A collaborative strategy to improve geriatric medical education

New horizons in undergraduate geriatric medicine education

Current projections show that between 2000 and 2050, increasing proportions of older individuals will be cared for by a smaller number of healthcare workers, which will exacerbate the existing challenges faced by those who support this patient demographic. This review of a collection of Age and Ageing papers on the topic in the past 10 years explores (1) what best practice geriatrics education is and (2) how careers in geriatrics could be made more appealing to improve recruitment and retention. Based on these deeper understandings, we consider, as clinician educators, how to close the gap both pragmatically and theoretically. We point out paradigm shifting solutions that include innovations at the Undergraduate level, use of simulation, incorporation of learner and patient perspectives, upskilling professionals outside of Geriatrics and integration of practice across disciplines through Interprofessional Learning. We also identify an education research methodological gap. Specifically, there is an abundance of simple descriptive or justification studies but few clarification education studies; the latter are essential to develop fresh insights into how Undergraduate students can learn more effectively to meet the needs of the global ageing challenge. A case of improving understanding in delirium education is presented as an illustrative example of a new approach to exploring at greater depth education and outlines suggested directions for the future.

The Use of Simulated Patients Is more Effective than Student Role Playing in Fostering Patient-Centred Attitudes during Communication Skills Training: A Mixed Method Study

Objective

While simulated patients (SPs) are considered a standard tool in communication skills training, there is no evidence thus far of their comparative benefit to the more cost-effective option of student role playing. We compared the effectiveness of both approaches in developing patient-centred attitudes in students.

Methods

We retrospectively compared students who participated in the clinical communication course (CCC), based on student role playing (CCCsp-, n = 160), to students who participated in the CCC with SPs (CCCsp+, n = 146), and students with no formal CCC (CCC-, n = 122). We used validated questionnaires to assess patient centredness. We also conducted focus group interviews (FGI) to better understand the impact of CCC with sp.

Results

Students after the CCC with simulated patients achieved a significantly higher score in the patient-practitioner orientation scale than other groups (p < 0.001).

Conclusions

There is a strong positive correlation between the implementation of simulated patients and patient-centred attitudes among students. Data from the FGI revealed that students perceived training with SP as more realistic, safe, and engaging than student role playing. Practice Implications. Our research provides evidence to justify costs and resources invested in simulated patient programs.

A scoping review of the changing landscape of geriatric medicine in undergraduate medical education: curricula, topics and teaching methods

PURPOSE

The world's population is ageing. Therefore, every doctor should receive geriatric medicine training during their undergraduate education. This review aims to summarise recent developments in geriatric medicine that will potentially inform developments and updating of undergraduate medical curricula for geriatric content.

METHODS

We systematically searched the electronic databases Ovid Medline, Ovid Embase and Pubmed, from 1st January 2009 to 18th May 2021. We included studies related to (1) undergraduate medical students and (2) geriatric medicine or ageing or older adults and (3) curriculum or curriculum topics or learning objectives or competencies or teaching methods or students' attitudes and (4) published in a scientific journal. No language restrictions were applied.

RESULTS

We identified 2503 records and assessed the full texts of 393 records for eligibility with 367 records included in the thematic analysis. Six major themes emerged: curriculum, topics, teaching methods, teaching settings, medical students' skills and medical students' attitudes. New curricula focussed on minimum Geriatrics Competencies, Geriatric Psychiatry and Comprehensive Geriatric Assessment; vertical integration of Geriatric Medicine into the curriculum has been advocated. Emerging or evolving topics included delirium, pharmacotherapeutics, healthy ageing and health promotion, and Telemedicine. Teaching methods emphasised interprofessional education, senior mentor programmes and intergenerational contact, student journaling and reflective writing, simulation, clinical placements and e-learning. Nursing homes featured among new teaching settings. Communication skills, empathy and professionalism were highlighted as essential skills for interacting with older adults.

CONCLUSION

We recommend that future undergraduate medical curricula in Geriatric Medicine should take into account recent developments described in this paper. In addition to including newly emerged topics and advances in existing topics, different teaching settings and methods should also be considered. Employing vertical integration throughout the undergraduate course can usefully supplement learning achieved in a dedicated Geriatric Medicine undergraduate course. Interprofessional education can improve understanding of the roles of other professionals and improve team-working skills. A focus on improving communication skills and empathy should particularly enable better interaction with older patients. Embedding expected levels of Geriatric competencies should ensure that medical students have acquired the skills necessary to effectively treat older patients.

Interprofessional education in geriatric medicine: towards best practice. A controlled before-after study of medical and nursing students

OBJECTIVES

To investigate nursing and medical students' readiness for interprofessional learning before and after implementing geriatric interprofessional education (IPE), based on problem-based learning (PBL) case scenarios. To define the optimal number of geriatric IPE sessions, the size and the ratio of participants from each profession in the learner groups, the outcomes related to the Kirkpatrick four-level typology of learning evaluation, students' concerns about joint learning and impact of geriatric IPE on these concerns. The study looked at the perception of roles and expertise of the 'other' profession in interprofessional teams, and students' choice of topics for future sessions. Students' expectations, experience, learning points and the influence on the understanding of IP collaboration, as well as their readiness to participate in such education again were investigated.

DESIGN

A controlled before-after study (2014/2015, 2015/2016) with data collected immediately before and after the intervention period. Study includes additional comparison of the results from the intervention with a control group of students. Outcomes were determined with a validated 'Readiness for Interprofessional Learning' questionnaire, to which we added questions with free comments, combining quantitative and qualitative research methods. The teaching sessions were facilitated by experienced practitioners/educators, so each group had both, a clinician (either geratology consultant or registrar) and a senior nurse.

PARTICIPANTS

300 medical, 150 nursing students.

SETTING

Tertiary care university teaching hospital.

RESULTS

Analysis of the returned forms in the intervention group had shown that nursing students scored higher on teamwork and collaboration post-IPE (M=40.78, SD=4.05) than pre-IPE (M=34.59, SD=10.36)-statistically significant. On negative professional identity, they scored lower post-IPE (M=7.21, SD=4.2) than pre-IPE (M=8.46, SD=4.1)-statistically significant. The higher score on positive professional identity post-IPE (M=16.43, SD=2.76) than pre-IPE (M=14.32, SD=4.59) was also statistically significant. Likewise, the lower score on roles and responsibilities post-IPE (M=5.41, SD=1.63) than pre-IPE (M=6.84, SD=2.75).Medical students scored higher on teamwork and collaboration post-IPE (M=36.66, SD=5.1) than pre-IPE (M=32.68, SD=7.4)-statistically significant. Higher positive professional identity post-IPE (M=14.3, SD=3.2) than pre-IPE (M=13.1, SD=4.31)-statistically significant. The lower negative professional identity post-IPE (M=7.6, SD=3.17) than pre-IPE (M=8.36, SD=2.91) was not statistically significant. Nor was the post-IPE difference over roles and responsibilities (M=7.4, SD=1.85), pre-IPE (M=7.85, SD=2.1).In the control group, medical students scored higher for teamwork and collaboration post-IPE (M=36.07, SD=3.8) than pre-IPE (M=33.95, SD=3.37)-statistically significant, same for positive professional identity post-IPE (M=13.74, SD=2.64), pre-IPE (M=12.8, SD=2.29), while negative professional identity post-IPE (M=8.48, SD=2.52), pre-IPE (M=9, SD=2.07), and roles and responsibilities post-IPE (M=7.89, SD=1.69), pre-IPE (M=7.91, SD=1.51) shown no statistically significant differences. Student concerns, enhanced understanding of collaboration and readiness for future joint work were addressed, but not understanding of roles.

CONCLUSIONS

Educators with nursing and medical backgrounds delivered geriatric IPE through case-based PBL. The optimal learner group size was determined. The equal numbers of participants from each profession for successful IPE are not necessary. The IPE delivered by clinicians and senior nurses had an overall positive impact on all participants, but more markedly on nursing students. Surprisingly, it had the same impact on medical students regardless if it was delivered to the mixed groups with nursing students, or to medical students alone. Teaching successfully addressed students' concerns about joint learning and communication and ethics were most commonly suggested topics for the future.

Paid worker and unfamiliar partner communication training: A scoping review

BACKGROUND

Communication partner training could be employed to train people working in the community to facilitate interaction with individuals who live with a variety of communication disorders. However, current evidence syntheses are limited to a single disorder (e.g., aphasia) and focus on a variety of familiar and unfamiliar communication partners. An understanding of the scope of literature across the evidence-base of acquired neurological populations may provide a better basis to develop interventions and future research tailored for community workers.

AIMS

To explore the scope of literature on paid worker and unfamiliar partner communication training for acquired neurogenic communication disorders with a focus on describing: 1) the types of communication disorders addressed by interventions; 2) the types of learners who received the interventions; 3) the nature of the interventions; and 4) the reported effects on trainees and people with a communication disorder.

METHODS & PROCEDURES

A scoping review was conducted. Studies were selected by a systematic keyword search, undertaken through four databases. Eligibility criteria included studies that: (i) reported an intervention directed at paid workers or unfamiliar partners where the primary goal was to improve communication with people with acquired neurogenic communication disorders, (ii) reported original results, (iii) contained quantitative or qualitative data on the effects of the intervention, (iv) were written in English or French and (v) were published in a peer-reviewed journal. The PRISMA-ScR was used to guide design and reporting of the scoping review.

RESULTS

Seventy publications met the inclusion criteria. Interventions were mostly disorder-specific and addressed communication with people with dementia, aphasia or traumatic brain injury. 15/70 studies examined training programs that were not restructured to a specific population (e.g., aphasia). Learners were mostly working or studying in the healthcare field and only 2/70 studies included community workers without primarily health training. Sixty different interventions were reported and were mostly delivered by speech-language pathologists. Training varied in terms of duration (a few minutes to 46 h) and content, but many shared training methods (e.g., presentation of theory on communication disorders). Nearly all studies demonstrated positive results, 23/26 studies suggested that paid worker and unfamiliar partner communication training may increase the knowledge of trainees, 24/26 studies suggested that it could improve their confidence when interacting with people with a communication disorder and 44/46 studies suggested that it could improve the trainees' communication abilities.

CONCLUSION

A small developing evidence-base exists for communication training programs for paid and unfamiliar communications partners that focuses beyond a single diagnosis or disorder. However, there is very limited knowledge on interventions for community workers from non-health professions. Future research should focus on the evaluation of existing programs tailored to, or explicitly designed for this context with the aim of identifying active ingredients that lead to improved and sustainable outcomes.

Dementia care boot camp: interprofessional education for healthcare students

Dementia prevalence is increasing exponentially and has a profound effect on individuals diagnosed as well as their family caregivers. Dementia care should be patient focused, not task or medically oriented. Patient-centered dementia care requires more staff time, is complex, and, as a result, financially threatens the healthcare system. Therefore, professionals must be prepared to meet the needs of this growing population. The aims of this mixed methods study were to examine the effect of a 16-h interprofessional program on healthcare students' dementia knowledge, attitudes toward people with dementia, confidence for dementia care and empathy, and to understand the relationships among the listed variables. Nursing, occupational therapy assistant, pharmacy, and psychology students participated in a 16-h team-based learning Dementia Care Bootcamp. Students reported significant improvements in dementia attitudes and knowledge, confidence for dementia care and empathy immediately after Bootcamp and 3 months later. Significant relationships among listed variables were noted. Qualitative data complemented the quantitative findings. In addition, the concept of dementia care competency emerged. Students recognized the benefits of learning about, with and from others from diverse professions. Interprofessional education has great potential to improve students' ability to care for people with dementia.

Interventions to Enhance Empathy and Person-Centered Care for Individuals With Dementia: A Systematic Review

Empathy, or the ability to imagine what someone else may be feeling or thinking, is a crucial component of meaningful care provision, including person-centered care (PCC), and has been shown to enhance care provider and patient well-being. The purpose of the current review was to examine the impact of interventions focused on improving the ability of health care providers or students to experience and/or communicate with empathy. Of 1,427 publications reviewed, 18 articles met inclusion criteria. All studies incorporated empathy or empathic communication competencies in their training or intended variables of change. PCC concepts were used in guiding the development of most interventions. Some interventions significantly improved participant empathy, attitudes toward patients with dementia, and certain verbal and nonverbal communication skills. Current study reports on improved positive interpersonal communication skills by nursing assistants are promising. Future study to improve therapeutic communication and delivery of dementia care with empathy using enhanced study design and measurement are needed. [Research in Gerontological Nursing, 13(3), 158-168.].

Evaluation of the geriatric curriculum implemented at Shiraz University of Medical Sciences, Iran, since 2017: A qualitative study

Background: Recently, there has been an increase in life expectancy due to improvements in nutrition, health, and sanitation. The aim of this study was to evaluate the geriatric curriculum in the field of general medicine at Shiraz University of Medical Sciences (SUMS), Iran to improve the quality of services provided to this population in the community. Methods: This was a qualitative study­­. Six educational hospitals and ambulatory centers of Shiraz University of Medical Sciences participated in this study. Within these centers, 15 medical education faculty members and educational experts, 6 medical students, 6 elderly patients and 6 nurses working in the university related to the geriatric field were selected using purposive sampling. Data were gathered through semi-structured interviews, focus group discussion and field observations in the teaching hospital and ambulatory setting of SUMS from June 2017 to May 2018.  Based on the qualitative research, the data underwent conventional content analysis and the main themes were developed from this. Results: Three main themes were extracted from the data: effective clinical education, geriatrics curriculum challenges and promotion strategies for geriatric medicine. Subcategories that emerged were a competent curriculum teacher, a challenging program, management of resources, promotion of the program, and the revision required in the curriculum, which were related to other concepts and described in the real-world situation of the geriatric curriculum in the university, as observed in field observations. Conclusions: This study identified three concepts as main themes that can be used to explain how to implement a geriatric curriculum in a medical university. The main contributing factor to different views of the participants was identified as the revision required to the curriculum for integrative care in a geriatric patient. This should be taken into consideration while planning any programs and decisions aimed at education of medical students on this topic.

A staff training intervention to improve communication between people living with dementia and health-care professionals in hospital: the VOICE mixed-methods development and evaluation study

Background

Twenty-five per cent of hospital beds are occupied by a person living with dementia. Dementia affects expressive communication and understanding. Health-care professionals report a lack of communication skills training.

Objectives

To identify teachable, effective strategies for communication between health-care professionals and people living with dementia, and to develop and evaluate a communication skills training course.

Design

We undertook a systematic literature review, video-recorded 41 encounters between staff and people with dementia, and used conversation analysis to investigate communication problems and solutions. We designed a communication skills training course using coproduction and multiple pedagogic approaches. We ran a pilot, followed by six courses for health-care professionals. We measured knowledge, confidence and communication behaviours before, immediately after and 1 month after the course, and undertook interviews with participants and managers. Behaviours were measured using blind-rated videos of simulations.

Setting

General hospital acute geriatric medical wards and two hospital clinical skills centres.

Participants

We video-recorded 26 people with dementia and 26 professionals. Ten experts in dementia care, education, simulation and communication contributed to intervention development. Six health-care professionals took part in a pilot course, and 45 took part in the training.

Results

The literature review identified 26 studies describing 10 communication strategies, with modest evidence of effectiveness. Health-care professional-initiated encounters followed a predictable phase structure. Problems were apparent in requests (with frequent refusals) and in closings. Success was more likely when requests were made directly, with high entitlement (authority to ask) and with lowered contingencies (made to sound less difficult, by minimising the extent or duration of the task, asking patients ‘to try’, offering help or proposing collaborative action). Closings were more successful if the health-care professional announced the end of the task, made a specific arrangement, body language matched talk, and through use of ‘closing idioms’. The training course comprised 2 days, 1 month apart, using experiential learning, including lectures, video workshops, small group discussions, simulations (with specially trained actors) and reflections. We emphasised the incorporation of previous expertise and commitment to person-centred care. Forty-four participants returned for the second training day and 43 provided complete evaluation data. Knowledge and confidence both increased. Some behaviours, especially relating to closings, were more commonly used after training. The course was rated highly in interviews, especially the use of simulations, real-life video clips and interdisciplinary learning. Participants reported that they found the methods useful in practice and were using them 1 month after the course finished.

Limitations

Data were from people with moderate to severe dementia, in an acute hospital, during health-care professional-initiated interactions. Analysis was limited to problems and solutions that were likely to be ‘trainable’. Actors required careful preparation to simulate people with dementia. Communication skills training course participants were volunteers, unlikely to be representative of the general workforce, who displayed high levels of baseline knowledge, confidence and skills. Before-and-after evaluations, and qualitative interviews, are prone to bias.

Conclusions

Requests and closings pose particular difficulties for professionals communicating with people with dementia. We identified solutions to these problems and incorporated them into communication skills training, which improved knowledge, confidence and some communication behaviours. Simulation was an effective training modality.

Future work

Further research should investigate a wider range of health, social care and family carers. Conversation analysis should be used to investigate other aspects of health-care communication.

Study registration

The systematic literature review is registered as CRD42015023437.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Using conversation analysis to inform role play and simulated interaction in communications skills training for healthcare professionals: identifying avenues for further development through a scoping review

BACKGROUND

This paper responds to previously published debate in this journal around the use of sociolinguistic methods in communication skills training (CST), which has raised the significant question of how far consultations with simulated patients reflect real clinical encounters. This debate concluded with a suggestion that sociolinguistic methods offer an alternative analytic lens for evaluating CST. We demonstrate here that the utility of sociolinguistic methods in CST is not limited to critique, but also presents an important tool for development and delivery.

METHODS

Following a scoping review of the use of role play and simulated interaction in CST for healthcare professionals, we consider the use of the specific sociolinguistic approach of conversation analysis (CA), which has been applied to the study of health communication in a wide range of settings, as well as to the development of training.

DISCUSSION

Role play and simulated interaction have been criticised by both clinicians and sociolinguists for a lack of authenticity as compared to real life interactions. However they contain a number of aspects which healthcare professionals report finding particularly useful: the need to think on one's feet in real time, as in actual interaction with patients; the ability to receive feedback on the simulation; and the ability to watch and reflect on how others approach the same simulation task in real time. Since sociolinguistic approaches can help to identify inauthenticity in role play and simulation, they can also be used to improve authenticity. Analysis of real-life interactions using sociolinguistic methods, and CA in particular, can identify actual interactional practices that are used by particular patient groups. These practices can then be used to inform the training of actors simulating patients. In addition, the emphasis of CA on talk as joint activity means that proper account can be taken of the way in which simulated interaction is co-constructed between simulator and trainee. We suggest that as well as identifying potential weaknesses in current role play and simulation practice, conversation analysis offers the potential to enhance and develop the authenticity of these training methods.

A Mixed-Methods Analysis of Changing Student Confidence in an Online Shelter Medicine Course

Maddie's Shelter Medicine Program at the University of Florida College of Veterinary Medicine offers comprehensive training in shelter medicine to veterinary students based on a set of core job skills identified by the Association of Shelter Veterinarians. In 2012, this program began teaching online distance education courses to students and practicing veterinarians worldwide who sought additional training in this newly recognized specialty area. Distance learning is a novel educational strategy in veterinary medicine; most instruction at veterinary medical schools is classroom based. No previous studies have shown whether online courses can prepare veterinarians to practice shelter medicine. In this study, we investigated how an online, graduate-level course titled "Shelter Animal Physical Health" changed student self-reported confidence. First, we compared pre-course confidence regarding eight specific shelter medical practice scenarios to post-course confidence through statistical analysis. Quantitative analysis showed a significant (p<.001) increase in self-reported confidence for all eight scenarios. Next, we used open coding to identify themes within reflection papers that students were asked to write during the course and used those findings to corroborate or refute the quantitative results. Qualitative analysis of students' reflection papers identified six themes: confidence, communication, population management, outbreak management, medical care, and application. The results of this study show that distance education can be an effective method of preparing veterinarians and veterinary students to practice shelter medicine.