2011; 33: e22–e26
WEB PAPER
Effects of interprofessional education on patient perceived quality of care KARIN HALLIN, PETER HENRIKSSON, NILS DALE´N & ANNA KIESSLING Karolinska Institutet, Sweden
Abstract Background: Active patient-based learning by working together at an interprofessional clinical education ward (CEW) increases collaborative and professional competence among students. Aim: To assess the patients’ perceptions of collaborative and communicative aspects of care when treated by interprofessional student teams as compared to usual care. Method: Patients treated by student teams (medical, nurse, physiotherapy and occupational therapy students) at a CEW comprised the intervention group. Patients treated at a regular ward were taken as controls. The patients answered a questionnaire representing collaborative and communicative aspects of care. Questionnaires from CEW (n ¼ 84) and control (n ¼ 62) patients were obtained (82% vs 73% response rates). Results: CEW patients rated a significantly higher grade of own participation in decisions regarding treatment as compared to controls ( p ¼ 0.006). They did further rate a higher grade of satisfaction with information regarding need of help at home ( p ¼ 0.003) and perceived that the CEW staff had taken their home situation into account at a higher grade in the preparation of discharge ( p ¼ 0.0002). Finally, CEW patients felt better informed ( p ¼ 0.02). Conclusion: Patients perceived a higher grade of quality of care as compared to controls with no signs of disadvantages when treated and informed by supervised interprofessional student teams.
Introduction
Practice points
The main aim of clinical education is to develop a competence to perform high-quality health care. However, it has been difficult to assess to what extent this mission is fulfilled. In traditional disciplinary clinical education, the different professions learn very little from and about one another. However, in shared learning, students are enabled to acquire knowledge, skills and attitudes that they would not be able to acquire effectively in uniprofessional education (Funnell 1995). Interprofessional education (IPE) occurs when two or more professions learn with, from and about each other in order to improve collaboration and the quality of practice (CAIPE 2002). IPE increases the students’ ability to look at the task from the perspective of other professions as well as from the perspective of their own profession (Barr 1996). Clinical interprofessional education wards (CEWs) were established in 1998 in Sweden and in 1999 in the United Kingdom. These clinical practice wards are platforms of clinical IPE. They provide an opportunity to pre-qualified health care students to, under supervision, systematically develop, e.g. collaborative skills (Mogensen et al. 2002; Reeves & Freeth 2002; Reeves et al. 2002; Ponzer et al. 2004; Hallin et al. 2008). We have previously shown that active patient-based learning by working together at a CEW was an effective means for the students to increase their collaborative and professional competence. All four student categories at our
. To evaluate outcome of medical education at patient level is important, complicated, but possible. . We have shown that from a patient perspective the CEW provides increased quality of communication and collaboration as compared to usual care. . We found no signs of disadvantages when patients were treated and informed by supervised interprofessional student teams. . A more structured interprofessional team-based care may be beneficial even in usual care. CEW improved their knowledge of other professions’ work, their own professional role and the educational period profoundly contributed to the students’ understanding of the importance of communication and teamwork to the quality of patient care (Hallin et al. 2008). However, there is a paucity of studies assessing effects at patient level when patients are treated by supervised students (O’Malley et al. 1997). This is true in particular as regards studies assessing the patients’ perceptions and experiences of the quality of care when treated by interprofessional student teams. The aim of this was to assess the patients’ perceptions of collaborative and communicative aspects of care when treated at a CEW as compared to usual care.
Correspondence: K. Hallin, Capio Artro Clinic AB, Box 5605, SE 11486 Stockholm, Sweden. Tel: 46 701684849 or 46 709605827; fax: 46 84062691; email:
[email protected]
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ISSN 0142–159X print/ISSN 1466–187X online/11/010022–5 ß 2011 Informa UK Ltd. DOI: 10.3109/0142159X.2011.530314
Quality of care by interprofessional learning
Methods Patients and study design The CEW at Danderyd University Hospital, Stockholm, Sweden, was incorporated as a part of a regular orthopaedic ward during the period of this study (2004–2005), where CEW consisted of eight patient beds and the rest of the ward had 12 patient beds. The patients treated at the ward represented a wide variety of orthopaedic diagnoses. They were admitted both from the emergency room and for elective surgery. A majority of the patients were elderly and presented – besides the orthopaedic diagnosis – a wide range of other diagnoses such as cardiovascular diseases, diabetes and malnutrition. Patients were randomly allocated to the CEW or to the regular part of the ward depending on patient beds available at the moment. Only patients in need of a single room or with dementia were excluded from care at the CEW. A staff nurse – at the arrival to the CEW – informed all patients about the CEW concept. They had an option to be treated by regular staff. Very few patients used this option. The occupational therapy supervisor was placed at CEW solely and the regular ward had another occupational therapist at their service. The rest of the staff had rotating schedules at the entire ward, including both CEW and the regular ward. Due to pedagogic skills and interest, some of the staff had their main placement at CEW. The staff were not instructed to alter their clinical practice when they changed between the regular part of the ward and the CEW. During weekends and other periods, with no students at the ward, regular staff treated all patients. Accordingly, the ward context with facilities, personnel and medical profile was equivalent in the two parts of the ward and the main difference was the participation of students at the CEW. Supervised IP pre-qualification student teams consisting of 1–2 medical students, 3 nurse students, 1 physiotherapy student and 1 occupational therapy student per team treated patients at the CEW. The 2-week CEW course was mandatory to the medical students during their eight term (out of 11) and to the other three student categories during their last (sixth) term. The main objectives of the students were to provide the patients independently, but under supervision, with good medical care, nursing care and rehabilitation activities; to develop their own professional role; to enhance their understanding of the other professions and to highlight the importance of good communication to teamwork and to patient care. The supervisors, representing all four professions, supported the students but kept to the background to give the students’ all opportunities to get involved. The cooperation and communication with patients as well as direct patient care were thus mainly performed by the students. Further details regarding intended learning outcomes, teaching and learning activities of the students, etc., have been presented earlier (Ponzer et al. 2004). Patients at the regular part of the ward were also treated by interprofessional teams but with qualified professional staff. However, these teams were less structured and did not include IP student attendance. We assessed all patients who were treated and prepared for discharge to their homes at the ward during the study period.
Patients discharged to another clinic or to inpatient aftercare were excluded. Furthermore, patients in need of a single room, usually due to serious illness or at high risk to acquire an infection and patients suffering from dementia were excluded. The reason was that care of such patients could not be performed at the CEW. We excluded patients discharged from the ward during weekends and on holidays when no students were present. In addition, patients readmitted to the hospital within 4 weeks after discharge were excluded. Thus the CEW group consisted of patients treated and prepared for discharge by supervised IPE student teams at the CEW. The control group consisted of equivalent patients treated by ordinary staff without participation of students.
Outcome measures All patients included in the study were asked to fill out a questionnaire after they had been prepared for discharge, i.e. after all information had been given to the patients by the students at the CEW or by the ordinary staff at the regular ward. In order to diminish any bias, only two persons handed out or mailed the questionnaires to the patients. Seven questions were chosen from a valid patient satisfaction questionnaire (Jenkinson et al. 2002) regularly used by the hospital for quality assurance purposes. The questions concerned the collaborative and communicative aspects of care – areas were student involvement could have a positive or negative impact. The patients had the option to fill out the questionnaire and put it in a sealed envelope at the ward or they could fill it out at home and use regular mail service. Patients who did not get a questionnaire at the ward had one sent to their homes within a week after discharge. In case of a missing answer, one reminder was mailed within 4 weeks after discharge. All patients had given written informed consent to participate and were informed that the answers were to be analysed at group level with no possibility to identify the answers of a particular individual.
Statistical analysis The aim of the analysis was to assess the effects of the IPE initiative on patient perceived quality of care. The assessments by patients at the CEW were compared to those of the control patients treated by qualified professional staff teams (usual care). Nonparametric and Chi-square analyses were performed. The patient characteristics are given as n (%) or n SD. The results were considered significant at p 5 0.05. All analyses were performed with the STATISTICA Stat Soft, Inc 8.0 package.
Results The study population consisted of 102 patients in the CEW group, treated by the student teams and 85 patients in the control group (usual care), treated by regular staff. A total of 35 reminders were mailed to patients in the CEW group and 26 to the controls. A total of 84 patients filled out the questionnaire in the CEW group and 62 patients in the control group. The response rates were 82% and 73%, respectively. There were no
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significant differences between the groups of responding patients regarding gender, age, length of the hospital stay or whether the patients were planned or acutely admitted to the ward. There were 62% women in the CEW group versus 60% women in the controls. The mean age was 64 years in the CEW group versus 62 years in the control group. The length of hospital stay was 5 2 days in the CEW group and 5 3 days in the controls. In the CEW group 43% of the patients were acutely admitted to hospital versus 58% in the controls. Furthermore, there was no significant difference between the groups as regards the distribution of the patients’ diagnoses. Forty per cent of the patients in both groups were attended due to fractures, where hip fractures dominated. Nine per cent of the patients were admitted due to other acute orthopaedic lesions than fractures. Thirty-four per cent of the patients were admitted to receive elective joint replacements, with hip replacement as the dominant procedure. Six per cent of the patients were admitted due to other elective orthopaedic procedures and a further 11% of the patients were tended due to lumbar spine disorders.
Perceived quality of care As shown in Table 1, the patients treated and prepared for discharge by student teams rated a higher grade of participation in the decisions regarding their care as compared to controls ( p ¼ 0.006). They also rated a higher grade of satisfaction with information regarding possible home assistance as compared to controls ( p ¼ 0.003). Furthermore, they stated in a higher grade that the CEW staff had taken their family and home situation into account when preparing for discharge as compared to usual care ( p ¼ 0.0002). In addition, CEW patients felt more well-informed as regards the results of their treatment than the controls ( p ¼ 0.02). No unfavourable effects or trends were noted in the CEW patients.
Reliability and validity analysis of the patient questionnaire The reliability of the questionnaire was good with a high internal consistency. The Cronbach alpha-coefficient of total satisfaction with the collaborative and communicative aspects of care (items 1–7) was 0.73.
Discussion We assessed the effects of this IPE intervention through the patients’ perceptions of the collaborative and communicative aspects of the quality of care. We found that patients with orthopaedic disorders treated by IPE students at a CEW perceived a higher quality of care compared to patients at a regular orthopaedic ward. Our results are in line with O’Malley et al. (1997). However, our study was, in contrast to theirs, performed in a setting with acute in-patient care and with an IPE team-based care with four professions in each team. Interprofessional collaboration (IPC) in teams is assumed to be beneficial because it allows a more holistic approach to patient care than what is possible in uniprofessional care (Funnell 1995). IPC has been defined as an activity that e24
involves members of more than one health- and or social-care profession interacting together with the explicit purpose to improve IPC (Zwarenstein et al. 2009). IPE has, according to Barr et al. (2006), three foci: to prepare individuals, to cultivate collaboration and to improve services. These three foci could be seen as three cogs where the first drives the second, which in turn drives the third. Translated into effects of IPE, the hypothesis is that preparation of individuals should lead to effective collaborative teamwork resulting in beneficial changes of service and care. This understanding has led to more and more patient centred IPE initiatives in pre-qualification health-care education. However, some worries regarding patient safety and quality of care have been posed if inexperienced students are allowed to independently take care of patients. The contention that IPE student care at a CEW should result in unfavourable effects, such as a reduced well-being of the patients, insufficient information to patients or a decreased patient involvement, could not be supported in this study. One plausible explanation to our positive results could be the competent and always present supervisors. In the CEW concept, this is a prerequisite for IPE learning. Patient outcome and quality of practice is important but intricate fields of IPE research (Barr et al. 2006). According to Kirkpatrick (1967), the outcome of educational interventions could in principle be evaluated at four levels: reaction, knowledge, behaviour/performance and result levels (Hutchinson 1999). The relevance to patients and also the complexity of the evaluation increases by each level. Barr et al. (2000) have revised Kirkpatrick’s levels as regards to classification of IPE outcomes and have added two levels (Hammick et al. 2007). Figure 1 shows an illustration including these two new outcome levels. The illustration is inspired from Kirkpatrick (1967) and Hammick et al. (2007). We assessed and found positive effects at two levels; both concerning service delivery and patient perceived quality of care. To our knowledge, this has not previously been shown in prequalification IPE. A weakness of our study is, of course, that only patient perceived quality of care was assessed. However, patients’ perceptions concerning disease and illness have been shown to be a sensitive marker that in many instances contains prognostic information that could not be assessed by conventional objective markers. An indication that the CEW patients had at least the same prognosis as the control patients was that there was no difference in readmission rate between the two groups. Another weakness was that it was not possible to make a strict randomisation because patients were allocated where there were empty beds. One could of course speculate that patients should be bothered by an anticipated less distinct and coherent information by the student teams but our results did not support such a contention. An explanation of the present results could be that one of the intended learning outcomes of students at CEW was to acquire skills on how to professionally inform patients. Each working session started with a team conference where all the students of the team and the supervisors of each profession gathered. The students discussed each patient’s relevant goals of the day and also the patient’s appointed goals
Quality of care by interprofessional learning
Table 1. Perceived quality of care among patients at the Clinical Education Ward compared to in Usual care. The answers were considered to be significant at p 5 0.05 are shown as bold values in the table.
CEW Question 1. Did you understand the information given to you regarding the results of your treatment? 2. Where you involved in the decisions regarding your care? 3. Did you get enough information regarding as to how your disease will influence your daily living? 4. Did you receive information regarding possible home assistance? 5. At discharge – were you informed on whom to contact if you had questions? 6. Were you bothered, at discharge, on how to cope at home? 7. Did the staff take your family and home situation into account when preparing for discharge?
Yes
Partly
61(73)
19(23)
63(76) 34(44) 49(72)
Usual care NA
Yes
Partly
No
NA
3(4)
1
36(60)
14(23)
10(17)
1
0.02
17(20) 28(36)
3(4) 15(20)
6
39(65) 22(37)
9(15) 23(38)
12(20) 15(25)
2
0.006 0.6
17(25)
2(3)
15
20(49)
12(29)
9(22)
19
0.003
17(23)
7
44(76)
14(24)
3
58(77)
No
45(54)
33(39)
6(7)
38(64)
14(24)
7(12)
62(75)
19(23)
2(2)
34(59)
10(17)
14(24)
p-value
0.8 0.12 0.0002
Notes: All values are given as count and percentage; n (%). p-values are calculated according to Chi-square statistics. Answers could be given as Yes; Partly; No or Not applicable (N A).
Relevance for patients Difficulty and complexity of evaluation
*Benefits to patients and clients *Change in organisational practice
Behavioural change
Acquisition of knowledge and skills
Modification of perceptions and attitudes
Reactions
Improvements in health or well being of patients and clients Wider changes in the organization and delivery of care Individuals’ transfer of interprofessional learning to their practice setting and their changed professional practice Knowledge and skills linked to interprofessional collaboration Changes in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude towards the value and or use of team approaches to caring for a specific client group Learners’ views on the learning experience and its interprofessional nature
Figure 1. Assessment of IPE outcome at six levels. The relevance to patients and the complexity of the evaluation increases by each level of the ladder. Adopted from Kirkpatrick (1967) and Hammick et al. (2007). Note: *Denotes the levels of evaluation used in this study.
of the hospital stay. The students’ objectives were to specify their own professional goals and needs. Subsequently, together with the other members of the student team they agreed upon the interprofessional tailored strategy that best suited the patients’ needs. Our strategy was to emphasize group culture as opposed to a culture of hierarchy (Singer et al. 2009). The supervisors helped the students, when needed, in the planning. Accordingly, the students were well prepared both professionally and interprofessionally, when they started the work of the day. Continuous follow-up of the goals were performed by the student team during the day. The day ended with a reflective session where the student team together with
one supervisor discussed the work of the day. Were the goals fulfilled? What went wrong? Why? How to improve? Any misunderstandings? Good examples of communication and cooperation during the day? We believe that this structured cooperation was a main reason of the beneficial results. The supervisors’ role was, of course, also vital in the support of the student teams. Our findings strengthen the assertion that IPC improves the quality of care (Reeves et al. 2008). We have shown that it was beneficial to include students in the close care of patients. Furthermore, this was shown to be true even when students from different professions worked together.
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The patient care at the regular part of the ward was also performed by interprofessional teams but not as structured as at the CEW. The rounds included a nurse and an orthopaedic surgeon and at times also a physiotherapist, an occupational therapist and a nurse’s aid. At most times, the patient information was shared by only two professions – usually a nurse and one of the other professions. The regular part of the ward had more patients to tend to and some of the patients had more severe conditions, not appropriate to the CEW. It can thus be argued that shortage of time made it difficult to implement structured teamwork and communication. However, we would suggest that the present result implies that a more structured IPC should have been beneficial also at a regular ward. There are several studies evaluating an association between organizational culture, collaboration, quality of care and patient safety (Singer et al. 2009). It is reported that beneficial strategies in this respect are reduced hierarchy and increased group orientation, well in accord with our results.
Conclusion From a patient’s point of view we found no signs of disadvantages in terms of collaborative and communicative aspects of care when care was performed by supervised IPE student teams at a CEW. By contrast, we found several indications that the patients perceived a higher grade of quality of care when cared by the supervised IPE student teams. A more structured interprofessional team-based care may be beneficial even in usual care. Our findings should be reassuring and be a further support in the future development of CEWs.
Ethical aspects The investigation conforms to the principles outlined in the ‘Declaration of Helsinki; 1964’. The Regional Ethical Review Board in Stockholm, Sweden, approved the study.
Acknowledgements We would like to thank all patients for their willingness to share their experiences and attitudes with us. We would also like to thank all professional staff at the CEW and at the regular ward for their support during this study. Funding was provided through the regional agreement on medical education and clinical research (ALF) between Stockholm County Council and Karolinska Institutet. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
Notes on contributors KARIN HALLIN, MD, was during the study Consultant at the Orthopaedic clinic and Director, Clinical Education Ward at Danderyd Hospital and is at
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present Orthopaedic Consultant, Capio Artro Clinic at Sophiahemmet, Stockholm, Sweden. PETER HENRIKSSON, MD, PhD, is a Professor and Director of studies at Karolinska Institutet and an experienced medical educator. NILS DALE´N, MD, PhD, is a Professor and Orthopaedic surgeon and an experienced Senior lecturer. ANNA KIESSLING, MD. PhD, is an experienced medical educator and Director, Centre for Clinical Education of North East Stockholm at Karolinska Institutet.
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