Abstract
Problem addressed A number of agencies that accredit university health sciences programs recently added standards for the acquisition of knowledge and skills with respect to interprofessional collaboration. Within primary care settings there are no practical training programs that allow students from different disciplines to develop competencies in this area.
Objective of the program The training program was developed within family medicine units affiliated with Université Laval in Quebec for family medicine residents and trainees from various disciplines to develop competencies in patient-centred, interprofessional collaborative practice in primary care.
Program description Based on adult learning theories, the program was divided into 3 phases—preparing family medicine unit professionals, training preceptors, and training the residents and trainees. The program’s pedagogic strategies allowed participants to learn with, from, and about one another while preparing them to engage in contemporary primary care practices. A combination of quantitative and qualitative methods was used to evaluate the implementation process and the immediate results of the training program.
Conclusion The training program had a positive effect on both the clinical settings and the students. Preparation of clinical settings is an important issue that must be considered when planning practical interprofessional training.
Primary health care professionals are facing an increase in patients presenting with multiple and varied biopsychosocial problems.1 Interprofessional collaboration is essential for managing these complex care situations.2 However, interprofessional collaborative practice in primary care faces a number of obstacles. Professionals sharing care treat outpatients presenting with a variety of problems and have few formal meetings to discuss cases, and they might even practice in different settings. The role of collaborator is 1 of the 7 key CanMEDS3 competencies physicians must develop. In addition, the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, and the Committee on Accreditation of Canadian Medical Schools are actively working with accreditation bodies in 5 other disciplines on the Accreditation for Interprofessional Health Education project.4
Family medicine units (FMUs) provide a variety of services adapted to community needs, contribute to research activities, and promote faculty development.5 Such clinical educational settings must tailor training programs for future health and social service professionals to the new realities of collaborative practice.6
A team composed of a social worker (L.P.), a physician (J.M.), and a nurse (F.P.) working in a Quebec city FMU tackled the challenge of developing and testing an interprofessional collaboration training program in French-speaking primary care educational settings. This educational program was part of a project involving Université Laval in Quebec and the Centre de santé et de services sociaux de la Vieille-Capitale in Quebec city, Que. The project was funded by Health Canada between 2005 and 2008 under the Interprofessional Education for Collaborative Patient-Centred Practice initiative, and it was approved by the Faculty of Medicine, the Faculty of Nursing, and the School of Social Work at Université Laval. As the whole project (development, implementation, and evaluation) was carried out in the context of an educational program, it was not subject to the same ethical rules (ie, approval from an ethics committee) as a research project would be.
The goal of this interprofessional practical training program for second-year family medicine residents and trainees in social work and nursing was to develop competencies for patient-centred, collaborative practice based on the specific knowledge, attitudes, and expertise required. The competencies and objectives are presented in Table 1. They reflect the objectives developed by the Royal College of Physicians and Surgeons of Canada3 and the National Interprofessional Competency Framework.7 Interprofessional education principles, which encourage 2 or more professions to learn with, from, and about one another to improve collaboration and the quality of care,8 guided the development of the educational strategies.
Program description
Before the program began, FMU and student participants were recruited and training sessions in the various FMUs were organized. Formal support from related university training programs helped encourage FMUs to participate. Recruiting FMU sites entailed meeting with FMU managers and professionals from each discipline likely to be involved in order to present a summary of the project. Training settings had to be able to accommodate social work and nursing trainees. The training program was divided into 3 phases.
Phase 1 consisted of 4 half-day sessions with professionals from each training setting to help them develop or strengthen their collaborative skills and prepare them to become role models for students. Before training, participants completed a survey about their clinical settings so that training could be adapted to their needs with a view to improving interprofessional collaboration.
Phase 2 focused on helping preceptors feel comfortable with the pedagogic material developed for the students. A half-day meeting was held to present the educational activities and material developed for residents and trainees.
Finally, phase 3 was designed for family medicine residents and social work and nursing trainees. It included 4, 90-minute workshops held during a 6-week period. Residents and trainees also took part in weekly 30-minute case discussions. Table 2 presents the themes and Box 1 outlines the educational strategies of phases 1 and 3.
Interprofessional collaboration training activities were incorporated into the family medicine residency program at each FMU. Each academic semester, meetings were held with the Faculty of Nursing and the School of Social Work to promote the training program and recruit students. Supported by colleagues, the training leader (L.P.) played a pivotal role in promoting and organizing the training program, coordinating activities based on the requirements of each academic program, and providing on-site support. It should be noted that no additional professional resources were added to the FMUs.
Evaluation design
The reference framework for the program evaluation was based on the combination of a classic health service evaluation framework, inspired by the work of Donabedian,9 and the logical model used to evaluate the Canadian Interprofessional Education for Collaborative Patient-Centred Practice initiative.10 It evaluated the program’s structural characteristics as well as its implementation processes, achievements (outputs), and immediate results. The team developed self-administered questionnaires using 5-point Likert scales (1 = strongly disagree, 5 = strongly agree). To evaluate the perceived acquisition of the skills targeted by the training program, questionnaires were administered before and after the training program. In the absence of validated questionnaires in French, the questions were developed based on literature on the subject and the pedagogic content of the training programs. They were reviewed and approved by the project leaders to ensure content validity. All questionnaires were completed anonymously and did not contain personal data. Supplemental data on factors associated with the implementation process were also collected in semistructured interviews with the project leader (L.P.).
Educational strategies
The following educational strategies were used:
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Exercises completed individually or in subgroups followed by full-group discussion of the key concepts of interprofessional collaboration through patients’ narration, clinical vignettes, video simulations, meetings with professionals from various disciplines, and summary slide shows
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Integration of the interprofessional collaboration process by
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-working in teams on issues determined by professionals and
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-experimental teamwork following simulated interviews in which students from various disciplines take turns meeting with the same patient
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Activities led by professionals from various disciplines
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Support for leaders during activities and follow-up between training sessions
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All clinical and educational opportunities were used during the training sessions to encourage collaboration
The compiled information was analyzed using a mixed quantitative and qualitative approach. SPSS, version 14.0, was used to analyze quantitative data through descriptive and parametric statistics. Nonparametric tests were also used for small samples. The averages obtained this way were used to calculate overall average scores for the statements. Qualitative data were subject to content analysis using NVivo 7.
Results
Participants’ characteristics
Professionals from 6 FMUs affiliated with Université Laval participated in phase 1 of the project. Phase 3 participants were second-year residents in family medicine, third-year undergraduate or graduate social work trainees, and second- and third-year undergraduate nursing trainees. Of the participating professionals, 35 of 42 completed their questionnaires, and 59 of 71 residents and trainees completed their questionnaires (an 83% response rate) (Table 3).
The resident-to-trainee ratio reflects the reality of clinical practice in family medicine in Quebec. For several FMUs, this was the first time they had had access to any social work or nursing trainees. Therefore, providing preceptors with ongoing support was critical.
Overall appreciation of themes
The professionals indicated that they appreciated the training themes, with an average score of 4.26 out of 5. The themes discussed in the training program earned an average of 4.00 among social work trainees, 4.44 among nursing trainees, and 3.70 among family medicine residents. The students particularly appreciated being able to better understand the roles and responsibilities of each professional.
Perception of knowledge and skills acquisition
The main goal of the training program was to improve primary caregivers’ skills and knowledge with respect to interprofessional collaboration. Comparison of the answers to the questionnaire before and after the training program shows that both professionals and students made considerable gains overall. These findings are presented in Table 4.
Change in attitude
The results from the retrospective questions showed that 51 participants had more positive attitudes toward interprofessional collaborative practice than they did before the training program. Moreover, 44.2% maintained their positive perceptions. Of all the participants, only 1 student did not have a positive or very positive perception of interprofessional collaboration in primary care after completing the training (Table 5).
Appreciation of pedagogic strategies and professionals as role models
Professional participants appreciated the obvious energy and teamwork of the training team, which always included representatives from the 3 disciplines. The team’s motivation led participants to adopt and pursue collaborative practices. Students appreciated the workshops and discussions of clinical cases. When asked to rate their level of agreement with the following statement “The pedagogical method made it possible to learn from, about, and with others” on a Likert scale from 1 to 5, the average for participating professionals was 4.45. For students, the average rating was 3.99 when asked about the workshops and 4.06 when asked about the clinical case discussions.
It is important to remember that the attitude of trainers and preceptors toward interprofessional training in patient-centred, collaborative practice is crucial because trainers and preceptors serve as role models and thus can influence students’ attitudes.11 The professionals were aware that they must first serve as an example, and the training gave them the tools to do so. Participating professionals rated their ability to act as role models for trainees and family medicine residents at 4.01 out of 5.
Still using the 5-point Likert scale, we asked residents and trainees to rate their appreciation of the trainers’ abilities to serve as role models. The 4.33 average obtained suggests that trainers and preceptors successfully assumed their roles in interprofessional training for patient-centred, collaborative practice.
Discussion
Apart from a few exceptions,12–14 most examples of practical interprofessional collaborative training come from experiments conducted in settings with more captive patient populations, such as those in geriatric, acute care, and rehabilitation units.15–19 This innovative experiment provided added value to existing practical training programs. That interprofessional collaboration is now essential speaks to the coherence and convergence of curriculums and the vision for organizing primary care and services.
The positive results obtained in terms of perceived knowledge and skills acquisition and changes in attitude regarding the possibility of working in settings with interprofessional collaboration are similar to those obtained in other projects.13,20–22 However, it is difficult to compare these studies with the present one owing to their very different content, duration, pedagogic approaches, and evaluation parameters. Unlike the other experiments, which emphasized clinical themes as a pretext for interprofessional collaboration training, the program developed here is dedicated specifically to interprofessional collaboration skills. The students ranked their level of agreement as lower than that of the professionals about the following statement: “The pedagogical method made it possible to learn from, about, and with others.” This could be owing to the different pedagogic methods used for the 2 groups and their perceptions of the usefulness of training on this subject. Professionals with less than 3 years’ experience who participated in phase 1 reported seeing little importance in the various aspects of interprofessional collaboration before being exposed to it in their practices.
One of the main goals of this training program was to equip professionals to act as role models in interprofessional practice and to be confident in their ability to play this role. The follow-up provided by the project leader (L.P.) enabled them to strengthen and validate their skills, and recognize and describe the aspects of interprofessional collaboration that needed to be addressed in clinical practice. This support is all the more important because most students learn to interact with their colleagues by observing the behaviour of professionals in educational settings. A study by Pollard23 shows that although students report that the interprofessional collaboration in their educational clinical settings is good, the behaviour described does not always correspond to that required for good collaborative practices. A number of authors have also noted discrepancies in how prepared preceptors are for practical training on interprofessional collaboration.19,23
As mentioned in other projects,24 the before-and-after measures used assume that participants are able to identify and gauge changes even before they have had the chance to put their learning into practice.
During the practical training period, the preceptors noticed that a climate of confidence and a better understanding of everyone’s contribution slowly emerged among students from different disciplines. The students confirmed that they were optimistic about the future possibility of working in settings with interprofessional collaboration.
The future of this interprofessional training program for collaborative practice hinges on the willingness of various stakeholders to maintain it and take part in its development. The family medicine residency program at Université Laval decided to make this training mandatory in each of its 12 affiliated FMUs by 2011. In time, preceptors will gain experience and become more comfortable with the pedagogic material, which will continue to be adapted to the knowledge that students gain in their preclinical courses. To maintain the interdisciplinary nature of the training program, the other faculties involved have been invited to take part in the process and officially appoint a person in charge of promoting and coordinating the program for social work and nursing trainees, and eventually for other disciplines.
Conclusion
The project faced several organizational challenges similar to those identified in the literature, such as preparing the practical clinical settings, identifying professionals to be responsible for activities in each FMU, and ongoing support.12,13
The pedagogic strategies appear to have allowed professionals, trainees, and residents to learn from, with, and about one another, which is the basis of interprofessional training.8 The pedagogic material and strategies developed for professionals and students can be adapted and made available in settings involving other academic training programs. In fact, phase 1 of the training has been successfully tested in the hospital setting.
Professionals and managers need to understand the implications of such a project and commit themselves to it to facilitate collaborative practice and develop role models in each field. Sustaining this type of practice requires administrators who make it a priority and agree to organize work in a way that fosters collaborative practice in a time of staff shortages.
Notes
EDITOR’S KEY POINTS
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Most examples of practical interprofessional collaborative training come from experiments conducted in settings with more captive patient populations, such as in geriatric, acute care, and rehabilitation units.
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One goal of this program was to develop competencies for patient-centred, collaborative practice based on the specific knowledge, attitudes, and expertise required. Another goal was to equip professionals to act as role models in interprofessional practice and to be confident in their ability to play this role in primary care.
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The positive results obtained in terms of perceived knowledge and skills acquisition, and changes in attitude about the possibility of working in settings with interprofessional collaboration, are similar to those achieved in other projects. The pedagogic strategies appeared to allow professionals, trainees, and residents to learn from, with, and about one another, which is the basis of interprofessional training.
POINTS DE REPÈRE DU RÉDACTEUR
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La plupart des exemples de formation pratique en collaboration interprofessionnelle proviennent d’expériences menées auprès de populations de patients captifs, par exemple en gériatrie, en soins aigus et en unités de réadaptation.
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L’un des buts de ce programme de formation interprofessionnelle pratique à l’intention des résidents de deuxième année de médecine familiale était de développer des compétences en vue d’une pratique en collaboration centrée sur le patient et fondée sur les connaissances, attitudes et expertises spécifiques requises. Un autre objectif important était de préparer les professionnels à agir comme modèles de rôle dans la pratique interprofessionnelle et à être confiants à l’égard de leur habileté à jouer ce rôle au niveau des soins primaires.
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Les résultats positifs obtenus pour ce qui est des connaissances et habiletés que les participants estimaient avoir acquises, et des changements d’attitude concernant la possibilité de travailler dans des contextes utilisant la collaboration interprofessionnelle, sont semblables à ceux obtenus dans d’autres projets. Les stratégies pédagogiques semblaient permettre aux professionnels, aux stagiaires et aux résidents d’apprendre des autres, avec les autres et sur les autres, ce qui est la base de la formation interprofessionnelle.
Footnotes
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This article has been peer reviewed.
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Cet article a fait l’objet d’une révision par des pairs.
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Contributors
Ms Paré was the project leader. She developed the content and educational strategies; coordinated the family medicine units and the trainees’ academic programs; recruited the preceptors and promoted the training among the students; and acted as a facilitator and coach throughout the project. Dr Maziade and Ms Pelletier co-led the project, worked on the educational context and strategies, and acted as facilitators. Ms Houle was the coordinator of the Interprofessional Education for Collaborative Patient-Centred Practice project and worked with the evaluation team. Mr Iloko-Fundi was the research professional for the coordination of the program evaluation process. All authors contributed to preparing the manuscript for publication and approved the final version.
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Competing interests
None declared
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