http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(6): 559–564 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.921899
ORIGINAL ARTICLE
The development of clinical reasoning and interprofessional behaviors: service-learning at a student-run free clinic Gretchen Seif1, Patty Coker-Bolt1, Sara Kraft1, Wanda Gonsalves2, Kit Simpson3 and Emily Johnson3 1
Department of Health Professions, Medical University of South Carolina, Charleston, SC, USA, 2Department of Family and Community Medicine, University of Kentucky College of Medicine, Louisville, KY, USA, and 3Department of Healthcare Leadership and Management, University of South Carolina, Charleston, SC, USA Abstract
Keywords
This article examines the benefits of a student run free clinic (SRFC) as a service learning experience for students in medicine, pharmacy, occupational therapy, physical therapy and physician assistant programs. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional health care teams and clinical reasoning skills compared to students who did not participate. Three assessments were administered to an experimental and control group of pre-clinical students from medical, occupational therapy, physical therapy, pharmacy and physician assistant programs before and after participation in an interprofessional service-learning course and volunteering at the SRFC. The tools were the Interdisciplinary Education Perception Scale (IEPS), Readiness for Interprofessional Learning Scale (RIPLS) and the Self-Assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course had improvements in interprofessional perceptions and attitudes (p ¼ 0.03) and perceptions of clinical reasoning skills when compared to the control group (p ¼ 0.002). This study is novel as it examined students’ perceptions of interprofessional attitudes and clinical reasoning following participation in an interprofessional service-learning course and participation in a SRFC.
Action research, education, interprofessional care
Introduction Community service has been a focus in health professions education for a number of years. However, the concept of service learning is relatively new. Service learning is defined as, ‘‘a structured learning experience that combines community service with explicit learning objectives, preparation and reflection’’ (Seifer, 1998, p. 274). Current Liaison Committee on Medical Education (LCME) accreditation standards for medical schools recommended ‘‘medical schools should make available sufficient opportunities for medical students to participate in servicelearning activities, and should encourage and support student participation’’ (LCME, 2013, p. 6). One of the most visible methods of service learning in health professions education is the development of student run-free medical clinics (SRFC). SRFCs, which began in the 1960s, have increased in number over the last decade (Meah, Smith, & Thomas, 2009). Currently, 49 medical schools now operate over 110 SRFCs in the United States (Meah et al., 2009). Through these clinics, underserved patients are able to receive care through the supervision of licensed professionals. The Community Aid, Relief, Education and Support Clinic (CARES) student-run free clinic (SRFC) is an example of an interprofessional service learning experience where students from
Correspondence: Gretchen Seif, Department of Health Professions, Medical University of South Carolina, Charleston, SC, USA. E-mail: [email protected]
History Received 6 October 2013 Revised 1 March 2014 Accepted 4 May 2014 Published online 27 May 2014
multiple professions and colleges work together to learn from each other while serving the community. Based at the Medical University of South Carolina, this service learning experience has provided a clinical experience to medical, occupational therapy (OT), physical therapy (PT), pharmacy and physician assistant (PA) students while providing health care to the uninsured population in the Charleston area and beyond. The CARES clinic has two sites. One clinic houses the medical, PA and pharmacy students and sees patients for their medical and pharmacological needs. Students examine, discuss and provide care for patients as a group with input from supervising licensed clinicians. The other clinic houses, the OT and PT students who see patients with rehabilitation needs under the supervision of licensed clinicians. The students enrolled in the service-learning course are divided into teams with representation from the various professions to discuss and present patient cases from the clinics. While there is little argument that SRFCs provide valuable care to uninsured individuals who may not otherwise have access to medical care; there are few studies examining the student learning associated with participation in these clinics. SRFCs offer students an opportunity to translate classroom learning directly to patient care in interprofessional teams much earlier in their educational program and prior to formal clinical experiences. This hands-on time with actual patients is essential for the development of clinical reasoning skills needed for entry-level practice (e.g. Cox, Irby, & Bowen, 2006; Kassirer, 2010; Scaffa & Smith, 2004; Scaffa & Wooster, 2004; Van Gessel, Nendaz, Vermeulen, Junod, & Vu, 2003).
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This type of learning experience allows students to demonstrate the decision-making process used by clinicians to determine the appropriate examination and treatment interventions critical for effective clinical practice. A search of current literature on SRFC identified very few studies which specifically examined changes in students’ clinical reasoning skills and even fewer studies which explored changes in interprofessional attitudes of students that provide hands on care of patients at these types of clinics (Reeves, Goldman, Burton, & Sawatzky-Girling, 2010; Remington, Foulk, & Williams, 2006; Sheu et al., 2011; Shrader, Thompson, & Gonsalves, 2010; Widyandana, Majoor, & Scherpbier, 2012). While there is a paucity of literature specifically examining student learning related to interprofessional attitudes and clinical reasoning in SRFC’s, there are European models. The interprofessional training wards are sites that allow pre-clinical medical, nursing, OT and PT students to work in interprofessional teams supervised by licensed practitioners in hospital wards with patients, a similar model to the CARES SRFC. The interprofessional training wards have demonstrated some positive changes in students in the areas of clinical reasoning and interprofessionalism (Freeth et al., 2001; Hylin et al., 2007; Jacobsen et al., 2009; Lidskog, Lo¨fmark, & Ahlstro¨m, 2009; Reeves & Freeth, 2002; Reeves et al., 2002). The purpose of this article is to examine the benefits of utilizing SRFCs as a service learning experience that not only improves access to patient care but also fosters positive interprofessional attitudes and enhances students’ clinical reasoning skills. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional healthcare teams and clinical reasoning skills in comparison to students who did not participate in an interprofessional service learning course and/or volunteer at a SRFC.
Methods Design This prospective cohort study used a non-randomized quasiexperimental pre- and post-test design for students assigned to experimental and control groups. Participants The experimental group consisted of pre-clinical PT, OT, PA, medical and pharmacy students. These students were enrolled in IP700 ‘‘Caring for the Community – A Service-Learning
Elective’’ and volunteered at the CARES clinic. The IP 700 is an interprofessional course that is offered during the spring and fall semesters. There are typically 50 students enrolled in the course each semester from the colleges of Medicine, Pharmacy and Health Professions (PT, OT and PA students). The participants meet weekly for various lectures, activities and clinical skills practice. Refer Table I for a listing of the course objectives for the course for both service learning and interprofessionalism. The program also provides two interprofessional clinics at different sites; the first clinic is a medical clinic off the main campus of the medical center, where patients are seen three days a week by medical, PA and pharmacy students. The second clinic is the PT and OT therapy clinic on the main campus of the medical center, where patients were seen one time a week. All students enrolled in the course are required to participate as student clinicians in the medical or therapy clinics at least four times or more during the semester long course. Licensed health care providers supervise student clinicians and provide mentorship and guidance during direct patient care visits. Student clinicians are expected to lead the patient care visits by reviewing the patient’s medical history, discuss an appropriate plan of care with the licensed heath care supervisor, provide the direct patient care and document all relevant information after the medical or therapy patient visit. The control group consisted of pre-clinical students from each academic program and the same year of study as students in the experimental group (PT, OT, PA, medicine and pharmacy). While distributing surveys to students in the control group in the spring 2012 semester, two different groupings of students for the control group were identified (n ¼ 232). One group consisted of students from OT, PT, pharmacy, medicine and PA programs that did not complete the IP 700 course, yet volunteered at the CARES Medical or Therapy Clinics. A second group consisted of students that did not participate in the program at all (either in course or by volunteering). The pre- and post-surveys were amended to allow students to indicate if they had no CARES experience or volunteered at the program. Data collection Students in both the experimental and control groups completed two interprofessional questionnaires and one clinical reasoning survey in the fall of 2011 and spring of 2012. All surveys were distributed and collected by the study investigators in paper format during regularly scheduled class time. Students from the experimental and control groups completed each survey at the beginning (pre) and end (post) of each semester (Figure 1).
Table I. Service learning and interprofessional learning objective from IP 700 course. IP 700 service learning course objectives Service learning
Interprofessional behaviors
Identify barriers to health care access. Identify barriers to closing the gap between prevailing and best practices. Map the process of care from a patient’s point of view for a clinical encounter. Identify available social services for the under and uninsured populations in the community. Describe common cultural barriers to health care in our community. Discuss racial and ethnic disparities in health care. Demonstrate an appreciation of patients’ needs and explore how these needs can be met. Describe why an interdisciplinary approach is necessary for continuous improvement in health care. Describe how an effective interdisciplinary team functions.
IP 700 clinical skills learning objectives Conduct a focused patient history and physical exam with guidance. Record pertinent information in a standard SOAP note format with guidance. Perform procedures appropriate to level of training (e.g. glucose check). Link clinic patient with the appropriate existing community resources. Demonstrate community needs as part of your continuous quality improvement project. Contribute to an interdisciplinary team effort to improve care. Display skill in communication and collaborative work with health professionals from other disciplines.
Clinical reasoning interprofessional behaviors
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Figure 1. Procedures for pre- and post-testing for experimental and control groups.
The surveys were coded for each participant in the experimental and control groups to assure confidentiality and allow matching of pre- and post-testing results. The following survey instruments were employed. First, the Interdisciplinary Education Perception Scale (IEPS) is an 18-item scale designed to measure student perception and attitudinal change following an experience. With six-point Likert scale responses, there are four factors: competence and autonomy, perceived need for cooperation, perceptions of actual cooperation and understanding others’ values. Internal consistency has been reported from r ¼ 0.51–0.87. The factors have a range in maximal possible scores from 72 to 96 and the maximum total score is 330 (Luecht, Madsen, Taugher, & Petterson, 1990; Page et al., 2009). Second, the Readiness for Interprofessional Learning Scale (RIPLS) is a 19-item questionnaire first reported by Parsell & Bligh (1999) that uses a five-point Likert-like scale (1 ¼ strongly disagree, 5 ¼ strongly agree) designed to measure attitudes toward interprofessional teams and readiness for IPE experiences. The measure consists of three subscales: teamwork and collaboration, professional identity and roles and responsibilities. It was subsequently found that the RIPLS was a valid tool for measuring interprofessional learning in the post-graduate student (Reid, Bruce, Allstaff, & McLernon, 2006). Third, the Self-Assessment of Clinical Reflection and Reasoning (SACRR) was originally developed by Royeen, Mu, Barrett, and Luebben (2001) based on theories generated by (Roth, 1989). This tool has 26 items rated on a five-point scale ranging from a 5, ‘‘strongly agree’’, to a 1, ‘‘strongly disagree’’ and can be used to assess students perceptions of teaching methods on their clinical reflection and reasoning (Coker, 2010; Scaffa & Wooster, 2004). The psychometric properties of the SACRR using Chronbach’s alpha demonstrate internal consistency scores of 0.87 pre-test and 0.92 for post-test (Musolino & Mostrom, 2005; Roth, 1989; Royeen et al., 2001). The Spearman rank order correlation coefficient for test–retest reliability is moderate with a score of 0.60 (Musolino & Mostrom, 2005; Roth, 1989; Royeen et al., 2001). Based on these psychometric properties, we believe that the SACRR is a valid and reliable tool. Although the SACRR has been primarily used in the occupational therapy literature the tool can be used with students in the health professions and has been tested on other student populations (Coker, 2010; Musolino & Mostrom, 2005; Royeen et al., 2001; Scaffa & Smith, 2004; Scaffa & Wooster, 2004). Data analysis The pre- and post-test data were collected anonymously, but coded so that the data could be paired by respondent. Data from two student surveys in the control group were discarded due to inability to obtain post-surveys. All three instruments use Likert scales to measure student responses. The distribution of the Likert-type responses for each question was examined for normality. Most questions on each survey met the normality assumption and individual question responses for the pre- and post-tests were therefore examined using paired t-tests. Questions with a non-normal distribution of responses were compared using
Table II. Participants in the experimental and control groups. OT PT Pharmacy Medicine PA Total Experimental CARES IP 700 class, 4 4 fall 2011 and spring 2012 Control Volunteered at 36 36 CARES Clinic NO time at CARES Clinic 6 21 Total 42 57
9
64
19
100
5
4
1
82
71 76
33 37
19 20
150 232
a Wilcoxon test. Responses were summed across the instruments. All summary responses were normally distributed and were therefore compared using a paired t-test. Ethical considerations The Medical University of South Carolina Institutional Review Board approved this study.
Results In the experimental group, 100 students who participated in the service learning IP 700 course and provided hands on patient care at the CARES clinic completed all pre- and post-surveys. These surveys were distributed before and after completion of the course. The majority of students in this group were medical and PA students who receive the majority of available spaces in the course. The specific allocation of space in the IP 700 course for each profession is impacted by the need for medicine and PA students to staff the medical clinic, who see patients three nights a week, in comparison to OT and PT students who see patients in the therapy clinic one night a week. In the control group, a total of 232 students completed both pre- and post-surveys which were distributed during program specific courses. The responses were more evenly distributed among OT, PT, pharmacy, medicine and PA students (Table II). An analysis of student survey responses in the control group found no statistically significant difference between students who volunteered at the clinics, but did not participate in the service learning CARES course and students that did not participate in either the service learning course or clinics (p ¼ 0.59). For this reason, all data collected from students in the control group was combined when comparing results to students in the experimental group. We found no statistically significant difference in pre- and post-test scores on the RIPLS for both experimental and control groups. However, there was a significant difference between preand post-test scores on the IEPS measure in the experimental group (p ¼ 0.03) and between group differences on the IEPS when analyzing the experimental and control group scores on this measure (p ¼ 0.0112; Table III). Both experimental and control groups of students show a statistically significant change in their perception of their own clinical reasoning skills based on pre- and post-test SACRR total scores (experimental group: p ¼ 0.03 and control group: p ¼ 0.08, Table III). However, the students in the
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Table III. Survey results for IEPS, RIPLS and SACRR.
IEPS overall Experimental group Control group RIPLS overall Experimental group Control group SACCR overall Experimental group Control group
Mean pre-test
SD
Mean post-test
SD
91.02 90.79 91.14 78.16 80.7 77.1 103.2 103.9 102.9
8.43 8.17 8.60 8.22 6.86 8.39 9.98 10.84 9.55
92.71 93.36 92.41 79.21 80.8 78.5 106.0 107.3 105.5
7.99 8.30 7.84 8.20 7.54 8.55 10.36 11.1 9.97
p Value within groups
p Value between groups p ¼ 0.0112a
p ¼ 0.03a p ¼ 0.113
p ¼ 0.1049 p ¼ 0.8190 p ¼ 0.0744
p ¼ 0.0008a
a
p ¼ 0.03 p ¼ 0.08a
Experimental group is students involved in IP 700 and CARES SRFC. Control group is students not involved in the IP 700 elective. a Denotes significance. Table IV. IEPS, RIPLS and SACRR questions with significant changes after student participation in the CARES course.
IEPS Individuals in my profession think highly of other related professions Individuals in my profession work well with each other RIPLS Shared learning will help me think positively about other health and social care professionals. Clinical problem solving can only be done effectively with students/ professional from my own school/organization. SACRR I don’t make judgments until I have sufficient data I think in terms of comparing and contrasting information about a client’s problems and proposed solutions to them. I look to frames of reference for planning my intervention strategy. When there is conflicting information about a clinical problem, I identify assumptions underlying the differing views. Regarding a proposed intervention strategy, I think, ‘‘What makes it work?’’
Mean pre-test
SD
Mean post-test
SD
p Value
4.69 5.00
0.99 0.87
5.0 5.23
0.81 0.70
p ¼ 0.02a p ¼ 0.04a
4.29
0.70
4.56
0.68
p ¼ 0.007a
1.51
0.66
1.74
0.70
p ¼ 0.03a
3.87 4.00
0.79 0.67
4.13 4.30
0.75 0.61
p ¼ 0.02a p ¼ 0.001a
3.99 3.69
0.69 0.76
4.18 3.99
0.64 0.75
p ¼ 0.04a p ¼ 0.006a
4.09
0.81
4.32
0.73
p ¼ 0.04a
a
Denotes significance.
experimental group who completed the service learning CARES course and volunteered at the CARES clinics showed a statistically significant change in their perception of their clinical reasoning skills when compared to the control group (p ¼ 0.002; Table III). There were several questions on each of the survey measures that demonstrated a statistical significance change between preand post-testing for students in the experimental group and students in the control group (Table IV).
Discussion This study examined both students’ interprofessional attitudes and behaviors and their perceptions of their own clinical reasoning skills following participation in an interprofessional service learning course and participation in a SRFC. Students that completed an interprofessional service learning course while also providing hands on patient care at a SRFC showed improvements in measures of interprofessional behavior and their perceptions of their clinical reasoning skills in comparison to peers who did not complete the course or volunteer in the SRFC. Student’s post-test scores in the experimental group were significantly greater than post-test scores of students in the control group and several specific questions from interprofessional attitudes and clinical reasoning surveys highlight the important relationship between interprofessional learning and development of team attitudes and clinical reasoning skills. We surmise that the differences in scores on IEPS and SACRR measures between the experimental and control groups are due to the participation in the service learning
course which incorporates hands on patient care followed by clinical reflections. The students are asked to complete five reflections with feedback from the instructor after an experience at the SRFC. Clinical reflection is an overall component of the clinical reasoning process and builds effective decision-making in medical and allied health students (Cox et al., 2006; Musolino & Mostrom, 2005; Roth, 1989; Royeen et al., 2001; Scaffa & Wooster, 2004; Van Gessel et al., 2003; Windish, 2000). Other studies examining interprofessional attitudes have shown that students who participate in case-based and experiential learning showed improvements in professional confidence and knowledge of their own professional roles following engagement with students in other professions (Jacobsen et al., 2009; Nørgaard et al., 2013; Wamsley et al., 2012). Students, who participated in interprofessional teams in the CARES course while providing patient care at a SRFC, demonstrated a statistically significant change on measures of clinical reasoning as well as interprofessional questions related to clinical reasoning. One question on the RIPLS related specifically to clinical reasoning is ‘‘clinical problem solving can only be done effectively with students/professional from my own school/ organization’’ and students in our experimental group showed significant change on this question after engaging with an interprofessional team providing direct patient care. This question demonstrates a possible link between the development of interprofessional behaviors and clinical reasoning which would be an important clinical outcome of interprofessional education. The results of the SACRR also demonstrate that an
DOI: 10.3109/13561820.2014.921899
interprofessional experiential learning experience with other health care professionals can not only improve interprofessional attitudes and behaviors, but also the students’ own perceptions of their clinical reasoning skills. Several previous studies have examined various experiential learning activities to develop the students’ clinical reasoning skills necessary for future patient care. A few have demonstrated improvements in students’ perceived changes in their clinical reasoning after working with actual patients (Coker, 2010; Scaffa & Smith, 2004; Scaffa & Wooster, 2004; Sheu et al., 2011). Furthermore, students involved in interprofessional clinical experiences had more independence in making clinical decisions and were better prepared for their role as future clinicians (Freeth et al., 2001; Reeves et al., 2002). These types of pre-clinical experiences have been shown to have a positive effect on students’ perceived clinical reasoning while on their first clinical rotation (Widyandana et al., 2012). The findings in these previous studies are similar to the findings in this current study. The results suggest that students that participated in a service learning experience at a SRFC had clinically significant changes in their perceptions of clinical reasoning on the SACRR. The study results also highlight the difficulty with using the current validated assessments for interprofessional behaviors and attitudes, the IEPS and the RIPLS. Institutions that are providing increased interprofessional educational opportunities may have students with very high pre-test scores at the start of an interprofessional educational program, making measurement of changes due to a specific interprofessional educational intervention difficult to find. Several studies have concluded that early exposure to interprofessional activities can lead to overall high scores on the IEPS or the RIPLS (Giordano, Umland, & Lyons, 2012; Hayashi et al., 2012; Hertweck et al., 2012; Wellmon, Gillin, Knauss, & Linn, 2012). Students at our institution begin interprofessional education at their program orientation prior to starting any instructional coursework and participate in several mandatory and elective interprofessional activities throughout their programs of study. Since our study results found no significant differences within both control and treatment group pre- and post-tests, we can surmise that the tools may not be sensitive enough to measure within group differences when students have had significant early exposure to interprofessional experiences. There is a need to develop a more sensitive measure of not only readiness for interprofessional learning, but also how students perceive interprofessional learning may change the way they will deliver care to future patients. There are several limitations to this study. There may have been a maturation effect overall; all students enrolled in this study were continuing to progress through their program of study and hopefully continuing to gain clinical reasoning skills and improve interprofessional attitudes. In addition, while these tools have been validated and used in various studies, they are tools of self-perception and only can show changes in what someone believes is their skill and are not truly measuring the skill themselves. There may also be self-selection bias as all the students in the experimental group that participated in the class and SRFC chose to do so voluntarily. In addition, due to the structure and enrollment of students in the course CARES class, a disproportionate amount of survey data was collected from medical and PA students versus OT and PT students, while survey data in the control group was more evenly distributed among all professions. Finally, as discussed, the interprofessional tools (IEPS and RIPLS) may have a ceiling effect in our population due to the emphasis and early exposure to interprofessional education at The Medical University of South Carolina.
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Concluding comments This study measured the changes in students’ perceptions of both clinical reasoning and interprofessional attitudes after participation as a member of an interprofessional team providing hands-on patient care at a SRFC. It builds on the body of knowledge on experiential learning and interprofessional education and highlights the importance of embedding service-learning components that merge community service at a SRFC with educational objectives and student self-reflection. Future studies should further focus on the measurement of not only interprofessional behaviors, but also other measures of clinical reasoning utilizing service learning pedagogy. There is a need for more long-term follow-up to see if interprofessional education is really having a positive impact on patient care through the focus on communication, teamwork and safety (Abu-Rish et al., 2012; Thibault, 2012). If the emphasis of interprofessional education is to truly improve communication, build effective teams and enhance communication between health care providers, future interprofessional assessment tools must be developed to measure these qualities in students participating in interprofessional educational initiatives.
Declaration of interest The authors report no conflicts of interest. The authors are responsible for the writing and content of this paper. This research was supported from an internal grant from the Medical University of South Carolina: Interprofessional Collaboration Grant Opportunity Pilot Project Program.
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ORIGINAL ARTICLE
The development of clinical reasoning and interprofessional behaviors: service-learning at a student-run free clinic Gretchen Seif1, Patty Coker-Bolt1, Sara Kraft1, Wanda Gonsalves2, Kit Simpson3 and Emily Johnson3 1
Department of Health Professions, Medical University of South Carolina, Charleston, SC, USA, 2Department of Family and Community Medicine, University of Kentucky College of Medicine, Louisville, KY, USA, and 3Department of Healthcare Leadership and Management, University of South Carolina, Charleston, SC, USA Abstract
Keywords
This article examines the benefits of a student run free clinic (SRFC) as a service learning experience for students in medicine, pharmacy, occupational therapy, physical therapy and physician assistant programs. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional health care teams and clinical reasoning skills compared to students who did not participate. Three assessments were administered to an experimental and control group of pre-clinical students from medical, occupational therapy, physical therapy, pharmacy and physician assistant programs before and after participation in an interprofessional service-learning course and volunteering at the SRFC. The tools were the Interdisciplinary Education Perception Scale (IEPS), Readiness for Interprofessional Learning Scale (RIPLS) and the Self-Assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course had improvements in interprofessional perceptions and attitudes (p ¼ 0.03) and perceptions of clinical reasoning skills when compared to the control group (p ¼ 0.002). This study is novel as it examined students’ perceptions of interprofessional attitudes and clinical reasoning following participation in an interprofessional service-learning course and participation in a SRFC.
Action research, education, interprofessional care
Introduction Community service has been a focus in health professions education for a number of years. However, the concept of service learning is relatively new. Service learning is defined as, ‘‘a structured learning experience that combines community service with explicit learning objectives, preparation and reflection’’ (Seifer, 1998, p. 274). Current Liaison Committee on Medical Education (LCME) accreditation standards for medical schools recommended ‘‘medical schools should make available sufficient opportunities for medical students to participate in servicelearning activities, and should encourage and support student participation’’ (LCME, 2013, p. 6). One of the most visible methods of service learning in health professions education is the development of student run-free medical clinics (SRFC). SRFCs, which began in the 1960s, have increased in number over the last decade (Meah, Smith, & Thomas, 2009). Currently, 49 medical schools now operate over 110 SRFCs in the United States (Meah et al., 2009). Through these clinics, underserved patients are able to receive care through the supervision of licensed professionals. The Community Aid, Relief, Education and Support Clinic (CARES) student-run free clinic (SRFC) is an example of an interprofessional service learning experience where students from
Correspondence: Gretchen Seif, Department of Health Professions, Medical University of South Carolina, Charleston, SC, USA. E-mail: [email protected]
History Received 6 October 2013 Revised 1 March 2014 Accepted 4 May 2014 Published online 27 May 2014
multiple professions and colleges work together to learn from each other while serving the community. Based at the Medical University of South Carolina, this service learning experience has provided a clinical experience to medical, occupational therapy (OT), physical therapy (PT), pharmacy and physician assistant (PA) students while providing health care to the uninsured population in the Charleston area and beyond. The CARES clinic has two sites. One clinic houses the medical, PA and pharmacy students and sees patients for their medical and pharmacological needs. Students examine, discuss and provide care for patients as a group with input from supervising licensed clinicians. The other clinic houses, the OT and PT students who see patients with rehabilitation needs under the supervision of licensed clinicians. The students enrolled in the service-learning course are divided into teams with representation from the various professions to discuss and present patient cases from the clinics. While there is little argument that SRFCs provide valuable care to uninsured individuals who may not otherwise have access to medical care; there are few studies examining the student learning associated with participation in these clinics. SRFCs offer students an opportunity to translate classroom learning directly to patient care in interprofessional teams much earlier in their educational program and prior to formal clinical experiences. This hands-on time with actual patients is essential for the development of clinical reasoning skills needed for entry-level practice (e.g. Cox, Irby, & Bowen, 2006; Kassirer, 2010; Scaffa & Smith, 2004; Scaffa & Wooster, 2004; Van Gessel, Nendaz, Vermeulen, Junod, & Vu, 2003).
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This type of learning experience allows students to demonstrate the decision-making process used by clinicians to determine the appropriate examination and treatment interventions critical for effective clinical practice. A search of current literature on SRFC identified very few studies which specifically examined changes in students’ clinical reasoning skills and even fewer studies which explored changes in interprofessional attitudes of students that provide hands on care of patients at these types of clinics (Reeves, Goldman, Burton, & Sawatzky-Girling, 2010; Remington, Foulk, & Williams, 2006; Sheu et al., 2011; Shrader, Thompson, & Gonsalves, 2010; Widyandana, Majoor, & Scherpbier, 2012). While there is a paucity of literature specifically examining student learning related to interprofessional attitudes and clinical reasoning in SRFC’s, there are European models. The interprofessional training wards are sites that allow pre-clinical medical, nursing, OT and PT students to work in interprofessional teams supervised by licensed practitioners in hospital wards with patients, a similar model to the CARES SRFC. The interprofessional training wards have demonstrated some positive changes in students in the areas of clinical reasoning and interprofessionalism (Freeth et al., 2001; Hylin et al., 2007; Jacobsen et al., 2009; Lidskog, Lo¨fmark, & Ahlstro¨m, 2009; Reeves & Freeth, 2002; Reeves et al., 2002). The purpose of this article is to examine the benefits of utilizing SRFCs as a service learning experience that not only improves access to patient care but also fosters positive interprofessional attitudes and enhances students’ clinical reasoning skills. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional healthcare teams and clinical reasoning skills in comparison to students who did not participate in an interprofessional service learning course and/or volunteer at a SRFC.
Methods Design This prospective cohort study used a non-randomized quasiexperimental pre- and post-test design for students assigned to experimental and control groups. Participants The experimental group consisted of pre-clinical PT, OT, PA, medical and pharmacy students. These students were enrolled in IP700 ‘‘Caring for the Community – A Service-Learning
Elective’’ and volunteered at the CARES clinic. The IP 700 is an interprofessional course that is offered during the spring and fall semesters. There are typically 50 students enrolled in the course each semester from the colleges of Medicine, Pharmacy and Health Professions (PT, OT and PA students). The participants meet weekly for various lectures, activities and clinical skills practice. Refer Table I for a listing of the course objectives for the course for both service learning and interprofessionalism. The program also provides two interprofessional clinics at different sites; the first clinic is a medical clinic off the main campus of the medical center, where patients are seen three days a week by medical, PA and pharmacy students. The second clinic is the PT and OT therapy clinic on the main campus of the medical center, where patients were seen one time a week. All students enrolled in the course are required to participate as student clinicians in the medical or therapy clinics at least four times or more during the semester long course. Licensed health care providers supervise student clinicians and provide mentorship and guidance during direct patient care visits. Student clinicians are expected to lead the patient care visits by reviewing the patient’s medical history, discuss an appropriate plan of care with the licensed heath care supervisor, provide the direct patient care and document all relevant information after the medical or therapy patient visit. The control group consisted of pre-clinical students from each academic program and the same year of study as students in the experimental group (PT, OT, PA, medicine and pharmacy). While distributing surveys to students in the control group in the spring 2012 semester, two different groupings of students for the control group were identified (n ¼ 232). One group consisted of students from OT, PT, pharmacy, medicine and PA programs that did not complete the IP 700 course, yet volunteered at the CARES Medical or Therapy Clinics. A second group consisted of students that did not participate in the program at all (either in course or by volunteering). The pre- and post-surveys were amended to allow students to indicate if they had no CARES experience or volunteered at the program. Data collection Students in both the experimental and control groups completed two interprofessional questionnaires and one clinical reasoning survey in the fall of 2011 and spring of 2012. All surveys were distributed and collected by the study investigators in paper format during regularly scheduled class time. Students from the experimental and control groups completed each survey at the beginning (pre) and end (post) of each semester (Figure 1).
Table I. Service learning and interprofessional learning objective from IP 700 course. IP 700 service learning course objectives Service learning
Interprofessional behaviors
Identify barriers to health care access. Identify barriers to closing the gap between prevailing and best practices. Map the process of care from a patient’s point of view for a clinical encounter. Identify available social services for the under and uninsured populations in the community. Describe common cultural barriers to health care in our community. Discuss racial and ethnic disparities in health care. Demonstrate an appreciation of patients’ needs and explore how these needs can be met. Describe why an interdisciplinary approach is necessary for continuous improvement in health care. Describe how an effective interdisciplinary team functions.
IP 700 clinical skills learning objectives Conduct a focused patient history and physical exam with guidance. Record pertinent information in a standard SOAP note format with guidance. Perform procedures appropriate to level of training (e.g. glucose check). Link clinic patient with the appropriate existing community resources. Demonstrate community needs as part of your continuous quality improvement project. Contribute to an interdisciplinary team effort to improve care. Display skill in communication and collaborative work with health professionals from other disciplines.
Clinical reasoning interprofessional behaviors
DOI: 10.3109/13561820.2014.921899
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Figure 1. Procedures for pre- and post-testing for experimental and control groups.
The surveys were coded for each participant in the experimental and control groups to assure confidentiality and allow matching of pre- and post-testing results. The following survey instruments were employed. First, the Interdisciplinary Education Perception Scale (IEPS) is an 18-item scale designed to measure student perception and attitudinal change following an experience. With six-point Likert scale responses, there are four factors: competence and autonomy, perceived need for cooperation, perceptions of actual cooperation and understanding others’ values. Internal consistency has been reported from r ¼ 0.51–0.87. The factors have a range in maximal possible scores from 72 to 96 and the maximum total score is 330 (Luecht, Madsen, Taugher, & Petterson, 1990; Page et al., 2009). Second, the Readiness for Interprofessional Learning Scale (RIPLS) is a 19-item questionnaire first reported by Parsell & Bligh (1999) that uses a five-point Likert-like scale (1 ¼ strongly disagree, 5 ¼ strongly agree) designed to measure attitudes toward interprofessional teams and readiness for IPE experiences. The measure consists of three subscales: teamwork and collaboration, professional identity and roles and responsibilities. It was subsequently found that the RIPLS was a valid tool for measuring interprofessional learning in the post-graduate student (Reid, Bruce, Allstaff, & McLernon, 2006). Third, the Self-Assessment of Clinical Reflection and Reasoning (SACRR) was originally developed by Royeen, Mu, Barrett, and Luebben (2001) based on theories generated by (Roth, 1989). This tool has 26 items rated on a five-point scale ranging from a 5, ‘‘strongly agree’’, to a 1, ‘‘strongly disagree’’ and can be used to assess students perceptions of teaching methods on their clinical reflection and reasoning (Coker, 2010; Scaffa & Wooster, 2004). The psychometric properties of the SACRR using Chronbach’s alpha demonstrate internal consistency scores of 0.87 pre-test and 0.92 for post-test (Musolino & Mostrom, 2005; Roth, 1989; Royeen et al., 2001). The Spearman rank order correlation coefficient for test–retest reliability is moderate with a score of 0.60 (Musolino & Mostrom, 2005; Roth, 1989; Royeen et al., 2001). Based on these psychometric properties, we believe that the SACRR is a valid and reliable tool. Although the SACRR has been primarily used in the occupational therapy literature the tool can be used with students in the health professions and has been tested on other student populations (Coker, 2010; Musolino & Mostrom, 2005; Royeen et al., 2001; Scaffa & Smith, 2004; Scaffa & Wooster, 2004). Data analysis The pre- and post-test data were collected anonymously, but coded so that the data could be paired by respondent. Data from two student surveys in the control group were discarded due to inability to obtain post-surveys. All three instruments use Likert scales to measure student responses. The distribution of the Likert-type responses for each question was examined for normality. Most questions on each survey met the normality assumption and individual question responses for the pre- and post-tests were therefore examined using paired t-tests. Questions with a non-normal distribution of responses were compared using
Table II. Participants in the experimental and control groups. OT PT Pharmacy Medicine PA Total Experimental CARES IP 700 class, 4 4 fall 2011 and spring 2012 Control Volunteered at 36 36 CARES Clinic NO time at CARES Clinic 6 21 Total 42 57
9
64
19
100
5
4
1
82
71 76
33 37
19 20
150 232
a Wilcoxon test. Responses were summed across the instruments. All summary responses were normally distributed and were therefore compared using a paired t-test. Ethical considerations The Medical University of South Carolina Institutional Review Board approved this study.
Results In the experimental group, 100 students who participated in the service learning IP 700 course and provided hands on patient care at the CARES clinic completed all pre- and post-surveys. These surveys were distributed before and after completion of the course. The majority of students in this group were medical and PA students who receive the majority of available spaces in the course. The specific allocation of space in the IP 700 course for each profession is impacted by the need for medicine and PA students to staff the medical clinic, who see patients three nights a week, in comparison to OT and PT students who see patients in the therapy clinic one night a week. In the control group, a total of 232 students completed both pre- and post-surveys which were distributed during program specific courses. The responses were more evenly distributed among OT, PT, pharmacy, medicine and PA students (Table II). An analysis of student survey responses in the control group found no statistically significant difference between students who volunteered at the clinics, but did not participate in the service learning CARES course and students that did not participate in either the service learning course or clinics (p ¼ 0.59). For this reason, all data collected from students in the control group was combined when comparing results to students in the experimental group. We found no statistically significant difference in pre- and post-test scores on the RIPLS for both experimental and control groups. However, there was a significant difference between preand post-test scores on the IEPS measure in the experimental group (p ¼ 0.03) and between group differences on the IEPS when analyzing the experimental and control group scores on this measure (p ¼ 0.0112; Table III). Both experimental and control groups of students show a statistically significant change in their perception of their own clinical reasoning skills based on pre- and post-test SACRR total scores (experimental group: p ¼ 0.03 and control group: p ¼ 0.08, Table III). However, the students in the
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Table III. Survey results for IEPS, RIPLS and SACRR.
IEPS overall Experimental group Control group RIPLS overall Experimental group Control group SACCR overall Experimental group Control group
Mean pre-test
SD
Mean post-test
SD
91.02 90.79 91.14 78.16 80.7 77.1 103.2 103.9 102.9
8.43 8.17 8.60 8.22 6.86 8.39 9.98 10.84 9.55
92.71 93.36 92.41 79.21 80.8 78.5 106.0 107.3 105.5
7.99 8.30 7.84 8.20 7.54 8.55 10.36 11.1 9.97
p Value within groups
p Value between groups p ¼ 0.0112a
p ¼ 0.03a p ¼ 0.113
p ¼ 0.1049 p ¼ 0.8190 p ¼ 0.0744
p ¼ 0.0008a
a
p ¼ 0.03 p ¼ 0.08a
Experimental group is students involved in IP 700 and CARES SRFC. Control group is students not involved in the IP 700 elective. a Denotes significance. Table IV. IEPS, RIPLS and SACRR questions with significant changes after student participation in the CARES course.
IEPS Individuals in my profession think highly of other related professions Individuals in my profession work well with each other RIPLS Shared learning will help me think positively about other health and social care professionals. Clinical problem solving can only be done effectively with students/ professional from my own school/organization. SACRR I don’t make judgments until I have sufficient data I think in terms of comparing and contrasting information about a client’s problems and proposed solutions to them. I look to frames of reference for planning my intervention strategy. When there is conflicting information about a clinical problem, I identify assumptions underlying the differing views. Regarding a proposed intervention strategy, I think, ‘‘What makes it work?’’
Mean pre-test
SD
Mean post-test
SD
p Value
4.69 5.00
0.99 0.87
5.0 5.23
0.81 0.70
p ¼ 0.02a p ¼ 0.04a
4.29
0.70
4.56
0.68
p ¼ 0.007a
1.51
0.66
1.74
0.70
p ¼ 0.03a
3.87 4.00
0.79 0.67
4.13 4.30
0.75 0.61
p ¼ 0.02a p ¼ 0.001a
3.99 3.69
0.69 0.76
4.18 3.99
0.64 0.75
p ¼ 0.04a p ¼ 0.006a
4.09
0.81
4.32
0.73
p ¼ 0.04a
a
Denotes significance.
experimental group who completed the service learning CARES course and volunteered at the CARES clinics showed a statistically significant change in their perception of their clinical reasoning skills when compared to the control group (p ¼ 0.002; Table III). There were several questions on each of the survey measures that demonstrated a statistical significance change between preand post-testing for students in the experimental group and students in the control group (Table IV).
Discussion This study examined both students’ interprofessional attitudes and behaviors and their perceptions of their own clinical reasoning skills following participation in an interprofessional service learning course and participation in a SRFC. Students that completed an interprofessional service learning course while also providing hands on patient care at a SRFC showed improvements in measures of interprofessional behavior and their perceptions of their clinical reasoning skills in comparison to peers who did not complete the course or volunteer in the SRFC. Student’s post-test scores in the experimental group were significantly greater than post-test scores of students in the control group and several specific questions from interprofessional attitudes and clinical reasoning surveys highlight the important relationship between interprofessional learning and development of team attitudes and clinical reasoning skills. We surmise that the differences in scores on IEPS and SACRR measures between the experimental and control groups are due to the participation in the service learning
course which incorporates hands on patient care followed by clinical reflections. The students are asked to complete five reflections with feedback from the instructor after an experience at the SRFC. Clinical reflection is an overall component of the clinical reasoning process and builds effective decision-making in medical and allied health students (Cox et al., 2006; Musolino & Mostrom, 2005; Roth, 1989; Royeen et al., 2001; Scaffa & Wooster, 2004; Van Gessel et al., 2003; Windish, 2000). Other studies examining interprofessional attitudes have shown that students who participate in case-based and experiential learning showed improvements in professional confidence and knowledge of their own professional roles following engagement with students in other professions (Jacobsen et al., 2009; Nørgaard et al., 2013; Wamsley et al., 2012). Students, who participated in interprofessional teams in the CARES course while providing patient care at a SRFC, demonstrated a statistically significant change on measures of clinical reasoning as well as interprofessional questions related to clinical reasoning. One question on the RIPLS related specifically to clinical reasoning is ‘‘clinical problem solving can only be done effectively with students/professional from my own school/ organization’’ and students in our experimental group showed significant change on this question after engaging with an interprofessional team providing direct patient care. This question demonstrates a possible link between the development of interprofessional behaviors and clinical reasoning which would be an important clinical outcome of interprofessional education. The results of the SACRR also demonstrate that an
DOI: 10.3109/13561820.2014.921899
interprofessional experiential learning experience with other health care professionals can not only improve interprofessional attitudes and behaviors, but also the students’ own perceptions of their clinical reasoning skills. Several previous studies have examined various experiential learning activities to develop the students’ clinical reasoning skills necessary for future patient care. A few have demonstrated improvements in students’ perceived changes in their clinical reasoning after working with actual patients (Coker, 2010; Scaffa & Smith, 2004; Scaffa & Wooster, 2004; Sheu et al., 2011). Furthermore, students involved in interprofessional clinical experiences had more independence in making clinical decisions and were better prepared for their role as future clinicians (Freeth et al., 2001; Reeves et al., 2002). These types of pre-clinical experiences have been shown to have a positive effect on students’ perceived clinical reasoning while on their first clinical rotation (Widyandana et al., 2012). The findings in these previous studies are similar to the findings in this current study. The results suggest that students that participated in a service learning experience at a SRFC had clinically significant changes in their perceptions of clinical reasoning on the SACRR. The study results also highlight the difficulty with using the current validated assessments for interprofessional behaviors and attitudes, the IEPS and the RIPLS. Institutions that are providing increased interprofessional educational opportunities may have students with very high pre-test scores at the start of an interprofessional educational program, making measurement of changes due to a specific interprofessional educational intervention difficult to find. Several studies have concluded that early exposure to interprofessional activities can lead to overall high scores on the IEPS or the RIPLS (Giordano, Umland, & Lyons, 2012; Hayashi et al., 2012; Hertweck et al., 2012; Wellmon, Gillin, Knauss, & Linn, 2012). Students at our institution begin interprofessional education at their program orientation prior to starting any instructional coursework and participate in several mandatory and elective interprofessional activities throughout their programs of study. Since our study results found no significant differences within both control and treatment group pre- and post-tests, we can surmise that the tools may not be sensitive enough to measure within group differences when students have had significant early exposure to interprofessional experiences. There is a need to develop a more sensitive measure of not only readiness for interprofessional learning, but also how students perceive interprofessional learning may change the way they will deliver care to future patients. There are several limitations to this study. There may have been a maturation effect overall; all students enrolled in this study were continuing to progress through their program of study and hopefully continuing to gain clinical reasoning skills and improve interprofessional attitudes. In addition, while these tools have been validated and used in various studies, they are tools of self-perception and only can show changes in what someone believes is their skill and are not truly measuring the skill themselves. There may also be self-selection bias as all the students in the experimental group that participated in the class and SRFC chose to do so voluntarily. In addition, due to the structure and enrollment of students in the course CARES class, a disproportionate amount of survey data was collected from medical and PA students versus OT and PT students, while survey data in the control group was more evenly distributed among all professions. Finally, as discussed, the interprofessional tools (IEPS and RIPLS) may have a ceiling effect in our population due to the emphasis and early exposure to interprofessional education at The Medical University of South Carolina.
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Concluding comments This study measured the changes in students’ perceptions of both clinical reasoning and interprofessional attitudes after participation as a member of an interprofessional team providing hands-on patient care at a SRFC. It builds on the body of knowledge on experiential learning and interprofessional education and highlights the importance of embedding service-learning components that merge community service at a SRFC with educational objectives and student self-reflection. Future studies should further focus on the measurement of not only interprofessional behaviors, but also other measures of clinical reasoning utilizing service learning pedagogy. There is a need for more long-term follow-up to see if interprofessional education is really having a positive impact on patient care through the focus on communication, teamwork and safety (Abu-Rish et al., 2012; Thibault, 2012). If the emphasis of interprofessional education is to truly improve communication, build effective teams and enhance communication between health care providers, future interprofessional assessment tools must be developed to measure these qualities in students participating in interprofessional educational initiatives.
Declaration of interest The authors report no conflicts of interest. The authors are responsible for the writing and content of this paper. This research was supported from an internal grant from the Medical University of South Carolina: Interprofessional Collaboration Grant Opportunity Pilot Project Program.
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