from different angles, so that is quite pleasing isn’t it, focus group extract. Another sub-theme concerned how the student team could overcome barriers that existed in patients relationships with members of the PHCTs because as students they were less authoritative: We had one patient and the family did not want any input from external agencies. We sent in the students and had a positive outcome . . . , Family Doctor. Following the student engagement practitioners had noticed improvements in patient mood: Things like this often make them feel quite special, that they are being cherished, and that they have something that is valued nursing sister.

Facilitators The facilitator’s confirmed these findings and in addition they cited many individual cases relating to how students work had contributed to improving patient care (Figure 3). In particular, practical solutions to mobility and hygiene such as patient needs for referrals for wet rooms; elderly financial concerns resulting in welfare rights financial assessments; and child protection concerns, which resulted in the involvement of social services. They identified more themes relating to changes in organisation and the delivery of care such as non-attendance at hospital appointments; for example,

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Medical student speaks first Asks about how the paent monitors her blood sugar levels. Sasfied with the answer the paent demonstrates the use of the blood tesng home kit. The student then asks about compliance with medicaons and is sasfied. Student thinks all is OK.

Nursing student speaks next The student has been looking at the paent and has made an analysis that she may have problems in mobilising and asks, how do you get your food? What do you eat and cook? Slightly unconvinced by the answer she asks the paent to show them in the kitchen. She confirms that there is no fresh food in the house and that she really is not cooking sensible food for her condion as she cannot stand for long.

Social Work student follows Realises that the lack of compliance is all about her inability to cook and look aer herself and states that she could have help at home describing various types.

The student group Make a recommendaon that a District nurse and social worker should visit at home as there are real problems with her mobility. The lady had been seeing the pracce nurse for diabec monitoring and leg ulcer dressings; telling her many untruths. She was taken to the surgery by a friend. Outcome She subsequently had a social work assessment and home support. This improved her diabec control.

Figure 3. Facilitator case example summarised.

mothers with disabled children given appointments at unrealistic times, which was ultimately impacting on child care. These issues were fed back to the clinic. They endorsed that these insights had come because the learning was interprofessional. They perceived how the different knowledge base of each student assured a holistic patient assessment.

Patients The patients’ themes focussed on their enjoyment of the student home visit and how they had been concerned about their experiences within health and social care. They stated that the students had been knowledgeable with several identifying subsequent changes in their care, which they directly attributed to the student input: She [one of the female students] said to me is there anything you want in your life to make you feel better? I said I am trying to save up for a shower but every time I get it [money] it just goes. . . . A few weeks later Dr XX gave me a paper and said one of the students . . . said you were after a shower, so I have put in for one with social services . . . I had the 500

shower in four months, adult with chronic health problems. The patients listened to the student analysis of their concerns and considered the student solutions to their problems which had not previously been considered by their practitioners until after the student input: They brought my attention to one or two things . . . clubs for my daughter and things to do like activities . . . several mentioned support groups . . . In March this year I went to a support group that was of great benefit. A referral was made and I managed to get swimming lessons, mother of a disabled child. Some patients were not sure if the students had helped them; ‘‘I don’t know what they did behind my back to be honest’’, disabled gentleman. A dominant patient theme was a sense of wellbeing and increased confidence from talking through their problems and worries with the students. This was linked with patients feeling pleased to have helped the students in their training. Patients were aware that the students were learning interprofessionally and they endorsed this as being excellent.

Student groups improve patient care

Students’ management plans The student learning output, the feedback forms, identified the work the students had achieved, and the recommendations cover a wide range of possible care that could be offered to identify patient need (Table 3). The future recommendations for the child cases considered factors relating to the child’s needs, such as the need for S & LT inputs, to help language development and concern for the pressures on mothers caring for disabled children proposing counselling services. Of the mid-life cases, the students considered the impact of the health problems on their mental health and well being suggesting local support groups and the need for medical reviews of drugs or blood tests. Of the elderly patients, improvements to the quality of life were dominant including the need for modifications to their houses or new accommodation.

Discussion In this study, we listened to the views of professionals working in challenging inner city communities, their patients and facilitators involved in the Leicester Model of Interprofessional Education (LMIPE) to consider how this learning benefited patient care or service design. We had already perceived that students value this learning process to help them understand about patient-centred team working (Anderson & Lennox 2009), but, in this study, we focussed on higher learning outcomes for IPE considering how the learning influenced organisational change (level 4a) and benefitted patients (level 4b) (Figure 1). The data indicate impacts on healthcare systems, for example, internal referral reporting (level 4a) and to the quality of patient care (level 4b), for example, the right drugs and intervention. In a few situations, the student visits had been timely and identified issues of a more serious nature relating to patient safety, which resulted in immediate professional action. Advances in the quality of care were mediated through the student impact on the PHCT members who had been held to account for their practice which had ‘‘kept them on their toes’’ and in this way assured high quality care. The qualitative approach in this study has limitations because of the authors’ commitment to the LMIPE. The researchers worked to try and ensure a reflexive approach in making judgements concerning the themes. The data driven thematic analysis was detailed and nuanced. The triangulation of the rich data set, of patient, practitioner and facilitator perspectives compared to the student management plans, offered the opportunity to explore the experiences and reality of what actually took place. A smaller number of patients than anticipated completed the home-interviews, but with several patients, unwell the data set were considered during analysis and perceived to be saturated. Further work is required to illicit the way in which students work through the learning cycle together. The ability of students’ learning alongside practitioners to energise change in patient care or systems comes to some extent from the underpinning theoretical elements within the student learning cycle. The LMIPE, adapted from the Kolb learning cycle, has the potential to generate in-depth

assessment between different professional viewpoints within a collaborative learning process (Kolb 1984; Clarke 2006). The shared experience (concrete experience) of working with the patient and with practitioners leads to opportunities to look, think and reflect (reflective observation), sharing each other’s different professional perspectives, which leads to the re-framing and pooling of these perspectives (active conceptualization) towards higher competence analysis as new solutions are proposed (active experimentation). The new outputs to advance practice evolved because the students were from different professions. Indeed, all participants including the patients noticed that the students were different by their lines of questioning and approach. In essence, the learning outcomes, which impacts on practice, stem directly from the social learning process involving complex team discourse (Bleakley 2006). There are therefore values in enabling student interprofessional insights, which are broader than those identified solely from medical students when the course was first established in 1995–1998 (Lennox & Petersen 1998). The study shows how each student brought their own ‘‘cognitive’’ maps or profession-specific interpretive knowledge basis to the patient situation underpinned by their professional value bases (Petrie 1976; Drinka & Clarke 2000). It was possible for the facilitators to observe the new practice insights or solutions to identified problems being socially constructed knowledge elements following Piaget’s notion of ‘‘decentering’’, built up from the student interactions with each other, centrally the patient and practitioners and facilitators (Piaget 1973; von Glasersfeld 1997). The value of working together in small teams possibly brought comfort in numbers but it certainly brought a place for students to project their professional stance and then have to reflect again from within an interprofessional stance. Learning that one profession does it one way and another, a different way provided a platform for appreciating the value of interprofessional reflection (Wakerhausen 2009). Another key factor in gaining the high value learning outputs is the buy in of the professional practice teams who were in essence willing to have the students dissect their work. In this way, there was a culture of openness and the student work was valued, welcomed and openly received. By being part of the programme, they were being propelled by the students to engage in new-analysis of patient problems through reflection, and this often forced them to return to their knowledge base. The outcomes for them were helpful as they literally gave students ‘‘those cases they were stuck on’’. There was a realisation from the teams that in order to gain these new patient and service insights the students’ questions could be challenging often leaving practitioner’s feeling uncomfortable in the process. Students and the practice teams with the facilitators became a collective group engaged in collaborative learning, mediated through experiential learning (D’Eon 2005). In addition, the students had helped the practice team to create new social maps becoming linked to agencies in their community that they previously did not know existed creating a new community of learning and practice (Wenger 1998).

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Table 3. Student case feedback—Examples.

Type of case Child cases Child (disabled)

Child (down’s syndrome)

Child (attention disorder and learning difficulties) Child (down’s syndrome and global development delay) Child (developmental delay and hyperactivity) Child (physical disabilities)

Child (behavioural problems and epilepsy) Child (genetic disability and learning disability)

Adult cases Adult (alcohol misuse, anxiety and depression) Adult (type 2 diabetes) Adult (disabled—wheelchair user)

Adult (chronic ill-health—diabetes, pain management issues) Adult (bipolar disorder)

Adult (chronic pain) Adult (type 2 diabetes, cardiac failure and diverticulitis) Adult (prostate cancer)

Elderly cases Elderly (chronic ill-health—unable to leave home) Elderly (osteoarthritis and depression)

Elderly (chronic health problems and frailty—unable to leave home) Elderly (stroke)

Elderly (incontinence and mobility problems)

Elderly (chronic obstructive pulmonary disease)

Future management

Referrals to other agencies

Financial needs. Consider emotional support for carers and other children. Lack of stimulation for child—not accessing local playgroups. Concerns that child is not eating properly—highlighted by mother. Consider mother’s needs, and ability to cope.

Referrals (i) benefits offices—welfare rights for financial assessment. (ii) for respite for care. Integrate into local Sure Start (playgroup) activities.

Address mother’s concerns of lack of speech; requires hearing assessment? Stimulation and play not being addressed. PHCT to meet and discuss lack of integrated care package. Carers assessment required. Requires downstairs bathroom. Assess dental problems and link with diet and nutrition. Consider counselling and/or social support for older brother. Drug interactions and poor language development. Requires advocate to assess cultural barriers preventing access to local services. PHCT to look at why they are not accessing appropriate support services? Encourage patient to become active and engage in the community. PHCT need to consider health education and promotion especially around exercise. PHCT need increased awareness of support for disabled people. Requires review of medication, e.g. zopiclone. Students suggest reassessment as they suspect worsening of mobility issues. Support needs for wife and son not being considered. Consider why patient not leaving the house. Consider communication system between agencies. Depression? Concerns with family support. Blood test to check if anaemic. Concern not compliance with warfarin treatment and diabetes. Review follow-up as patient very ill and travelling long distances.

Suggest OT assessment to look at home safety. Reassessment of housing needs. Counselling. Chase slow response from social services for ‘‘meals on wheels’’. Discuss with patient appropriateness of staying in own home. Requires ongoing therapy from speech and language. Set up prescription home delivery. Respite care for carer. Consider suitability of housing. Referral for motorised wheelchair.

Elderly (cancer)

Requires portable nebuliser to go out. Help her to review suitable nursing homes as concerns for safety living alone. Consider nicotine patches to help quit smoking. Better communication required between agencies.

Elderly (chronic obstructive pulmonary disease and arthritis)

Stair-lift or alternative council housing required. Offer more services to get patient out of house.

502

Referral Referral Referral Referral

to to to to

support and/or counselling. voluntary groups and Sure Start. speech therapy. play therapy.

Referral to carer agency. Reassessment by primary health care team in a meeting with specialist health visitor. Referral to social services for reassessment of housing needs, and emotional support for family.

Requires medication review. Referral to speech and language therapy. Referral to welfare rights and benefits. Referral to caring for carers services.

Referral to local community and voluntary sector agencies. Referral for physical activity, e.g. gym referral. Family doctor to make a referral to exercise programme. Referral to centre for integrated living—voluntary sector provision. Referral to community physiotherapy and occupational therapy (OT). Social services reassessment. Referral to a community group where he can spend time away from family. Referral to local community project. Referral for psychological assessment. Referral to pain clinic. Referral for urgent assessment by district nurse.

Travel—help with transport. Local review. McMillan assessment. Referral to voluntary organisations for visiting at home, e.g. faith organisations Referral to social services. Referral to counselling. Referral to local befriending service.

Reassessment from social services. Financial benefits review required. Refer to welfare rights. Urgent incontinence nurse assessment. Referral to local services for getting patient out of the house. Referral to social services. Social Services referral for assessment of safety at home.

Referral for carer support (e.g. counselling) as patient terminal. Referral to local voluntary sector. Reassessment from social services.

Student groups improve patient care

Conclusion Innovation in curriculum design should offer interprofessional student teams opportunities to learn together alongside actual teams in a symbiotic manner (Barr & Low 2012). At a time when education has been asked to be directly linked to ‘‘learning improvements in patient care and health outcomes’’ (DOH 2013), we have shown that this workable model can do just that. We endorse this type of learning, which helps students embrace the realities of their future work and supports practitioners in developing realistic insights, understanding the complexity of team working while practising interprofessional skills (Lemieux-Charles & McGuire 2006; West et al. 2006; Ham 2008). A practice-based model like this offers interprofessional student assistantships, which support frontline practice, while advancing students insights into their future practice and are a way forward. Healthcare education leaders in the UK recently met to debate how best to prepare the workforce for practice, confirming that training should reflect the ‘‘roles’’ that students will adopt ‘‘as members of teams and across pathways’’. In affirming the place of IPL they stated, ‘‘training has got to be more than just a lot of separate silos of professionals with sets of skills and competencies that work OK in their box but not with everyone else’’ (Moore 2012).

Notes on contributors ELIZABETH SUSAN ANDERSON, PhD, is a Professor of Interprofessional education and patient safety lead in Leicester Medical School, UK. LUCY NICHOLA THORPE, is a reseach fellow who has worked in primary care research before exploring interprofessional education.

Declaration of interest: We report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

References Anderson ES, Lennox A. 2009. The Leicester model of interprofessional education: Developing, delivering and learning from student voices for 10 years. J Interprof Care 23(6):557–573. Anderson ES, Smith RS, Thorpe LN. 2010. Learning from lives together: Medical and social work students experiences of learning from disabled people in the community. Health Soc Care Community 18(3):229–240. Anderson ES, Thorpe LN. 2010. Learning together in practice – Evaluating the Leicester Model of Interprofessional Education in a hospital setting. Clin Teac 7:19–25. Barr H, Lowe H. 2012. Interprofessional education in pre-registration courses. A CAIPE guide for commissioners and regulators of education. Fareham: CAIPE. Barr J, Koppel I, Reeves S, Hammick M, Freeth D. 2005. Effective interprofessional education. Argument, assumption & evidence. Oxford: CAIPE, Blackwell Publishing. Bleakley A. 2006. Broadening conceptions of learning in medical education: The message from teamworking. Med Educ 40:150–157. Braun V, Clarke V. 2006. Using thematic analysis in psychology. Qual Res Psychol 3:77–101. Carpenter J, Dickinson H. 2008. Interprofessional education and training. Bristol: Community Care.

Carter B, New C. 2004. Making realism work: Realist social theory and empirical research. London: Routledge. Clarke PG. 2006. What would a theory of interprofessional education look like? Some suggestions for developing a theoretical framework for teamwork training. J Interprof Care 20(6):577–589. D’Eon M. 2005. A blueprint for interprofessional learning. J Interprof Care 19(Suppl 1):49–59. Department of Health(DOH). 2013. The education outcomes framework. Leeds: Department of Health, Education and Policy. Drinka TJK, Clarke PG. 2000. Health care teamwork: Interdisciplinary practice and teaching. Westport, CT: Auburn House/Greenwood. Freeth D, Hammick M, Koppell I, Reeves S, Barr H. 2002. A critical review of evaluations of interprofessional Education, CAIPE. London: LTSNCentre for Health Sciences and Practice. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, et al. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. A global Independent Commission. Lancet 376: 1923–1958. General Medical Council. 2009. Tomorrow’s Doctors. Outcomes and standards for undergraduate medical education. London: GMC. Ham C. 2008. Clinically integrated systems: The next step in English Health Reform? London: The Nuffield Trust, 2005. Hammersley M, Atkinson P. 1983. Ethnography: Principles in practice. 1st edn. London: Routledge. pp. 199. Hammick M, Freeth D, Koppel I, Reeves S, Barr H. 2007. A best evidence systematic review of interprofessional education. Med Teach 29(8):735–751. Jackson JA, Bluteau PAS. 2007. At first it’s like shifting sands: Setting up interprofessional learning within a secondary setting. J Interprof Care 21(3):251–353. Joffe H, Yardley L. 2004. Content and thematic analysis. In: Marks DF, Yardley L, editors. Research methods for clinical health psychology. London: Sage, pp 56–68. Kinnair D, Anderson ES, Thorpe LN. 2012. Development of interprofessional education in mental health practice: Adapting the Leicester Model. J Interprof Care 26:189–197. Kirkpatrick DI. 1967. Evaluation of training. In: Craig R, Bittel I, editors. Training and development handbook. New York: McGraw-Hill, pp 87–112. Kolb DA. 1984. Experiential learning. Englewood Cliffs, NJ: Prentice-Hall. Lemieux-Charles L, McGuire WL. 2006. What do we know about healthcare team effectiveness? A review of the literature. Med Care Res Rev 63: 263–300. Lennox A, Anderson ES. 2007. The Leicester Model of Interprofessional Education. A practical guide to Implementation in Health and Social Care Education. The Higher Education Academy for Medicine, Dentistry and Veterinary Medicine; Special Report 9. [Accessed January 2013] Available from http://www.medev.ac.uk/funding/61/ mini-projects/historical_funded/. Lennox A, Anderson ES. 2012. Delivering improvements in patient care: The application of the Leicester Model or Interprofessional Education. Qual Prim Care 20(3):219–226. Lennox A, Petersen S. 1998. Development and evaluation of community based, multi-agency course for medical students; descriptive study. BMJ 316:596–599. Moore A. 2012. Education: Round table – A lot to learn. Health Serv J (Suppl 6):21–26. Petrie HG. 1976. Do you see what I see? The epistemology of interdisciplinary inquiry. J Aesthet Educ 10:290–243. Piaget J. 1973. To understand is to invent. New York: Grossman. Pollard KC, Miers ME. 2008. From students to professionals: Results of a longitudinal study of attitudes to pre-qualifying collaborative learning and working in health and social care in the United Kingdom. J Interprof Care 22(4):399–416. Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Koppel I. 2008. Interprofessional education: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev 1:CD002213. doi: 10.1002/ 14651858. CD003313.pub2.

503

E. S. Anderson & L. N. Thorpe

Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Koppel I, Hammick M. 2010. The effectiveness of interprofessional education: Key findings from a new systematic review. J Interprof Care 24(3):230–241. Sayer A. 1992. Methods in social science: A realist approach. London: Routledge. Silverman D. 2011. Interpreting qualitative data. 4th ed. London: Sage. p. 388. Thistlethwaite J. 2012. Interprofessional education: a review of context, learning and the research agenda. Med Educ 46:58–70. Von Glasersfeld E. 1997. Homage to Jean Piaget (1896-1982). Ir J Psychol 18:293–306. Vygostsky LM. 1978. Mind in Society. Cambridge: Harvard University Press. Wakerhausen S. 2009. Collaboration, professional identify and reflection across boundaries. J Interprof Care 23(5):455–473. Wenger E. 1998. Communities of practice: Learning, meaning, and identity. Cambridge, England: Cambridge University Press.

504

West MA, Guthrie JP, Dawson JF, Borroll CS, Carter M. 2006. Reducing patient mortality in hospitals the role of human resource management. J Organ Behavi 27:983–1002. Wilhelmsson M, Pelling S, Ludvigsson J, Hammer J, Dahlgren L-O, Faresjo00 T. 2009. Twenty years experience of interprofessional education in Linko¨ping-ground breaking and sustainable. J Interprof Care 23: 121–133. Wilhelmsson M, Staffan P, Uhlin L, Dahlgren LO, Faresjo¨ T, Forslund K. 2012. How to think about interprofessional competence: A metacognitive model. J Interprof Care 26:85–91. World Health Organisation. 2010. Framework for action on interprofessional education and collaborative practice. Geneva: WHO. Zwarenstein M, Reeves S, Perrier L. 2005. Effectiveness of prelicensure interprofessional education and post-licensure collaborative interventions. J Interprof Care 19(Suppl 1):148–165.

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Students improve patient care and prepare for professional practice: an interprofessional community-based study.

We report on an education model that enables students to contribute to practice while experiencing the realities of complex team-working in the commun...
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