http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(5): 413–418 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.907779
ORIGINAL ARTICLE
The student-run free clinic: an ideal site to teach interprofessional education? Brian Sick1, Lisa Sheldon2, Katy Ajer3, Qi Wang4 and Lei Zhang5 1
Internal Medicine, University of Minnesota, Minneapolis, MN, USA, 2Park Nicollet Health Services, St. Louis Park, MN, USA, 3HealthEast Care System, Bethesda Hospital, St. Paul, MN, USA, 4Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA, and 5Biostatistics Design and Analysis Center, University of Minnesota, Minneapolis, MN, USA Abstract
Keywords
Student-run free clinics (SRFCs) often include an interprofessional group of health professions students and preceptors working together toward the common goal of caring for underserved populations. Therefore, it would seem that these clinics would be an ideal place for students to participate in an interprofessional collaborative practice and for interprofessional education to occur. This article describes a prospective, observational cohort study of interprofessional attitudes and skills including communication and teamwork skills and attitudes about interprofessional learning, relationships and interactions of student volunteers in a SRFC compared to students who applied and were not accepted to the clinic and to students who never applied to the clinic. This study showed a decrease in attitudes and skills after the first year for all groups. Over the next two years, the total score on the survey for the accepted students was higher than the not accepted students. The students who were not accepted also became more similar to students who never applied. This suggests a protective effect against declining interprofessional attitudes and skills for the student volunteers in a SRFC. These findings are likely a function of the design of the clinical and educational experience in the clinic and of the length of contact the students have with other professions.
Interprofessional care, interprofessional education, student-run free clinic, surveys, underserved, volunteerism
Introduction It is generally recognized that health professions students need to learn in interprofessional environments to be ready for their future work as healthcare providers in an interprofessional collaborative practice (D’Amour & Oandasan, 2005; Institute of Medicine, 1972; World Health Organization, 2010). Schools often struggle finding locations in which their students can experience a seamless linkage between interprofessional education and practice. Student-run free clinics (SRFCs) can provide just this type of connection. They often include volunteer students from multiple health professions providing health care under the supervision and tutelage of volunteer faculty. Therefore, SRFCs should be an ideal place for students to participate in an interprofessional collaborative practice and for interprofessional education to occur. Although there are many descriptions of student-run clinics with interprofessional models of care and education (Beck, 2005; Clark, Melillo, Wallace, Pierrel, & Buck, 2003; Collins, 1995; Jimenez et al., 2008; Moskowitz, Glasco, Johnson, & Wong, 2006; Pi, 1995; Simpson & Long, 2007; Yap & Thorton, 1995), very few have reported their learners’ outcomes (Holmqvist, Courtney, Meili, & Dick, 2012). In a study of interprofessional student teams who delivered geriatric care through a service
Correspondence: Dr. Brian Sick, MD, Internal Medicine, University of Minnesota, 420 Delaware Str SE, MMC 741, Minneapolis, MN 55455, USA. E-mail: [email protected]
History Received 11 September 2013 Revised 17 January 2014 Accepted 20 March 2014 Published online 21 April 2014
learning model in Idaho, learners reported improvements in their professional competence and autonomy, their cooperation and resource sharing within and across professions and their understanding of the value and contribution of other professionals (Neill, Hayward, & Peterson, 2007). A study by Sheu et al. (2010), which evaluated students in medicine, nursing and pharmacy who completed a didactic hepatitis B elective with or without optional participation in a student-run clinic, no group differences were found for learners’ comfort level in working as teams or in partnership with students from other health professions in a clinical setting. A study by Gilkey and Earp (2006) showed that simply putting health professional students together in an interdisciplinary student-run clinic was not enough for successful interdisciplinary training; rather they posited that careful attention must also be paid to the social environment, which includes: frequent participation, training on interdisciplinary collaboration, time and space for effective sharing of patient information, cross-disciplinary networking and reflection. To our knowledge, there are no published studies of the longitudinal impact of SRFCs on interprofessional attitudes and skills of health professions students. We report our findings from a prospective, observational cohort study in which we assessed the interprofessional attitudes and skills of firstand second-year health professions students over the course of their two years volunteering in a SRFC. Changes in these students’ outcomes were compared with those students who applied but were not accepted to the clinic and students who did not apply.
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Methods Setting The Phillips Neighborhood Clinic (PNC) is a SRFC located in one of the poorest neighborhoods of Minneapolis, MN, with a dual mission of caring for underserved patients and education of health professions students. The PNC is open twice a week in the basement of a church as a first-come, first-served walk-in clinic. Care is provided by students from the University of Minnesota Schools of Medicine, Nursing, Pharmacy, Physical Therapy, Public Health and Social Work. Patient visits are conducted in interprofessional teams of students who see the patients as a group with pre- and post-visit huddles. Students are supervised by volunteer preceptors from the various health professions. Patient services include free medications, laboratories, acute and chronic care medical visits, physical therapy visits, mental health counseling, nutrition counseling, health education and foot care. Clinic operations are funded by grants, donations and fundraising. Technical and administrative support is provided by the University of Minnesota. In September of their first year of education, about 220 students from the aforementioned schools apply for approximately 160 positions in the clinic. After filling out an application and participating in an interview, students who are accepted agree to a two-year commitment as a clinic volunteer. While some students from smaller schools, such as social work or nursing, or with high-need skills, such as the ability to speak Spanish, are accepted unless there is a concern about their application, most students are chosen by the students on the board who make selections based on how closely students exemplify the missions of the clinic. PNC roles for first-year students include patient advocate, registration specialist, lab guru, community health worker and clinic clerk. PNC roles for second-year students are more aligned with the student’s future health profession; they can serve as medical, pharmacy, physical therapy, mental health, nutrition and nursing clinicians; clinic coordinator; or research, finance and process improvement specialists. Students also have an opportunity to apply for a leadership role in their second year. Study participants Since 2009, we enrolled three cohorts of students into our study, comprising students from medicine, nursing, pharmacy, physical therapy, public health and social work who were starting their first year of health profession training in September 2009, 2010 or 2011 (cohorts 1, 2 and 3, respectively). Only students from the same schools from which the PNC draws its student volunteers were invited to take the survey. Within each cohort, study participants fell into three categories – students who applied and were accepted to the PNC (AAA), students who applied and were not accepted to the PNC (ANA) and students who never applied to the PNC (NA). The latter two groups served as controls for the accepted students. Those who were not accepted would presumably have had similar motivations for applying to the PNC as those who were accepted. Survey We administered the University of West England Interprofessional Questionnaire (UWE IPQ), as developed by Pollard, Miers, and Gilchrist (2004). We selected this instrument because, as in our study, the survey creators were interested in assessing changes in the interprofessional attitudes and skills of health professions students from entry in their education program to program completions. The 35-item survey is split into four scales – Communication and Teamwork (CT), Interprofessional Learning (IL), Interprofessional Interactions
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(II) and Interprofessional Relationships (IR). The CT, IL and II scales all have nine questions, whereas the IR has eight questions. Responses to each question are ranked on a 1–5 scale from Strongly Disagree to Strongly Agree with reverse scoring where necessary. A high score indicates more positive interprofessional attitudes or better interprofessional skills. Pollard et al. grouped the total score for each scale into negative, neutral or positive categories, whereas we treated the score for each question as a continuous variable from 1 to 5. They also did not administer the IR portion of the questionnaire at entry level because their students had limited experiences in health and social environments. However, we found that many of our entry-level students had ample experiences in these environments, so we included all four scales at each time point. Data collection For each cohort, we administered the UWE IPQ survey at three time points: at the start of students’ first year of health professions training and before the PNC acceptance date (time 1, September 2009, 2010 or 2011), at the end of their first year of training (time 2, May 2010, 2011 or 2012) and at the end of their second year of training (time 3, May 2011, 2012 or 2013). For time 1 data collection, paper surveys were given to all of the students who applied for a position in the PNC after their application interview but before they found out if they were selected for the clinic. This was done to maximize the number of surveys that were collected from students who applied to the PNC. It was made clear, both verbally and written, that the results had no impact on their application to the clinic. The completed surveys were collected and kept confidential. At the same time that PNC applicants received the survey, an e-mail was sent to all first-year students from the schools involved with the PNC inviting them to fill out an electronic version of the survey. If the students had filled out a paper survey when they applied to the PNC, they were asked to not fill it out a second time; if they did, the electronic survey was excluded. At the end of their first and second years of health professions education, the students who completed the first survey were invited by e-mail to take the survey again for a total of three survey testing points. As an incentive to complete the second and third surveys, all students who completed the follow-up surveys were entered in a drawing for one of eight $25 gift certificates to a popular store. Data analysis For our analyses of changes in interprofessional attitudes and skills over time (time 1, 2 and 3) and by application status (AAA, ANA and NA), we combined the data from all three cohorts for each time point. For example, all time 1 survey responses for AAA students were combined, regardless of the calendar year in which the students had initiated their health professions training (2009, 2010 or 2011). Since our primary goal was to investigate the effects of time in training, school and application status on interprofessional attitudes and skills, we used a linear mixed model for the analysis, adjusting for sex and age. The overall effect for each factor was examined with the F-test. Group comparisons were adjusted for multiple comparisons by using the Tukey–Kramer method. Differences between the three application statuses (AAA, ANA and NA) at baseline (time 1) were assessed using ANOVA for continuous variables and Chi-square test for categorical variables. A p value of 50.05 was considered statistically significant. All analyses were performed in SAS, version 9.2 (SAS Institute, Cary, NC); graphs were plotted in R.
Interprofessional education in student-run free clinics
DOI: 10.3109/13561820.2014.907779
Ethical considerations The institutional review board approved this study prior to the start of the study. All students consented to participation in the survey. The students provided their university e-mail address as a unique identifier on all surveys to track the cohort to which the student belonged. Each study participant was then assigned a unique code known only to the primary investigator for purposes of data analysis.
Results In this section, we report survey response rates at each time point, the demographics of study participants at baseline (time 1) by application status group, differences in students’ attitudes and skills toward interprofessionalism by group at each time point and changes in students’ attitudes and skills over time, within and among groups. We also looked to see if we could identify individual survey questions that could discriminate amongst the three groups. A total of 720 students applied to the PNC over the three years that we studied. Of these applicants, 503 were accepted and 217 were not accepted. A total of 2139 surveys were sent to first-year students who were training in the schools represented in the PNC but did apply to the PNC. Response rates for time 1 (three cohorts combined) were 84.5% (425/503) for the AAA group, 78.8% (171/217) for the ANA group and 17.1% (365/2139) for the NA group. We expected a higher response rate for those who applied to the PNC (AAA and ANA) because these students were given the survey at the time of their interview. Response rates for time 2 were 46.8% (199/425), 31.6% (54/171) and 39.7% (145/365) for the AAA, ANA and NA groups, respectively; and for time 3 were 27.5% (117/425), 26.9% (46/171) and 22.5% (82/365) for the AAA, ANA and NA groups, respectively. Demographics The survey assessed each respondent’s age, sex, school and year in their program. We observed some statistically significant differences at baseline (time 1) in the demographics of each of the application status groups (Table I). Students who applied to the PNC (AAA and ANA) were younger than those who did not apply. There is also a large difference in the proportion of females compared to males. Most of the schools from which PNC students
come have a female majority on average across the years of our study. The expected percentage of females across our survey population was 72.4%, which is similar to the percentage of female students who applied to the PNC (AAA and ANA) but lower than the NA group. The NA group has a larger number of female-predominant social work and public health students than the other groups, which likely explains this difference. There were differences in the schools across the application statuses with the biggest difference coming from public health students where a larger proportion did not apply to the PNC. There were also a larger number of students in Cohort 1 (2009) who did not apply. We believe this is because the person assisting with sending e-mail surveys to students from the school of public health in 2009 was more enthusiastic in inviting students to take the survey than the people in subsequent years. Outcomes The data for the AAA group, as seen in Table II and Figure 1, showed a statistically significant decline in attitudes and skills from before the students started volunteering in the PNC to after the first year in all areas except IR (p ¼ 0.083): CT (36.9 vs 35.1, p50.001), IL (41.7 vs 39.7, p50.001), II (22.2 vs 20.8, p50.001) and total score (133.5 vs 128.0, p50.001). There was a statistically significant decline in the ANA group from the first survey to the second survey for all of the scales and for the total score. The scores for the NA group improved from the first survey to the second survey for IL (35.9 vs 38.0, p50.001) and for the total (120.6 vs 122.5, p ¼ 0.033). There were no statistically significant changes from the second survey to the third survey for any of the groups on any of the scales. Not surprisingly, the attitudes and skills toward interprofessionalism for all of the scales (i.e. the four individual scales and the total score) for all of the students who applied for a position in the PNC (AAA and ANA) were better than those who did not apply (NA) at the time of the first survey. The students who applied to the PNC chose to be part of a clinic, which was very vocal about its interprofessional model of care, so presumably these students would have better attitudes and skills. As seen on Table III, the AAA and the ANA groups were very close on all measures at the time of the first survey; however, the two groups separated after the second survey. This separation at the second survey reached statistical significance for the total
Table I. Participant characteristics at baseline (time 1) by application status. Application status Variable Age in years, mean (SD) Sex, n (%) Male Female School, n (%) Medicine Nursing Pharmacy Physical therapy Public health Social work Cohort, n (%) 2009 2010 2011
Applied and accepted, AAA (N ¼ 425) 24.37 (3.6) 118 (27.8%) 307 (72.2%)
Applied, not accepted, ANA (N ¼ 171) 23.55 (3.0) 46 (26.9%) 125 (73.1%)
Did not apply, NA (N ¼ 365) 27.73 (6.5)
p Value 50.001 0.005
67 (18.4%) 298 (81.6%) 50.001
122 59 75 58 88 23
(28.7%) (13.9%) (17.7%) (13.6%) (20.7%) (5.4%)
38 42 42 13 36 0
(22.2%) (24.6%) (24.6%) (7.6%) (21.1%) (0)
39 17 47 12 170 80
(10.7%) (4.7%) (12.9%) (3.3%) (46.6%) (21.9%) 50.001
121 (28.5%) 168 (39.5%) 136 (32.0%)
415
37 (21.6%) 70 (40.9%) 64 (37.4%)
195 (53.4%) 99 (27.1%) 71 (19.5%)
To test for group differences, ANOVA was used for continuous variables and Chi-square test for categorical variables.
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Table II. Comparison of participants’ attitudes and skills towards interprofessionalism at three time points. Time of survey administration Time 2 (end of training year 1)
Time 3 (end of training year 2)
Time 1 vs time 2
Time 2 vs time 3
Communication and Teamwork Accepted 36.9 Not accepted 36.6 Not apply 34.3
35.1 34.1 34.0
25.8 34.5 34.3
50.001 50.001 0.635
0.118 0.855 0.736
Interprofessional Learning Accepted Not accepted Not apply
41.7 42.0 35.9
39.7 38.4 38.0
40.0 38.5 38.2
50.001 50.001 50.001
0.831 0.990 0.969
Interprofessional Interactions Accepted 22.2 Not accepted 22.5 Not apply 20.1
20.8 20.4 20.1
20.8 19.6 19.6
50.001 50.001 0.971
0.997 0.404 0.391
Interprofessional Relationships Accepted 32.9 Not accepted 32.7 Not apply 30.3
32.3 31.3 30.4
32.8 31.1 31.1
0.083 0.009 0.994
0.409 0.947 0.133
128.0 124.2 122.5
129.4 123.7 123.2
50.001 50.001 0.033
0.262 0.933 0.814
Application status
Total score Accepted Not accepted Not apply
Time 1 (start of training year 1)
p Value (Tukey–Kramer)
133.5 133.7 120.6
Communication and Teamwork (0–45), Interprofessional Learning (0–45), Interprofessional Interactions (0–45), Interprofessional Relationships (0–40). Shaded values indicate p value 50.05.
Discussion
Figure 1. Total score by application status.
score (128.0 vs 124.2, p ¼ 0.027), but not for the individual scales. The difference between the AAA and the ANA groups on the third survey was significant for the IR scale (32.8 vs 31.1, p ¼ 0.014) and the total score (129.4 vs 123.7, p ¼ 0.001). The ANA group scores became much closer to the NA group than to the AAA group after the first survey with no statistically significant differences between the ANA and NA group for any of the scales on the second and third surveys. The differences between AAA and NA were statistically significant for all scales and all surveys except on the II scale at the time of the second survey (Table III). When looking at the individual questions, there were only 10 of 35 questions across all of the scales, which showed a persistently significant difference between the AAA and the NA group on both the first and the third surveys. These questions and their statistics are described in Table IV.
Despite practicing in an excellent interprofessional environment, the attitudes and skills for the students who were accepted to the PNC had a large decline after the first year. While this type of clinic may attract those students who are interested in working interprofessionally, it does little to prevent the decline in attitudes that others (Coster et al., 2008; Pollard et al., 2004) have seen after the first year. We know from their applications that many of the students write and talk about wanting to have a meaningful impact on those who most need their help and cite teamwork as an ideal way to do this. We postulate that by the end of their first year, they see the challenges inherent in caring for patients with complexities to their care that are outside even a team’s ability to affect such as lack of employment, inadequate housing, poor access to food and unsafe neighborhoods. On the second and third surveys, the total score was statistically higher for the accepted students versus not accepted students. In addition, the total scores on the surveys of the not accepted students were no longer significantly different than the students who never applied to the PNC. This would suggest that the PNC may have a protective effect from declining interprofessional attitudes and skills. Further study will have to be done to see if these changes persist. It is also possible that length of contact with other professions may be a factor in protection of positive interprofessional attitudes and skills (Carpenter, 1995; Carpenter & Hewstone, 1996; Hean & Dickinson, 2005). The average student spends 35 hours per semester involved in PNC-related activities such as clinical care, outreach in the community and training activities. Although it was not specifically measured in this study, the contact hypothesis may explain the lack of decline in clinic volunteers’ interprofessional attitudes and skills. By the end of their second year at the PNC, students have worked in close contact with the other professions approximately twice as much after their first year. The PNC students have some of the ideal conditions, which would foster a positive attitude change through increased contact such as
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DOI: 10.3109/13561820.2014.907779
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Table III. Comparison of participants’ attitudes and skills towards interprofessionalism for students by application status. Application status
p Value (Tukey–Kramer)
Time of survey administration
Accepted (AAA)
Not accepted (ANA)
Not apply (NA)
AAA vs ANA
AAA vs NA
ANA vs NA
Communication and Teamwork Time 1 Time 2 Time 3
36.9 35.1 25.8
36.6 34.1 34.5
34.3 34.0 34.3
0.753 0.174 0.072
50.001 0.021 0.011
50.001 0.972 0.974
Interprofessional Learning Time 1 Time 2 Time 3
41.7 39.7 40.0
42.0 38.4 38.5
35.9 38.0 38.2
0.789 0.115 0.118
50.001 0.003 0.012
50.001 0.887 0.920
Interprofessional Interactions Time 1 Time 2 Time 3
22.2 20.8 20.8
22.5 20.4 19.6
20.1 20.1 19.6
0.630 0.797 0.134
50.001 0.270 0.047
50.001 0.878 0.998
32.9 32.3 32.8
32.7 31.3 31.1
30.3 30.4 31.1
0.841 0.120 0.014
50.001 50.001 0.002
50.001 0.187 0.999
133.5 128.0 129.4
133.7 124.2 123.7
120.6 122.5 123.2
0.976 0.027 0.001
50.001 50.001 50.001
50.001 0.526 0.964
Interprofessional Relationships Time 1 Time 2 Time 3 Total score Time 1 Time 2 Time 3
Communication and Teamwork (0–45), Interprofessional Learning (0–45), Interprofessional Interactions (0–45) and Interprofessional Relationships (0–40). Shaded values indicate p value 50.05. Time 1 ¼ at the start of students’ first year of health professions training and before PNC acceptance date (September 2009, 2010 or 2011). Time 2 ¼ at the end of their first year of training (May 2010, 2011 or 2012). Time 3 ¼ At the end of their second year of training (May 2011, 2012 or 2013).
Table IV. Survey questions distinguishing the AAA and the NA groups at both survey 1 and 3. Scale CT CT II IL IL IL IR IR
Question I feel comfortable justifying recommendations/advice face-to-face with more senior people. I feel comfortable working in a group. It is easy to communicate openly with people from other health and social care disciplines. My skills in communicating with patients/clients would be improved through learning with students from other health and social care professions. My skills in communicating with other health and social care professions would be improved through learning with students from other health and social care professions. Learning with students from other health and social care professions is likely to improve the service for patient/client. I am confident in my relationships with my peers from my own professional discipline.
IR
I am confident in my relationships with people from other health and social care disciplines. I am comfortable working with people from other health and social care disciplines.
IR
I lack confidence when I work with people from other health and social care disciplines.
a cooperative atmosphere, a common goal, institutional support and positive expectations (Hean & Dickinson, 2005). In looking at the questions that reliably differentiate the accepted students from those that did not apply, it would seem that the model of care in the PNC drives most of this difference. The students present their care plans to preceptors as a group, which is reflected in their confidence in presenting to more senior people and in working in a group. The care model for patient care in the PNC means that the students work with and learn from all of the professions, so it is not surprising that they would feel that this would improve their communication skills; strengthen
Survey
AAA
NA
p Value
1 3 1 3 1 3 1 3 1 3
4.2 4.2 4.6 4.4 3.3 3.4 4.7 4.4 4.7 4.6
3.8 3.8 4.2 4.2 2.9 3.0 4.1 4.1 4.3 4.3
50.001 0.006 50.001 0.008 50.001 0.003 50.001 0.001 50.001 0.002
1 3 1 3 1 3 1 3 1 3
4.7 4.6 4.4 4.3 3.8 3.9 4.4 4.2 4.0 3.8
4.1 4.4 4.1 4.1 3.5 3.5 4.0 4.0 3.6 3.5
50.001 0.043 50.001 0.053 50.001 0.001 50.001 0.049 50.001 0.040
relationships and comfort with other professions; and improve patient care. The selection of the students accepted to the PNC was not a random process and was partially based on their desire to work on interprofessional teams as stated during the interview process. Therefore, it follows that their interprofessional attitudes and skills would be higher than those who were not accepted or did not apply. However, the focus on interprofessional team work is known and advertised to the students prior to their application to the clinic, and most applicants give answers during their interviews that fit with the clinic’s mission of teamwork.
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Another limitation is that the response rate was not optimal especially for the third survey. This may have limited our ability to capture the full range of attitudes or skills from our students. Finally, the care model in our clinic may mean that the findings are not generalizable to other settings, although, in our experiences in talking with other SRFCs, many involve more than one type of health professions student working in teams. Therefore, it is likely that our data would be applicable to their sites.
Conclusion To our knowledge, this is the first study to describe the longitudinal impact of a SRFC on the interprofessional attitudes and skills of health professions students. We found that simply creating an optimal environment for interprofessional collaboration to occur is not sufficient to improve or to even prevent a decline in interprofessional attitudes and skills during their first year in the clinic; however, compared to students who were not involved in the clinic, the accepted students were protected from further decline. These findings are likely explained by the educational and clinical model at the clinic but may also be explained by the length of contact the students had with other professions. While more research is needed to see if these findings can be replicated across other SRFC sites and to determine which elements of the care and education model drive the differences seen, this study shows that SRFCs, such as the PNC, can provide an environment for students to practice their interprofessional communication and teamwork skills, learn from and interact with other health professions students and develop the relationships that will prepare them for a interprofessional collaborative practice. Institutions looking to start a SRFC should ensure there is an interprofessional aspect to the care provided by the students because, as we have demonstrated, this setting can be valuable for teaching and reinforcing an interprofessional model of care for health professions students. It is important to emphasize to the students that interprofessional education and interactions are important to providing patient care; however, while pointing out the importance of interprofessional collaboration, those overseeing the educational components of the clinic should help the students set realistic expectations for how this is operationalized. Perhaps then the students will find a balance between their expectations and reality and not experience the decline typically seen after the first year.
Acknowledgements We would like to thank Anne Marie Weber-Main, PhD and Anne Joseph, MD for their assistance in designing the study and reviewing the manuscript.
Declaration of interest The authors report no conflict of interest. The authors are responsible for the writing and content of this article.
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ORIGINAL ARTICLE
The student-run free clinic: an ideal site to teach interprofessional education? Brian Sick1, Lisa Sheldon2, Katy Ajer3, Qi Wang4 and Lei Zhang5 1
Internal Medicine, University of Minnesota, Minneapolis, MN, USA, 2Park Nicollet Health Services, St. Louis Park, MN, USA, 3HealthEast Care System, Bethesda Hospital, St. Paul, MN, USA, 4Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA, and 5Biostatistics Design and Analysis Center, University of Minnesota, Minneapolis, MN, USA Abstract
Keywords
Student-run free clinics (SRFCs) often include an interprofessional group of health professions students and preceptors working together toward the common goal of caring for underserved populations. Therefore, it would seem that these clinics would be an ideal place for students to participate in an interprofessional collaborative practice and for interprofessional education to occur. This article describes a prospective, observational cohort study of interprofessional attitudes and skills including communication and teamwork skills and attitudes about interprofessional learning, relationships and interactions of student volunteers in a SRFC compared to students who applied and were not accepted to the clinic and to students who never applied to the clinic. This study showed a decrease in attitudes and skills after the first year for all groups. Over the next two years, the total score on the survey for the accepted students was higher than the not accepted students. The students who were not accepted also became more similar to students who never applied. This suggests a protective effect against declining interprofessional attitudes and skills for the student volunteers in a SRFC. These findings are likely a function of the design of the clinical and educational experience in the clinic and of the length of contact the students have with other professions.
Interprofessional care, interprofessional education, student-run free clinic, surveys, underserved, volunteerism
Introduction It is generally recognized that health professions students need to learn in interprofessional environments to be ready for their future work as healthcare providers in an interprofessional collaborative practice (D’Amour & Oandasan, 2005; Institute of Medicine, 1972; World Health Organization, 2010). Schools often struggle finding locations in which their students can experience a seamless linkage between interprofessional education and practice. Student-run free clinics (SRFCs) can provide just this type of connection. They often include volunteer students from multiple health professions providing health care under the supervision and tutelage of volunteer faculty. Therefore, SRFCs should be an ideal place for students to participate in an interprofessional collaborative practice and for interprofessional education to occur. Although there are many descriptions of student-run clinics with interprofessional models of care and education (Beck, 2005; Clark, Melillo, Wallace, Pierrel, & Buck, 2003; Collins, 1995; Jimenez et al., 2008; Moskowitz, Glasco, Johnson, & Wong, 2006; Pi, 1995; Simpson & Long, 2007; Yap & Thorton, 1995), very few have reported their learners’ outcomes (Holmqvist, Courtney, Meili, & Dick, 2012). In a study of interprofessional student teams who delivered geriatric care through a service
Correspondence: Dr. Brian Sick, MD, Internal Medicine, University of Minnesota, 420 Delaware Str SE, MMC 741, Minneapolis, MN 55455, USA. E-mail: [email protected]
History Received 11 September 2013 Revised 17 January 2014 Accepted 20 March 2014 Published online 21 April 2014
learning model in Idaho, learners reported improvements in their professional competence and autonomy, their cooperation and resource sharing within and across professions and their understanding of the value and contribution of other professionals (Neill, Hayward, & Peterson, 2007). A study by Sheu et al. (2010), which evaluated students in medicine, nursing and pharmacy who completed a didactic hepatitis B elective with or without optional participation in a student-run clinic, no group differences were found for learners’ comfort level in working as teams or in partnership with students from other health professions in a clinical setting. A study by Gilkey and Earp (2006) showed that simply putting health professional students together in an interdisciplinary student-run clinic was not enough for successful interdisciplinary training; rather they posited that careful attention must also be paid to the social environment, which includes: frequent participation, training on interdisciplinary collaboration, time and space for effective sharing of patient information, cross-disciplinary networking and reflection. To our knowledge, there are no published studies of the longitudinal impact of SRFCs on interprofessional attitudes and skills of health professions students. We report our findings from a prospective, observational cohort study in which we assessed the interprofessional attitudes and skills of firstand second-year health professions students over the course of their two years volunteering in a SRFC. Changes in these students’ outcomes were compared with those students who applied but were not accepted to the clinic and students who did not apply.
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Methods Setting The Phillips Neighborhood Clinic (PNC) is a SRFC located in one of the poorest neighborhoods of Minneapolis, MN, with a dual mission of caring for underserved patients and education of health professions students. The PNC is open twice a week in the basement of a church as a first-come, first-served walk-in clinic. Care is provided by students from the University of Minnesota Schools of Medicine, Nursing, Pharmacy, Physical Therapy, Public Health and Social Work. Patient visits are conducted in interprofessional teams of students who see the patients as a group with pre- and post-visit huddles. Students are supervised by volunteer preceptors from the various health professions. Patient services include free medications, laboratories, acute and chronic care medical visits, physical therapy visits, mental health counseling, nutrition counseling, health education and foot care. Clinic operations are funded by grants, donations and fundraising. Technical and administrative support is provided by the University of Minnesota. In September of their first year of education, about 220 students from the aforementioned schools apply for approximately 160 positions in the clinic. After filling out an application and participating in an interview, students who are accepted agree to a two-year commitment as a clinic volunteer. While some students from smaller schools, such as social work or nursing, or with high-need skills, such as the ability to speak Spanish, are accepted unless there is a concern about their application, most students are chosen by the students on the board who make selections based on how closely students exemplify the missions of the clinic. PNC roles for first-year students include patient advocate, registration specialist, lab guru, community health worker and clinic clerk. PNC roles for second-year students are more aligned with the student’s future health profession; they can serve as medical, pharmacy, physical therapy, mental health, nutrition and nursing clinicians; clinic coordinator; or research, finance and process improvement specialists. Students also have an opportunity to apply for a leadership role in their second year. Study participants Since 2009, we enrolled three cohorts of students into our study, comprising students from medicine, nursing, pharmacy, physical therapy, public health and social work who were starting their first year of health profession training in September 2009, 2010 or 2011 (cohorts 1, 2 and 3, respectively). Only students from the same schools from which the PNC draws its student volunteers were invited to take the survey. Within each cohort, study participants fell into three categories – students who applied and were accepted to the PNC (AAA), students who applied and were not accepted to the PNC (ANA) and students who never applied to the PNC (NA). The latter two groups served as controls for the accepted students. Those who were not accepted would presumably have had similar motivations for applying to the PNC as those who were accepted. Survey We administered the University of West England Interprofessional Questionnaire (UWE IPQ), as developed by Pollard, Miers, and Gilchrist (2004). We selected this instrument because, as in our study, the survey creators were interested in assessing changes in the interprofessional attitudes and skills of health professions students from entry in their education program to program completions. The 35-item survey is split into four scales – Communication and Teamwork (CT), Interprofessional Learning (IL), Interprofessional Interactions
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(II) and Interprofessional Relationships (IR). The CT, IL and II scales all have nine questions, whereas the IR has eight questions. Responses to each question are ranked on a 1–5 scale from Strongly Disagree to Strongly Agree with reverse scoring where necessary. A high score indicates more positive interprofessional attitudes or better interprofessional skills. Pollard et al. grouped the total score for each scale into negative, neutral or positive categories, whereas we treated the score for each question as a continuous variable from 1 to 5. They also did not administer the IR portion of the questionnaire at entry level because their students had limited experiences in health and social environments. However, we found that many of our entry-level students had ample experiences in these environments, so we included all four scales at each time point. Data collection For each cohort, we administered the UWE IPQ survey at three time points: at the start of students’ first year of health professions training and before the PNC acceptance date (time 1, September 2009, 2010 or 2011), at the end of their first year of training (time 2, May 2010, 2011 or 2012) and at the end of their second year of training (time 3, May 2011, 2012 or 2013). For time 1 data collection, paper surveys were given to all of the students who applied for a position in the PNC after their application interview but before they found out if they were selected for the clinic. This was done to maximize the number of surveys that were collected from students who applied to the PNC. It was made clear, both verbally and written, that the results had no impact on their application to the clinic. The completed surveys were collected and kept confidential. At the same time that PNC applicants received the survey, an e-mail was sent to all first-year students from the schools involved with the PNC inviting them to fill out an electronic version of the survey. If the students had filled out a paper survey when they applied to the PNC, they were asked to not fill it out a second time; if they did, the electronic survey was excluded. At the end of their first and second years of health professions education, the students who completed the first survey were invited by e-mail to take the survey again for a total of three survey testing points. As an incentive to complete the second and third surveys, all students who completed the follow-up surveys were entered in a drawing for one of eight $25 gift certificates to a popular store. Data analysis For our analyses of changes in interprofessional attitudes and skills over time (time 1, 2 and 3) and by application status (AAA, ANA and NA), we combined the data from all three cohorts for each time point. For example, all time 1 survey responses for AAA students were combined, regardless of the calendar year in which the students had initiated their health professions training (2009, 2010 or 2011). Since our primary goal was to investigate the effects of time in training, school and application status on interprofessional attitudes and skills, we used a linear mixed model for the analysis, adjusting for sex and age. The overall effect for each factor was examined with the F-test. Group comparisons were adjusted for multiple comparisons by using the Tukey–Kramer method. Differences between the three application statuses (AAA, ANA and NA) at baseline (time 1) were assessed using ANOVA for continuous variables and Chi-square test for categorical variables. A p value of 50.05 was considered statistically significant. All analyses were performed in SAS, version 9.2 (SAS Institute, Cary, NC); graphs were plotted in R.
Interprofessional education in student-run free clinics
DOI: 10.3109/13561820.2014.907779
Ethical considerations The institutional review board approved this study prior to the start of the study. All students consented to participation in the survey. The students provided their university e-mail address as a unique identifier on all surveys to track the cohort to which the student belonged. Each study participant was then assigned a unique code known only to the primary investigator for purposes of data analysis.
Results In this section, we report survey response rates at each time point, the demographics of study participants at baseline (time 1) by application status group, differences in students’ attitudes and skills toward interprofessionalism by group at each time point and changes in students’ attitudes and skills over time, within and among groups. We also looked to see if we could identify individual survey questions that could discriminate amongst the three groups. A total of 720 students applied to the PNC over the three years that we studied. Of these applicants, 503 were accepted and 217 were not accepted. A total of 2139 surveys were sent to first-year students who were training in the schools represented in the PNC but did apply to the PNC. Response rates for time 1 (three cohorts combined) were 84.5% (425/503) for the AAA group, 78.8% (171/217) for the ANA group and 17.1% (365/2139) for the NA group. We expected a higher response rate for those who applied to the PNC (AAA and ANA) because these students were given the survey at the time of their interview. Response rates for time 2 were 46.8% (199/425), 31.6% (54/171) and 39.7% (145/365) for the AAA, ANA and NA groups, respectively; and for time 3 were 27.5% (117/425), 26.9% (46/171) and 22.5% (82/365) for the AAA, ANA and NA groups, respectively. Demographics The survey assessed each respondent’s age, sex, school and year in their program. We observed some statistically significant differences at baseline (time 1) in the demographics of each of the application status groups (Table I). Students who applied to the PNC (AAA and ANA) were younger than those who did not apply. There is also a large difference in the proportion of females compared to males. Most of the schools from which PNC students
come have a female majority on average across the years of our study. The expected percentage of females across our survey population was 72.4%, which is similar to the percentage of female students who applied to the PNC (AAA and ANA) but lower than the NA group. The NA group has a larger number of female-predominant social work and public health students than the other groups, which likely explains this difference. There were differences in the schools across the application statuses with the biggest difference coming from public health students where a larger proportion did not apply to the PNC. There were also a larger number of students in Cohort 1 (2009) who did not apply. We believe this is because the person assisting with sending e-mail surveys to students from the school of public health in 2009 was more enthusiastic in inviting students to take the survey than the people in subsequent years. Outcomes The data for the AAA group, as seen in Table II and Figure 1, showed a statistically significant decline in attitudes and skills from before the students started volunteering in the PNC to after the first year in all areas except IR (p ¼ 0.083): CT (36.9 vs 35.1, p50.001), IL (41.7 vs 39.7, p50.001), II (22.2 vs 20.8, p50.001) and total score (133.5 vs 128.0, p50.001). There was a statistically significant decline in the ANA group from the first survey to the second survey for all of the scales and for the total score. The scores for the NA group improved from the first survey to the second survey for IL (35.9 vs 38.0, p50.001) and for the total (120.6 vs 122.5, p ¼ 0.033). There were no statistically significant changes from the second survey to the third survey for any of the groups on any of the scales. Not surprisingly, the attitudes and skills toward interprofessionalism for all of the scales (i.e. the four individual scales and the total score) for all of the students who applied for a position in the PNC (AAA and ANA) were better than those who did not apply (NA) at the time of the first survey. The students who applied to the PNC chose to be part of a clinic, which was very vocal about its interprofessional model of care, so presumably these students would have better attitudes and skills. As seen on Table III, the AAA and the ANA groups were very close on all measures at the time of the first survey; however, the two groups separated after the second survey. This separation at the second survey reached statistical significance for the total
Table I. Participant characteristics at baseline (time 1) by application status. Application status Variable Age in years, mean (SD) Sex, n (%) Male Female School, n (%) Medicine Nursing Pharmacy Physical therapy Public health Social work Cohort, n (%) 2009 2010 2011
Applied and accepted, AAA (N ¼ 425) 24.37 (3.6) 118 (27.8%) 307 (72.2%)
Applied, not accepted, ANA (N ¼ 171) 23.55 (3.0) 46 (26.9%) 125 (73.1%)
Did not apply, NA (N ¼ 365) 27.73 (6.5)
p Value 50.001 0.005
67 (18.4%) 298 (81.6%) 50.001
122 59 75 58 88 23
(28.7%) (13.9%) (17.7%) (13.6%) (20.7%) (5.4%)
38 42 42 13 36 0
(22.2%) (24.6%) (24.6%) (7.6%) (21.1%) (0)
39 17 47 12 170 80
(10.7%) (4.7%) (12.9%) (3.3%) (46.6%) (21.9%) 50.001
121 (28.5%) 168 (39.5%) 136 (32.0%)
415
37 (21.6%) 70 (40.9%) 64 (37.4%)
195 (53.4%) 99 (27.1%) 71 (19.5%)
To test for group differences, ANOVA was used for continuous variables and Chi-square test for categorical variables.
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Table II. Comparison of participants’ attitudes and skills towards interprofessionalism at three time points. Time of survey administration Time 2 (end of training year 1)
Time 3 (end of training year 2)
Time 1 vs time 2
Time 2 vs time 3
Communication and Teamwork Accepted 36.9 Not accepted 36.6 Not apply 34.3
35.1 34.1 34.0
25.8 34.5 34.3
50.001 50.001 0.635
0.118 0.855 0.736
Interprofessional Learning Accepted Not accepted Not apply
41.7 42.0 35.9
39.7 38.4 38.0
40.0 38.5 38.2
50.001 50.001 50.001
0.831 0.990 0.969
Interprofessional Interactions Accepted 22.2 Not accepted 22.5 Not apply 20.1
20.8 20.4 20.1
20.8 19.6 19.6
50.001 50.001 0.971
0.997 0.404 0.391
Interprofessional Relationships Accepted 32.9 Not accepted 32.7 Not apply 30.3
32.3 31.3 30.4
32.8 31.1 31.1
0.083 0.009 0.994
0.409 0.947 0.133
128.0 124.2 122.5
129.4 123.7 123.2
50.001 50.001 0.033
0.262 0.933 0.814
Application status
Total score Accepted Not accepted Not apply
Time 1 (start of training year 1)
p Value (Tukey–Kramer)
133.5 133.7 120.6
Communication and Teamwork (0–45), Interprofessional Learning (0–45), Interprofessional Interactions (0–45), Interprofessional Relationships (0–40). Shaded values indicate p value 50.05.
Discussion
Figure 1. Total score by application status.
score (128.0 vs 124.2, p ¼ 0.027), but not for the individual scales. The difference between the AAA and the ANA groups on the third survey was significant for the IR scale (32.8 vs 31.1, p ¼ 0.014) and the total score (129.4 vs 123.7, p ¼ 0.001). The ANA group scores became much closer to the NA group than to the AAA group after the first survey with no statistically significant differences between the ANA and NA group for any of the scales on the second and third surveys. The differences between AAA and NA were statistically significant for all scales and all surveys except on the II scale at the time of the second survey (Table III). When looking at the individual questions, there were only 10 of 35 questions across all of the scales, which showed a persistently significant difference between the AAA and the NA group on both the first and the third surveys. These questions and their statistics are described in Table IV.
Despite practicing in an excellent interprofessional environment, the attitudes and skills for the students who were accepted to the PNC had a large decline after the first year. While this type of clinic may attract those students who are interested in working interprofessionally, it does little to prevent the decline in attitudes that others (Coster et al., 2008; Pollard et al., 2004) have seen after the first year. We know from their applications that many of the students write and talk about wanting to have a meaningful impact on those who most need their help and cite teamwork as an ideal way to do this. We postulate that by the end of their first year, they see the challenges inherent in caring for patients with complexities to their care that are outside even a team’s ability to affect such as lack of employment, inadequate housing, poor access to food and unsafe neighborhoods. On the second and third surveys, the total score was statistically higher for the accepted students versus not accepted students. In addition, the total scores on the surveys of the not accepted students were no longer significantly different than the students who never applied to the PNC. This would suggest that the PNC may have a protective effect from declining interprofessional attitudes and skills. Further study will have to be done to see if these changes persist. It is also possible that length of contact with other professions may be a factor in protection of positive interprofessional attitudes and skills (Carpenter, 1995; Carpenter & Hewstone, 1996; Hean & Dickinson, 2005). The average student spends 35 hours per semester involved in PNC-related activities such as clinical care, outreach in the community and training activities. Although it was not specifically measured in this study, the contact hypothesis may explain the lack of decline in clinic volunteers’ interprofessional attitudes and skills. By the end of their second year at the PNC, students have worked in close contact with the other professions approximately twice as much after their first year. The PNC students have some of the ideal conditions, which would foster a positive attitude change through increased contact such as
Interprofessional education in student-run free clinics
DOI: 10.3109/13561820.2014.907779
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Table III. Comparison of participants’ attitudes and skills towards interprofessionalism for students by application status. Application status
p Value (Tukey–Kramer)
Time of survey administration
Accepted (AAA)
Not accepted (ANA)
Not apply (NA)
AAA vs ANA
AAA vs NA
ANA vs NA
Communication and Teamwork Time 1 Time 2 Time 3
36.9 35.1 25.8
36.6 34.1 34.5
34.3 34.0 34.3
0.753 0.174 0.072
50.001 0.021 0.011
50.001 0.972 0.974
Interprofessional Learning Time 1 Time 2 Time 3
41.7 39.7 40.0
42.0 38.4 38.5
35.9 38.0 38.2
0.789 0.115 0.118
50.001 0.003 0.012
50.001 0.887 0.920
Interprofessional Interactions Time 1 Time 2 Time 3
22.2 20.8 20.8
22.5 20.4 19.6
20.1 20.1 19.6
0.630 0.797 0.134
50.001 0.270 0.047
50.001 0.878 0.998
32.9 32.3 32.8
32.7 31.3 31.1
30.3 30.4 31.1
0.841 0.120 0.014
50.001 50.001 0.002
50.001 0.187 0.999
133.5 128.0 129.4
133.7 124.2 123.7
120.6 122.5 123.2
0.976 0.027 0.001
50.001 50.001 50.001
50.001 0.526 0.964
Interprofessional Relationships Time 1 Time 2 Time 3 Total score Time 1 Time 2 Time 3
Communication and Teamwork (0–45), Interprofessional Learning (0–45), Interprofessional Interactions (0–45) and Interprofessional Relationships (0–40). Shaded values indicate p value 50.05. Time 1 ¼ at the start of students’ first year of health professions training and before PNC acceptance date (September 2009, 2010 or 2011). Time 2 ¼ at the end of their first year of training (May 2010, 2011 or 2012). Time 3 ¼ At the end of their second year of training (May 2011, 2012 or 2013).
Table IV. Survey questions distinguishing the AAA and the NA groups at both survey 1 and 3. Scale CT CT II IL IL IL IR IR
Question I feel comfortable justifying recommendations/advice face-to-face with more senior people. I feel comfortable working in a group. It is easy to communicate openly with people from other health and social care disciplines. My skills in communicating with patients/clients would be improved through learning with students from other health and social care professions. My skills in communicating with other health and social care professions would be improved through learning with students from other health and social care professions. Learning with students from other health and social care professions is likely to improve the service for patient/client. I am confident in my relationships with my peers from my own professional discipline.
IR
I am confident in my relationships with people from other health and social care disciplines. I am comfortable working with people from other health and social care disciplines.
IR
I lack confidence when I work with people from other health and social care disciplines.
a cooperative atmosphere, a common goal, institutional support and positive expectations (Hean & Dickinson, 2005). In looking at the questions that reliably differentiate the accepted students from those that did not apply, it would seem that the model of care in the PNC drives most of this difference. The students present their care plans to preceptors as a group, which is reflected in their confidence in presenting to more senior people and in working in a group. The care model for patient care in the PNC means that the students work with and learn from all of the professions, so it is not surprising that they would feel that this would improve their communication skills; strengthen
Survey
AAA
NA
p Value
1 3 1 3 1 3 1 3 1 3
4.2 4.2 4.6 4.4 3.3 3.4 4.7 4.4 4.7 4.6
3.8 3.8 4.2 4.2 2.9 3.0 4.1 4.1 4.3 4.3
50.001 0.006 50.001 0.008 50.001 0.003 50.001 0.001 50.001 0.002
1 3 1 3 1 3 1 3 1 3
4.7 4.6 4.4 4.3 3.8 3.9 4.4 4.2 4.0 3.8
4.1 4.4 4.1 4.1 3.5 3.5 4.0 4.0 3.6 3.5
50.001 0.043 50.001 0.053 50.001 0.001 50.001 0.049 50.001 0.040
relationships and comfort with other professions; and improve patient care. The selection of the students accepted to the PNC was not a random process and was partially based on their desire to work on interprofessional teams as stated during the interview process. Therefore, it follows that their interprofessional attitudes and skills would be higher than those who were not accepted or did not apply. However, the focus on interprofessional team work is known and advertised to the students prior to their application to the clinic, and most applicants give answers during their interviews that fit with the clinic’s mission of teamwork.
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Another limitation is that the response rate was not optimal especially for the third survey. This may have limited our ability to capture the full range of attitudes or skills from our students. Finally, the care model in our clinic may mean that the findings are not generalizable to other settings, although, in our experiences in talking with other SRFCs, many involve more than one type of health professions student working in teams. Therefore, it is likely that our data would be applicable to their sites.
Conclusion To our knowledge, this is the first study to describe the longitudinal impact of a SRFC on the interprofessional attitudes and skills of health professions students. We found that simply creating an optimal environment for interprofessional collaboration to occur is not sufficient to improve or to even prevent a decline in interprofessional attitudes and skills during their first year in the clinic; however, compared to students who were not involved in the clinic, the accepted students were protected from further decline. These findings are likely explained by the educational and clinical model at the clinic but may also be explained by the length of contact the students had with other professions. While more research is needed to see if these findings can be replicated across other SRFC sites and to determine which elements of the care and education model drive the differences seen, this study shows that SRFCs, such as the PNC, can provide an environment for students to practice their interprofessional communication and teamwork skills, learn from and interact with other health professions students and develop the relationships that will prepare them for a interprofessional collaborative practice. Institutions looking to start a SRFC should ensure there is an interprofessional aspect to the care provided by the students because, as we have demonstrated, this setting can be valuable for teaching and reinforcing an interprofessional model of care for health professions students. It is important to emphasize to the students that interprofessional education and interactions are important to providing patient care; however, while pointing out the importance of interprofessional collaboration, those overseeing the educational components of the clinic should help the students set realistic expectations for how this is operationalized. Perhaps then the students will find a balance between their expectations and reality and not experience the decline typically seen after the first year.
Acknowledgements We would like to thank Anne Marie Weber-Main, PhD and Anne Joseph, MD for their assistance in designing the study and reviewing the manuscript.
Declaration of interest The authors report no conflict of interest. The authors are responsible for the writing and content of this article.
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