Realist approach to evaluating an interprofessional education program for medical students in clinical practice at a community hospital

A roadmap to realist interviews in health professions education research: Recommendations based on a critical analysis

CONTEXT

Realist evaluation is increasingly employed in health professions education research (HPER) because it can unpack the extent to which complex educational interventions work (or not), for whom under what circumstances and how. While realist evaluation is not wedded to particular methods, realist interviews are commonly the primary, if not only, data collection method in realist evaluations. While qualitative interviewing from an interpretivist standpoint has been well-articulated in the HPER literature, realist interviewing differs substantially. The former elicits participants' views and experiences of a topic of inquiry, whereas realist interviewing focuses on building, testing and/or refining programme theory. Therefore, this article aims to help readers better understand, conduct, report and critique realist interviews as part of realist evaluations.

METHODS

In this paper, we describe what realist approaches are, what realist interviewing is and why realist interviewing matters. We outline five stages to realist interviewing (developing initial programme theory, realist sampling/samples, the interview itself, realist analysis and reporting realist interviews), drawing on two illustrative cases from our own realist evaluations employing interviewing to bring theory to life. We provide a critical analysis of 12 realist evaluations employing interviewing in the HPER literature. Alongside reporting standards, and our own realist interviewing experiences, this critical analysis of published articles serves to foreground our recommendations for realist interviewing.

CONCLUSIONS

We encourage HPE researchers to consider realist interviews as part of realist evaluations of complex interventions. Our critical analysis reveals that realist interviews can provide unique insights into HPE, but authors now need to report their sampling approach, type of interviewing and interview questions more explicitly. Studies should also more explicitly draw on existing realist interviewing literature and follow reporting guidelines for realist evaluations. We hope this paper provides a useful roadmap to conducting, reporting and critically appraising realist interviews in HPER.

Culture and context in Interprofessional education: Expectations in Australia and Japan

The attributes of collaborative practice in health care vary across contexts, necessitating the adaptation of interprofessional education curricula to prepare students for the collaborative practice expected in their respective health care systems. Culture, when conceptualised through an organisational lens, allows an analysis of the shared assumptions, beliefs and values, without seeking to reduce to a uniform construct. This article explores the differences in interprofessional education competencies between Australia and Japan and considers the systems and patient expectations, which underpin each. While collaborative competence exhibits some similarities across contexts, competency frameworks differ in emphasis, language and key terminology, which highlight multiple points of difference in the expectations of interprofessional collaborative practice across contexts. There are education and practice consequences of these different perspectives of collaborative practice, in an increasingly mobile international workforce.

The effectiveness of community-based interprofessional education for undergraduate medical and health promotion students

BACKGROUND

Community-based interprofessional education (CBIPE) has been proven effective in enhancing the interprofessional competencies of medical and health professional students. However, there is a lack of evaluation on the impact of experiential CBIPE among undergraduate medical and health promotion students in Thailand. Therefore, the objective of this study is to assess the influence of CBIPE learning on the collaborative competencies of these students.

METHODS

A one-group pre-posttest design in 193 (152 medical students and 41 health promotion) students were involved in the CBIPE program, later divided into 12 groups. Data was collected by direct observations of mentors using the Interprofessional Collaborative Competencies Attainment Survey (ICCAS). The Wilcoxon matched-pairs signed-rank test was conducted to evaluate the effectiveness of the CBIPE program.

RESULTS

A total of 175 (90.67%) completed ICCAS and satisfaction questions before and after the CBIPE program. The mean age of respondents was 20.29 ± 1.63 years; 60.57% were women and 39.43% were men. The results showed a significant increase in collaborative competencies before and after the 2-week course. Gender-stratified analysis showed an improvement after CBIPE training for all subscales in women, while the communication, collaboration, conflict management, and functioning team skills segment score was significantly higher in the post-assessment among men.

CONCLUSION

The implementation of CBIPE learning was successful in enhancing collaborative competencies among both medical and health promotion students. These findings will provide valuable insights for the design and improvement of CBIPE learning programs in other universities.

Methods in realist evaluation: A mapping review

Realist evaluation is becoming increasingly popular as an evaluation methodology. Its main objective is to uncover the mechanisms that lead to observed outcomes following an intervention and the contextual conditions that enabled this. The focus is on explaining why, for whom and in what circumstances an intervention works. It is a theory-driven approach and is explicitly method neutral, meaning that both quantitative and qualitative data collection methods can be used to unearth the underlying mechanisms that cause the intervention outcomes. In this review, we aim to map the methods used in realist evaluation studies, to draw lessons from the findings and to reflect on ways forward. We found that qualitative methods and interviews specifically are most commonly used in realist evaluations; that theory is often absent behind the methods and sampling techniques used; and that more innovative methods remain underexplored. We conclude the review by proposing four ways forward: (1) developing realist surveys, (2) exploring the relevance of innovative methods, (3) increasing the attention paid to sampling procedures and (4) strengthening the theory-driven nature of method. We believe that these four action points can strengthen the practice of realist evaluation and its outcomes.

Realist approach to community-based participatory research on a community health break-down in Japan: mechanism reasoning, knowledge and a trust partnership

BACKGROUND

Our 10-year programme of community health regeneration and community-based participatory research (CBPR) was initially unknown. However, we succeeded in creating a collaboration between residents, medical staff, and administrative staff. We adopted a realist approach as an evaluation method.

METHODS

The realist approach evaluates a programme using a Context-Mechanism-Outcome configuration (CMOc), which is a relatively new methodology. First, the programme manager summarised the entire programme, conducted questionnaires and interviews with seven core members, and summarised each into a CMOc. The programme was evaluated with particular focus on mechanistic reasoning.

RESULTS

The number of doctors and nurses increased and residents became more active. The success factors were the acquisition of participants' knowledge and trust partnerships. In addition, it was important that the timing of the activity was good and that the participants were highly conscious.

CONCLUSIONS

The 10-year CBPR was examined using a realist evaluation method. Knowledge acquisition and trust partnerships are important for reasoning mechanism.

How do medical students learn about SDH in the community? A qualitative study with a realist approach

INTRODUCTION

The need to learn social determinants of health (SDH) is increasing in disparate societies, but educational interventions are complex and learning mechanisms are unclear. Therefore, this study used a realist approach to identify SDH learning patterns, namely context (C), mechanism (M), and outcomes (O) in communities.

METHODS

A 4-week clinical practice program was conducted for 5^th- and 6^th-year medical students in Japan. The program included SDH lectures and group activities to explore cases linked to SDH in the community. The medical students' structural reflection reports for learning SDH were thematically analyzed through CMO perspectives.

RESULTS

First, medical students anticipated the concept of SDH and participated in a community in which a social model was central. They then transformed their perspective through observational learning and explanations from role models. Second, medical students' confrontation of contradictions in the medical model triggered integrated explanations of solid facts. Third, conceptual understanding of SDH was deepened through comparison and verbalization of concrete experiences in multiple regions. Fourth, empathy for lay people was fostered by participating from a non-authoritative position, which differed from that in medical settings.

CONCLUSION

Medical students can learn about the connections between society and medicine through four types of SDH learning patterns.

Nurses’ Contributions in Rural Family Medicine Education: A Mixed-Method Approach

Family medicine residents frequently collaborate with nurses regarding clinical decisions and treatments, which contributes to their education. In rural areas, these residents experience a wider scope of practice by collaborating with nurses. However, nurses’ contributions to rural family medicine education have not been clarified. This study measured the contributions of 88 rural community hospital nurses to family medicine education using a quantitative questionnaire and interviews. The interviews were recorded, transcribed verbatim, and analyzed using the grounded theory approach. Nurses’ average clinical experience was 20.16 years. Nurses’ contributions to the roles of teacher and provider of emotional support were statistically lower among participants working in acute care wards than those working in chronic care wards (p = 0.024 and 0.047, respectively). The qualitative analysis indicated that rural nurses’ contributions to family medicine education focused on professionalism, interprofessional collaboration, and respect for nurses’ working culture and competence. Additionally, nurses struggled to educate medical residents amid their busy routine; this education should be supported by other professionals. Rural family medicine education should incorporate clinical nurses as educators for professionalism and interprofessional collaboration and as facilitators of residents’ transition to new workplaces. Subsequently, other professionals should be more actively involved in improving education quality.

The Perception of Rural Medical Students Regarding the Future of General Medicine: A Thematic Analysis

Although the demand for general physicians has increased in Japan because of its aging population, medical universities primarily provide organ-based education; thus, medical students do not receive sufficient general medical education. The number of residents focusing on general medicine remains low; therefore, to understand the present situation regarding general medicine education, we attempted to clarify the views of medical students and the factors influencing them. In this qualitative study, semi-structured interviews were conducted in 12 medical students at Shimane University, and the results were analyzed through thematic analysis. The results indicated the emergence of three themes and 14 concepts. The three overarching themes were as follows: hopes for the field of general medicine, gaps between ideal and reality of general medicine, and factors affecting students’ motivation for specialization in general medicine. Medical students had a positive impression of general medicine and believed that it has potential for further development; however, they felt a gap between their ideals and reality (i.e., unclear expertise). Factors creating this gap included poorly developed education and medical policies. We need to restructure general medicine education based on the participants’ perceptions by establishing collaborative curricula between universities and community hospitals and by increasing students’ exposure to general medicine.

Validation of the professional self-identity questionnaire for medical students during clinical practice in Japan

OBJECTIVES

To validate the Professional Self Identity Questionnaire (PSIQ) for medical students during clinical practice.

METHODS

We conducted a single-year longitudinal questionnaire study using the PSIQ. The PSIQ rates the nine items of "teamwork", "communication", "conducting assessment", "cultural awareness", "ethical awareness", "using records", "dealing with emergencies", "reflection", and "teaching" on a scale of 1-7 points. The study participants consisted of 118 fifth- and sixth-grade medical students who completed a mandatory 4-week clinical practice in a community-based medical education (CBME) curriculum. The data were collected before and after the CBME curriculum and after clinical practice at the time of graduation. To validate the internal structure of the PSIQ, we calculated Cronbach's alpha in the three phases. Additionally, to assess construct validity, we analyzed the trends and differences in each of the nine items of the PSIQ using repeated measures analysis of variance (ANOVA). We also showed the differences in effect size before and after the CBME curriculum.

RESULTS

The data of 105 medical students were analyzed. Cronbach's alpha in the three phases was 0.932, 0.936, and 0.939, respectively. PSIQ scores increased progressively for all items, and the F-test for repeated measures ANOVA of nine items' average score across the three phases showed a significant difference F_(2,208) = 63.59, p<0.001. The effect size for professional identity of cultural awareness before and after the CBME curriculum was 0.67, or medium.

CONCLUSIONS

We validated the PSIQ for medical students during clinical practice. Reflecting on professional identity may provide an opportunity for meaningful feedback on readiness to become a doctor.

Empathy, better patient care, and how interprofessional education can help

Interprofessional education (IPE) has been promoted as one way to prepare healthcare students for interprofessional encounters they might experience in the workplace. However, the link between IPE, interprofessional care in the workforce, and better patient outcomes is tenuous, perhaps in part due to the inability of IPE programs to adequately address barriers associated with interprofessional care (e.g., power differentials, role disputes). Empathy, or understanding the experiences of others, has emerged as a critical tool to breaking down barriers inherent to working in teams. Given the evidence connecting empathy to stronger team collaboration and better patient care, researchers significantly revamped programming from a prior training called Interprofessional Education for Complex Neurological Cases (IPE Neuro) to enhance empathy, foster stronger team collaboration, and improve information integration among participants. In this improved three-session program, participants from seven different professions were grouped into teams, assessed a patient volunteer with neurological disorder, and created and presented an integrated, patient-centric treatment plan. Students (N = 31) were asked to report general empathy levels, as well as attitudes, team skills, and readiness toward interprofessional care, before and after the program. We conducted paired samples t-tests and thematic analysis to analyze the data. Results showed that participants reported higher empathy levels, more positive attitudes, and greater team skills pre- to posttest with moderate to large effects. Results bolster IPE Neuro programming as one approach to prepare students for interprofessional care while underscoring the potential implications of IPE to improve empathy levels of healthcare professionals.

From uniprofessionality to interprofessionality: dual vs dueling identities in healthcare

Healthcare systems are at times still viewed as siloed performances of single professions, wherein some groups hold hierarchical positions based on their expertise and prestige, rather than a collective functioning of interprofessional teams. Current policies, procedures, and regulations in healthcare education and practice seem to contribute to this context in which the various health and social care professions are set in opposition to one another. The historical, and still prominent, uniprofessional education and socialization practices position health and social care professions to view each as rivals and threats toward achieving their profession/al advancement and growth. The transformation from uniprofessionality to interprofessionality in healthcare requires the application of interprofessional socialization not just at the individual level, but also at the professional and system levels. In this process of interprofessional socialization, we need to embrace the uniqueness of each profession while cultivating an interprofessional collaboration culture in the system (dual identity). In so doing, we can facilitate a shifting mind-set, culture, operations, and policies in healthcare to recognize and foster the contribution and accountability of each profession toward achieving the quadruple aim of better care, better health, better value, and better work experience.

Stimulating Students' Interprofessional Teamwork Skills Through Community-Based Education: A Mixed Methods Evaluation

Background

Interprofessional education (IPE) is suggested as a good means to prepare future healthcare professionals for collaborative work in interprofessional teams enabling them to solve complex health problems. Previous studies have advocated experiential IPE, including community-based IPE (CBIPE). This study aims to evaluate a CBIPE programme by exploring the students’ perception toward CBIPE design and toward groups’ teamwork.

Methods

To identify students’ perceptions of teamwork, the Interprofessional Teamwork Evaluation questionnaire was administered to 254 students of medical, nursing and midwifery programme. Three uni-professional focus group (FG) discussions were conducted to analyse the students’ perception of the design of community-based education and underlying reasons for teamwork.

Results

FGs reported three aspects that influence skills development in collaborative practice among students that shed light on why midwifery and nursing students held less positive perceptions of communication and mutual support: 1) communication gap due to lack of confidence, 2) contrasting ways of thinking affect communication in decision-making, and 3) the leadership culture in the health services.

Conclusion

A CBIPE programme was successfully implemented at Universitas Islam Sultan Agung. It demonstrated that students in the health professions can develop skills in collaborative practice despite having some problems with communication and mutual support.