Interprofessional education in primary care for the elderly: a pilot study

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Interprofessional education in primary care for the elderly: a pilot study
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  RESEARCH ARTICLE Open Access Interprofessional education in primary care forthe elderly: a pilot study Barth Oeseburg 1* , Rudi Hilberts 2 , Truus A Luten 3 , Antoinette VM van Etten 4 , Joris PJ Slaets 5 and Petrie F Roodbol 1,2 Abstract Background:  The Dutch health care system faces huge challenges with regard to the demand on elderly care andthe competencies of nurses and physicians required to meet this demand.At present, the main focus of health care in the Netherlands lies on illness and treatment. However, (frail) elderlyneed care and support that takes their daily functioning and well-being into consideration as well. Therefore, healthcare professionals, especially those professionals working in primary care such as GPs and practice nurses, will bechallenged to a paradigm shift in emphasis from treating illness to promoting health (healthy ageing). Interprofes-sional education is necessary to realise this shift in professional behaviour. Evidence indicates that interprofessionaleducation (IPE) can play a pivotal role in enhancing the competencies of professionals in order to provide elderlycare that is both effectively, integrated and well-coordinated. At present, however, IPE in primary care is rarelyutilised in the Netherlands. Therefore, the aim of this pilot study was to develop an IPE program for GPs andpractice nurses and to evaluate the feasibility of an IPE program for professionals with different educationalbackgrounds and its effect on the division of professionals ’  tasks and responsibilities. Methods:  Ten GPs and 10 practice nurses from eight primary care practices in two provinces in the north of theNetherlands, Groningen and Drenthe (total population about 1.1 million people), participated in the pilot IPEprogram. A mixed methods design including quantitative and qualitative methods was used to evaluate the IPEprogram. Results:  During the program, tasks and responsibilities, in particular those related to the care plan, shifted from GPto practice nurse. The participants ’  attitude toward elderly (care) changed and the triage instrument, the practicaltool for prioritising preferences of the elderly and discussing their medication use, was considered to have anadded value to the development of the care plan. Conclusions:  The results of this pilot study show that an interprofessional education program for professionals withdifferent educational backgrounds (GPs and practice nurses) is feasible and has an added value to the redefining of tasks and responsibilities among GPs and practice nurses. Keywords:  Interprofessional, Learning, Primary care, Physician, Nursing Background The Dutch health care system faces huge challenges withregard to the demand on elderly care and the competenciesof nurses and physicians required to meet this demand,especially in primary care. However, the various partiesinvolved (the elderly, professionals, policy makers) feel thatthe competencies they currently possess are insufficient tomeet the increasingly complex needs of the elderly [1-6].The number of elderly persons (> 65 years) in theNetherlands (total population of about 16.7 million people)is growing rapidly from about 2.5 million to 4.1 million in2030. In addition, the number of frail elderly is likely toincrease between 2010 and 2030 from about 650,000 toover one million [2]. Approximately 95% of the elderly liveindependently at home and are registered with a generalpractitioner (GP). In turn, approximately 25% of the elderly who live independently are frail [2]. * Correspondence: b.oeseburg@umcg.nl 1 Wenckebach Institute, School of Nursing and Health, University MedicalCentre Groningen, University of Groningen, P.O. Box 30.001, 9700 RBGroningen, The NetherlandsFull list of author information is available at the end of the article © 2013 Oeseburg et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the srcinal work is properly cited. Oeseburg  et al. BMC Medical Education  2013,  13 :161http://www.biomedcentral.com/1472-6920/13/161  As a consequence of the growing number of elderly,the need for complex care will also increase.At present, health care in the Netherlands focusesmainly on illness and treatment. In addition, (frail)elderly have expressed unmet needs regarding daily functioning and well-being. Therefore, health care pro-fessionals, especially in primary care, will be challengedto a paradigm shift in emphasis from treating illness topromoting health (healthy ageing) [2-6].To meet the needs of the (frail) elderly and to optimisetheir daily functioning and well-being, while at the sametime controlling the increasing costs, a well-structuredand fully integrated care system is needed. Care shouldbe organised in the desired living environment of theelderly, which, in most cases, will be their own homes.The system needs to focus on the following aspects[7-9]: prevention of physical, psychological, and socialproblems on an individual and group level; early de-tection and comprehensive assessment of physical andpsychosocial needs; the delivery of effective care arrange-ments covering a wide range of health care and commu-nity services; coordination of care and interprofessionalcooperation; ongoing follow-up of the elderly; productiveinteraction between the elderly and professionals toempower the elderly to manage and adapt to ageing; andpromoting healthy ageing and well-being.Ideally, primary care professionals, such as GPs andpractice nurses (registered nurses or practice assistantswith vocational education employed by GPs), shouldplay a central role in the care for the elderly [2,5,6,10].GPs already play a key role in the Dutch health caresystem and function as gatekeepers for other community and institutional services. A substantial number of GPsemploy practice nurses in their practices, particularly forthe care given to chronically ill patients, e.g. patientswith diabetes or asthma/COPD. Care to these groups isbased on cooperation and coordination between GP andpractice nurse and involves shared responsibilities andadequate specifications of responsibilities delegated fromGP to practice nurses. However, as mentioned before,the provision of care to these groups is mainly focusedon treating illness and does not meet the needs of the(frail) multimorbid elderly [2,3,6-9]. The organisation of the care for complex patients needs to be defragmentedin order to meet the new demands [2,4-9].To realise a well-structured and fully integratedprimary care system, a shift in professional behaviour,particularly in the domains of proactive/preventive care,coordination of care, and communication and cooper-ation with the elderly and other professionals, is neces-sary. In addition, a redesign of tasks and responsibilitiesof GPs and practice nurses is expected to improve thequality of elderly care [2,5-9]. Professional behaviour isinextricably linked to the education of professionals.However, the curricula for initial and secondary educa-tion for professionals are not suited to educate profes-sionals in the competencies that are necessary for elderly care, because these curricula focus mainly on disease-related competencies and competencies relevant to theirown profession [11-13]. Changing professional behaviourand initiating a fully integrated and well-coordinatedprovision of elderly care, with shared responsibilities andadequate specifications of delegated responsibilities, re-quires interprofessional education (IPE) [2,5,6,14]. Evi-dence indicates that IPE can enhance the competenciesof professionals, which will lead to an improvement inthe quality of health care and better patient outcomes[15,16]. At present, however, IPE in primary care israrely utilised in the Netherlands. Therefore, a pilotstudy was initiated. The aim of this pilot study is todevelop an IPE-program for GPs and practice nursesand to evaluate both the feasibility of an IPE programfor professionals with different educational levels andthe effect such a program will have on the division of their tasks and responsibilities. Methods Intervention An IPE program, based on a social constructivistapproach and consisting of four half-day shared sessions,was developed [17]. The social constructivist approachemphasises the collaborative nature of learning. Learningis an active process, embedded in social and physicalcontexts in which learners construct their own compe-tencies based on prior competencies. Cooperation withothers creates the opportunity to define or refine learners ’ understanding and to create shared understandings withrespect to the division of tasks and responsibilitiesbetween GPs and practice nurses.During the IPE program, GPs and practice nursesprepared themselves for the shared education sessionsby reading relevant literature and the GP and practicenurse prepared practical assignments based on casesgenerated from their own local practice. Experts gaveshort lectures and led the plenary sessions in which thepractical assignments were discussed and reflected on.Draft versions of the IPE program were discussed withexpert group (GPs, practice nurses, geriatrician). Theeducational aim of the program was to realise a shift intasks and responsibilities from GP to practice nurse.The following objectives were outlined for the sessions: Session 1: Vision on elderly care and triage. The aim of this session was: to examine knowledge of and attitudestoward the elderly and elderly care; to explore the useof a comprehensive Web-based triage screeninginstrument, based on the INTERMED [18-20], the ‘ Groningen Frailty Indicator ’  [21,22], and the Oeseburg  et al. BMC Medical Education  2013,  13 :161 Page 2 of 7http://www.biomedcentral.com/1472-6920/13/161  Groningen Well-being Indicator [23]; and to collectdata on the medical, psychosocial, and functionalcapabilities and limitations of all elderly patients in theparticipating primary care practices.Session 2: Care plan. The aim of the second sessionwas to develop a comprehensive care plan based on thecare plan developed by the Dutch College of GeneralPractitioners [24] and a practical tool to prioritisepreferences of the elderly and discuss their medicationuse, based on Fried et al. [25].Session 3: Thinking in groups. In this session, elderly patients were empirically categorised into fivemeaningful segments (primary segmentation) withdifferent health-related needs: vital problems,psychosocial coping problems, physical and mobility problems, problems in multiple domains, and problemscaused by extremely frailty. These segments arecharacterised by the significant relations found withgender, age, frailty, bio-psychosocial complexity, livingarrangements, well-being, and preferred decisionalcontrol [26]. Segmenting the elderly based on theirneeds offers GP and practice nurse the possibility tointervene proactively; not only on an individual levelbut also on a group level. A proactive intervention plancan prevent health problems in the elderly and can helpkeep chronically ill patients as vital as possible.Session 4: Reflection and feedback on the IPE program.In this session the final practical assignment (session 3)was discussed and reflected on. In addition, the IPEprogram was evaluated with the participants andappointments were made for further evaluation. Participants and procedure A convenience sample of 10 GPs and 10 practice nursesfrom eight primary care practices in two provinces inthe north of the Netherlands, Groningen and Drenthe,(total population about 1.1 million people) participated.Six primary care practices were informed of the projectduring a meeting on a transition experiment in elderly care in Groningen in which they participated. Two pri-mary care practices (in Drenthe) were informed by oneof the project members and received additional educa-tional materials.A mixed methods design including quantitative andqualitative methods was used to evaluate the IPEprogram. The division of tasks and responsibilities of GPs and practice nurses was measured by a VAS scale.The following indicators were measured: case finding,the assessment of medical and psychosocial functioningand recording, medication, the development of a com-prehensive care plan, discussion with the elderly on thecare plan, execution of the care plan, consultation of other professionals in health and community care, andmonitoring the care (plan).The score on each indicator could range from 0 (tasksand responsibilities of the practice nurse) to 10 (tasks andresponsibilities of the GP). For example, a score of score 5indicated full cooperation between GP and practice nurse.Primary care practices (the GP and practice nurse) wereasked to rate the division of tasks and responsibilitiesbefore and during the program and to state their futurepreferences. Four of the eight primary care practicesresponded.The quality of the program was measured by a ques-tionnaire developed by the Wenckebach Institute aimedat evaluating educational programs. This questionnaireis based on Kirkpatrick ’ s model of evaluating trainingprograms [27] and measures the quality of the followingindicators: added value of the lectures; clarity, practic-ability, and added value of the practical assignments; andsuitability of the program to facilitate change withinpractices. The score on each indicator can range from 0(strongly disagree) to 5 (strongly agree).In addition to filling in the questionnaire, the parti-cipants were asked to report positive features of theprogram and to give advice on how to improve theprogram. The response rate was 60% (N=20). Finally,semi-structured telephone interviews were conductedwith primary care practices (GPs and practice nurses)which addressed the following issues: the participants ’ expectations with regard to the program; changes in theirattitude with regard to elderly and elderly care; suitability of the program to facilitate change within practices;change, or intentions to change tasks and responsibilitiesof the GP and practice nurse; and advice to improve theprogram. All the interviews with both GPs and practicenurses were tape-recorded and transcribed. Six out of eight primary care practices responded (response rate75%). In total, six GP ’ s and six practice nurses wereinterviewed. Analysis The raw descriptive data of the VAS scale were used toanalyse the division of tasks and responsibilities of theprimary care practices (N= 4) before and during theprogram and to list their wishes regarding the divisionof tasks and responsibilities in the future. Next, themean score and standard deviation were calculated forthe scores obtained on the Wenckebach Institute ’ s qual-ity questionnaire. Subsequently, scores for each session[1-3] were calculated. Finally, the recorded telephoneinterviews were transcribed for analysis. Two researchersindependently analysed and categorised the data into thethemes that structured the interview [28]. Ethical approval The project was funded by a grant from ZonMW (TheNational Care for the Elderly Program: 310300003; The Oeseburg  et al. BMC Medical Education  2013,  13 :161 Page 3 of 7http://www.biomedcentral.com/1472-6920/13/161  Netherlands Organisation for Health Research andDevelopment) as well as by the University MedicalCentre Groningen (UMCG). The study was presented tothe ethical review board of the UMCG, which did notfind further approval necessary. Results Tasks and responsibilities During the IPE program, a shift in tasks and responsibil-ities from GPs to practice nurses in the primary carepractices took place, especially with regard to tasks andresponsibilities related to the care plan. A shift in tasksand responsibilities between GP and practice nurses oncase finding and medication did not occur during theIPE program. In addition, in most primary care practicesthere is a need for a greater shift in tasks and responsi-bilities on activities with regard to the care plan fromGP to practice nurses in the future (Table 1). Quality of the program The mean scores on the Wenckebach Institute ’ s quality questionnaire on the three indicators in session one andtwo all ranged from 3 (neither agree nor disagree) to 4(agree). In session three, the mean scores ranged from 3to 2 (disagree) (Table 2). However, most deviations of the means are considerably large, indicating considerable variation in the answers of the respondents. Expectation Despite their willingness to participate in the IPE pro-gram, five of the interviewed participants (N= 12) indi-cated that they did not have any explicit expectations of the IPE program. The other seven participants expressedexpectations with respect to learning more about usingthe triage instrument and learning to interpret and man-age the data on the functioning of the elderly in theirown primary care practices. Participants also expected tobe offered practical tools and evidence-based interven-tions for handling problems specific to the elderly. Changes in attitude Most of the interviewed participants indicated that theIPE program changed their attitudes toward the elderly and care for the elderly. Key insights gained from theprogram included the importance of taking the patient ’ sperspective into account in the planning of care; beingmore proactive and preventing problems instead of being reactive and solving problems; becoming moreattentive to the needs of the elderly due to the risk of multimorbidity; and realising that elderly care comprisesmore than just disease management. Four participantsalso indicated that the collaboration with other disci-plines and other primary care practice led to a change intheir attitudes toward elderly care. Suitability of the program and change within practices Most of the interviewed participants indicated that thelectures and practical assignments with regard to thetriage instrument and the care plan had already initiateda shift in tasks and responsibilities from GP to practicenurse or that there was at least an incentive to realisethis shift. However, most participants also pointed outthat they required more concrete information andtraining on the following items of the program: thetriage instrument, individual care plans, practical toolsand evidenced based interventions for handling certainproblems in the elderly, and the availability of health Table 1 Tasks and responsibilities GPs and practicenurses before, during the program and desirable in thefuture (N=4 primary care practices) 0 1 PN 2 1 2 3 4 5 Both 6 7 8 9 10 GP Case finding Before 1 3During 1 3Future 4  Assessment of: medical and psychosocial functioning and recording Before 1 2 1During 1 3Future 2 2 Medication Before 1 1 2During 1 1 2Future 1 1 2 Development of a comprehensive care plan Before 1 1 1During 2 1Future 1 1 1 Execution of the care plan Before 1 1 1During 1 1 1Future 1 1 1 Consultation of other professionals in health and community care Before 2 1 1During 2 1 1Future 2 1 1 Monitoring the care(plan) Before 1 3During 1 3Future 2 1 1 1. Score range: 0 (tasks and responsibilities of the practice nurse) to 10 (tasksand responsibilities of the GP); the score 5 indicated (full cooperation betweenGP and practice nurse).2. PN=practice nurse. Oeseburg  et al. BMC Medical Education  2013,  13 :161 Page 4 of 7http://www.biomedcentral.com/1472-6920/13/161  care and community resources that can be linked up toprimary care.All of the interviewed participants indicated that thelecture and practical assignment on thinking in groups(segments of elderly) was too scientific and not directly suitable for primary care practice. Another issue thatbecame apparent during the sessions was that the partic-ipants did not have a procedure in mind for dealing withcomplex patients, nor was the number of such patientsin their own practices known to them.One participant indicated that the IPE program hadno added value at all. Advice to improve the program The participants offered several suggestions for improvingthe program. Twelve participants desired more informa-tion and training on: the interpretation and managementof the data generated by the triage instrument; the devel-opment of comprehensive care plans, practical tools, andevidenced- based interventions for handling problemsspecific to the elderly; training in communication skills;lectures and training on moral dilemmas; and informationon the availability of health care and community resourcesto link up to primary care. They also expressed a need forpractical tools for the prevention and management of (potential) health problems in the elderly (individual leveland segmentation level). Conclusion and discussion The results of this pilot study show that an interpro-fessional education (IPE) program for professionals withdifferent educational levels, in particular GPs and prac-tice nurses in primary care, is feasible and has an added value to the redefining of tasks and responsibilities.During the program, tasks and responsibilities, inparticular with respect to the care plan, shifted from GPto practice nurse. The program had a positive impact onthe participants ’  attitude toward elderly (care), and thetriage instrument in particular was considered to havean added value to the development of the care plan.Despite the fact that the IPE program was developed inclose cooperation with expert groups, the program didnot entirely meet the expectations of the participants. Thelength of the program, four half day sessions, was deemedtoo short to adequately increase the knowledge on, forexample, the interpretation of the data generated by thetriage instrument. The program was also too short toaddress the needs of the participants regarding practicaltools and evidenced based interventions to handle certainproblems in the elderly. Furthermore, participants foundthe information on the IPE program too concise, and GPsdid not inform their practice nurses sufficiently about theprogram ’ s content. Indeed, this latter point could haveinfluenced the expectations of the participants and thesubsequent success of the program [29].However, this was a pilot study, and one characteristicof a pilot study is that participants are both subjects anddevelopers of the intervention at the same time. Theresults of this pilot study and the participants ’  suggestionsfor improvement will be used to develop an adaptedinterprofessional education program for GPs and practicenurses. Strengths and limitations The strength of this study is that it is the first study inthe Netherlands that focuses on interprofessional educa-tion in primary care practice. Another strength was thatthe program was developed in collaboration with thetarget groups.However, this pilot study was limited in both scale andscope. Therefore, the findings should be interpreted withcaution. First, the participants were recruited via ournetwork and could be characterised as innovators [30].Second, we did not employ a comparison group and thenumber of participants was also limited. Third, the VASscale used to measure a shift in tasks and responsibilitiesfrom GP to practice nurse was developed specifically forthe program and has not been validated in research as yet. Finally, factors influencing the shift of tasks andresponsibilities were not evaluated, and the effects onthe health care system and patient outcomes were notincluded in the pilot study. Findings in relation to other studies To our knowledge, there is a paucity of literature oninterprofessional education specifically pertaining to GPs Table 2 Means and standard deviations on the Wenckebach Institute quality of the program questionnaire (N=12) Session 1 Session 2 Session 3Vision elderly care/triage Care plan Thinking in groups Mean sd  1 Mean sd Mean sd  Added value of the lectures 3.94 2 .33 3.67 .39 3.00 .71Clarity, practicability and added value of the practical assignments 3.32 .75 3.60 .63 2.64 .84Suitability of the program to facilitate change within practices 3.82 .87 3.41 .63 2.82 .98 1. sd=standard deviation.2. score range: 0 (strongly disagree) to 5 (strongly agree), score 3 indicates not disagree/not agree. Oeseburg  et al. BMC Medical Education  2013,  13 :161 Page 5 of 7http://www.biomedcentral.com/1472-6920/13/161
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