노령층 일차진료에 대한 다직군간 교육(Interprofessional education)

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

Barth Oeseburg1*, Rudi Hilberts2, Truus A Luten3, Antoinette VM van Etten4, Joris PJ Slaets5 and Petrie F Roodbol1,2

Background

네덜란드의 보건의료시스템은 노령 인구에 대한 의료를 책임질 의사와 간호사 인력과 역량에 대한 문제를 마주하고 있으며, 특히 일차의료 분야에서 심각하다. 여러 parties들은 현재 노령인구들의 복잡한 요구를 다 맞추기에 역량이 부족함을 느끼고 있다. 네덜란드의 고령 인구는 빠르게 증가하고 있고, 95%의 고령 인구는 집에서 홀로 지내면서 GP에게 등록되어 있다. 약 25%의 고령인구는 취약(frail)하다.

The Dutch health care system faces huge challenges with regard to the demand on elderly care and the competencies of nurses and physicians required to meet this demand, especially in primary care. However, the various parties involved (the elderly, professionals, policy makers) feel that the competencies they currently possess are insufficient to meet the increasingly complex needs of the elderly [1-6]. The number of elderly persons (> 65 years) in the Netherlands (total population of about 16.7 million people) is growing rapidly from about 2.5 million to 4.1 million in 2030. In addition, the number of frail elderly is likely to increase between 2010 and 2030 from about 650,000 to over one million [2]. Approximately 95% of the elderly live independently at home and are registered with a general practitioner (GP). In turn, approximately 25% of the elderly who live independently are frail [2].

고령 인구 수가 빠르게 증가하면서, complex care에 대한 요구도 높아지고 있다.

As a consequence of the growing number of elderly, the need for complex care will also increase.

현재 네덜란드의 의료는 질환과 치료에 초점을 맞추고 있으며, 취약한 고령인구는 일상생활과 웰빙에 필요한 요구를 충분히 충족받지 못하고 있다. 따라서 일차의료에 종사하는 의료인력은 질병을 치료하는 패러다임으로부터 건강을 증진하는 패러다임으로 이동해야 한다.

At present, health care in the Netherlands focuses mainly on illness and treatment. In addition, (frail) elderly have expressed unmet needs regarding daily functioning and well-being. Therefore, health care professionals, especially in primary care, will be challenged to a paradigm shift in emphasis from treating illness to promoting health (healthy ageing) [2-6].

취약한 고령층들이 일상생활에 필요한 기능을 할 수 있도록 도와주면서, 비용을 통제하려면 잘 통합된 care system이 필요하다. 이러한 시스템은 다음과 같은 측면을 갖추어야 한다. 

To meet the needs of the (frail) elderly and to optimise their daily functioning and well-being, while at the same time controlling the increasing costs, a well-structured and fully integrated care system is needed. Care should be organised in the desired living environment of the elderly, 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 social problems on an individual and group level; 
early detection and comprehensive assessment of physical and psychosocial needs;
the delivery of effective care arrangements covering a wide range of health care and community services;
coordination of care and interprofessional cooperation;
ongoing follow-up of the elderly;
productive interaction between the elderly and professionals to empower the elderly to manage and adapt to ageing; and
promoting healthy ageing and well-being.

이상적으로는 GP와 같은 일차의료진과 간호사들이 중추적 역할을 해야 한다. GP는 이미 네덜란드 보건의료시스템에서 gatekeeper의 역할을 하고 있으며, 많은 GP들이 천식이나 COPD같은 만성질환 환자에 대해서 필요한 간호를 위해 간호사를 고용하고 있다. 이러한 환자에 대한 care는 GP와 간호사의 협력과 협조 속에 이루어져야 한다. 그러나 앞서 기술된 것처럼 이들 그룹에 대한 care는 대체로 질병을 치료하는 것에 초점을 두고 있으며, 취약하고 여러가지 질병을 동시에 앓고 있는 고령층의 needs를 잘 맞추지 못하고 있다.

Ideally, primary care professionals, such as GPs and practice nurses (registered nurses or practice assistants with vocational education employed by GPs), should play a central role in the care for the elderly [2,5,6,10]. GPs already play a key role in the Dutch health care system and function as gatekeepers for other community and institutional services. A substantial number of GPs employ practice nurses in their practices, particularly for the care given to chronically ill patients, e.g. patients with diabetes or asthma/COPD. Care to these groups is based on cooperation and coordination between GP and practice nurse and involves shared responsibilities and adequate specifications of responsibilities delegated from GP to practice nurses. However, as mentioned before, the provision of care to these groups is mainly focused on 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 defragmented in order to meet the new demands [2,4-9].

잘 조직화되고 통합된 일차의료 시스템을 실현시키기 위해서는 전문직의 행동이 바뀌어야 한다. 또한 GP와 간호사의 업무/책임을 재설계해야한다. 그러나 initial education과 secondary education은 이러한 목적에 적합하지 않은데, 그 이유는 이 교육과정이 주로 질병과 관련된 역량에 대한 것이면서, 자기 직종의 역할에 대한 것만 다루고 있기 때문이다. 

전문직의 행동을 변화시키기 위해서는 IPE가 필요하다. 많은 근거들이 IPE를 통해 전문직의 역량을 향상시키고, 궁극적으로 더 나은 환자 outcome을 가져올 수 있다고 보고하고 있다. 그러나 현재 네덜란드의 IPE는 거의 활용되고 있지 않아, 이러한 파일럿 연구를 시작하게 되었다.

To realise a well-structured and fully integrated primary care system, a shift in professional behaviour, particularly in the domains of proactive/preventive care, coordination of care, and communication and cooperation with the elderly and other professionals, is necessary. In addition, a redesign of tasks and responsibilities of GPs and practice nurses is expected to improve the quality of elderly care [2,5-9]. Professional behaviour is inextricably linked to the education of professionals. However, the curricula for initial and secondary education for professionals are not suited to educate professionals in the competencies that are necessary for elderly care, because these curricula focus mainly on disease-related competencies and competencies relevant to their own profession [11-13]. Changing professional behaviour and initiating a fully integrated and well-coordinated provision of elderly care, with shared responsibilities and adequate specifications of delegated responsibilities, requires interprofessional education (IPE) [2,5,6,14]. Evidence indicates that IPE can enhance the competencies of professionals, which will lead to an improvement in the quality of health care and better patient outcomes [15,16]. At present, however, IPE in primary care is rarely utilised in the Netherlands. Therefore, a pilot study was initiated. The aim of this pilot study is to develop an IPE-program for GPs and practice nurses and to evaluate both the feasibility of an IPE program for professionals with different educational levels and the effect such a program will have on the division of their tasks and responsibilities.

Methods

Intervention

기본 접근방법 : Social constructivist approach

An IPE program, based on a social constructivist approach and consisting of four half-day shared sessions, was developed [17]. 

The social constructivist approach emphasises the collaborative nature of learning. Learning is an active process, embedded in social and physical contexts in which learners construct their own competencies based on prior competencies. Cooperation with others creates the opportunity to define or refine learners’ understanding and to create shared understandings with respect to the division of tasks and responsibilities between GPs and practice nurses.

프로그램에서 무엇을 하였는지

During the IPE program, GPs and practice nurses...

prepared themselves for the shared education sessions by reading relevant literature and the GP and 

practice nurse prepared practical assignments based on cases generated from their own local practice. 

Experts gave short lectures and led the plenary sessions in which the practical assignments were discussed and reflected on.

프로그램의 초안을 전문가가 검토하였음. 프로그램의 목적은 GP와 간호사의 업무와 책임의 변화를 이끌어내기 위한 것.

Draft versions of the IPE program were discussed with expert group (GPs, practice nurses, geriatrician). The educational aim of the program was to realise a shift in tasks and responsibilities from GP to practice nurse.

각 세션의 아웃라인

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 attitudes toward the elderly and elderly care; to explore the use of a comprehensive Web-based triage screening instrument, based on the INTERMED [18-20], the ‘Groningen Frailty Indicator’ [21,22], and the Groningen Well-being Indicator [23]; and to collect data on the medical, psychosocial, and functional capabilities and limitations of all elderly patients in the participating primary care practices.

Session 2: Care plan. The aim of the second session was to develop a comprehensive care plan based on the care plan developed by the Dutch College of General Practitioners [24] and a practical tool to prioritise preferences of the elderly and discuss their medication use, based on Fried et al. [25].

Session 3: Thinking in groups. In this session, elderly patients were empirically categorised into five meaningful segments (primary segmentation) with different health-related needs: vital problems, psychosocial coping problems, physical and mobility problems, problems in multiple domains, and problems caused by extremely frailty. These segments are characterised by the significant relations found with gender, age, frailty, bio-psychosocial complexity, living arrangements, well-being, and preferred decisional control [26]. Segmenting the elderly based on their needs offers GP and practice nurse the possibility to intervene proactively; not only on an individual level but also on a group level. A proactive intervention plan can prevent health problems in the elderly and can help keep 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 IPE program was evaluated with the participants and appointments were made for further evaluation.

Participants and procedure

A convenience sample of 10 GPs and 10 practice nurses from eight primary care practices in two provinces in the north of the Netherlands, Groningen and Drenthe, (total population about 1.1 million people) participated. Six primary care practices were informed of the project during a meeting on a transition experiment in elderly care in Groningen in which they participated. Two primary care practices (in Drenthe) were informed by one of the project members and received additional educational materials.

A mixed methods design including quantitative and qualitative methods was used to evaluate the IPE program. 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 functioning and recording,
medication,
the development of a comprehensive care plan,
discussion with the elderly on the care plan,
execution of the care plan,
consultation of other professionals in health and community care, and
monitoring the care (plan).

The score on each indicator could range from 0 (tasks and responsibilities of the practice nurse) to 10 (tasks and responsibilities of the GP). For example, a score of score 5 indicated full cooperation between GP and practice nurse. Primary care practices (the GP and practice nurse) were asked to rate the division of tasks and responsibilities before and during the program and to state their future preferences. Four of the eight primary care practices responded.

The quality of the program was measured by a questionnaire developed by the Wenckebach Institute aimed at evaluating educational programs. This questionnaire is based on Kirkpatrick’s model of evaluating training programs [27] and measures the quality of the following indicators: added value of the lectures; clarity, practicability, and added value of the practical assignments; and suitability of the program to facilitate change within practices. The score on each indicator can range from 0 (strongly disagree) to 5 (strongly agree).

In addition to filling in the questionnaire, the participants were asked to report positive features of the program and to give advice on how to improve the program. The response rate was 60% (N = 20). Finally, semi-structured telephone interviews were conducted with primary care practices (GPs and practice nurses) which addressed the following issues: the participants’ expectations with regard to the program; changes in their attitude with regard to elderly and elderly care; suitability of the program to facilitate change within practices; change, or intentions to change tasks and responsibilities of the GP and practice nurse; and advice to improve the program. All the interviews with both GPs and practice nurses were tape-recorded and transcribed. Six out of eight primary care practices responded (response rate 75%). In total, six GP’s and six practice nurses were interviewed.

Analysis

The raw descriptive data of the VAS scale were used to analyse the division of tasks and responsibilities of the primary care practices (N = 4) before and during the program and to list their wishes regarding the division of tasks and responsibilities in the future.

Next, the mean score and standard deviation were calculated for the scores obtained on the Wenckebach Institute’s quality questionnaire. Subsequently, scores for each session [1-3] were calculated. 

Finally, the recorded telephone interviews were transcribed for analysis. Two researchers independently analysed and categorised the data into the themes that structured the interview [28].

Ethical approval

어디에서 자금 지원을 받았으며, 어디에서 ethical review를 받았는가

The project was funded by a grant from ZonMW (The National Care for the Elderly Program: 310300003; The Netherlands Organisation for Health Research and Development) as well as by the University Medical Centre Groningen (UMCG). The study was presented to the ethical review board of the UMCG, which did not find further approval necessary.

Results

Tasks and responsibilities

Table 1. Tasks and responsibilities GPs and practice nurses before, during the program and desirable in the future (N = 4 primary care practices)

Quality of the program

Table 2. Means and standard deviations on the Wenckebach Institute quality of the program questionnaire (N = 12)

Expectation

Despite their willingness to participate in the IPE program, five of the interviewed participants (N = 12) indicated that they did not have any explicit expectations of the IPE program. 

Changes in attitude

Most of the interviewed participants indicated that the IPE program changed their attitudes toward the elderly and care for the elderly. 

Suitability of the program and change within practices

Most of the interviewed participants indicated that the lectures and practical assignments with regard to the triage instrument and the care plan had already initiated a shift in tasks and responsibilities from GP to practice nurse or that there was at least an incentive to realise this shift. 

Advice to improve the program

The participants offered several suggestions for improving the program. 

Conclusion and discussion

The results of this pilot study show that an interprofessional education (IPE) program for professionals with different educational levels, in particular GPs and practice nurses in primary care, is feasible and has an added value to the redefining of tasks and responsibilities.

(...)

전문가 그룹이 긴밀히 협력하여 프로그램을 만들었지만 참가자들의 기대를 완전히 충족시키지는 못하였다. 기간이 너무 짧다거나, IPE프로그램에 대한 정보가 너무 적었다고 하였다.

Despite the fact that the IPE program was developed in close cooperation with expert groups, the program did not entirely meet the expectations of the participants. The length of the program, four half day sessions, was deemed too short to adequately increase the knowledge on, for example, the interpretation of the data generated by the triage instrument. The program was also too short to address the needs of the participants regarding practical tools and evidenced based interventions to handle certain problems in the elderly. Furthermore, participants found the information on the IPE program too concise, and GPs did not inform their practice nurses sufficiently about the program’s content. Indeed, this latter point could have influenced the expectations of the participants and the subsequent success of the program [29].

그러나, 이것은 파일럿 연구이고, 파일럿 연구의 특징은 참여자들이 subject이면서 developer라는 사실이다.

However, this was a pilot study, and one characteristic of a pilot study is that participants are both subjects and developers of the intervention at the same time. The results of this pilot study and the participants’ suggestions for improvement will be used to develop an adapted interprofessional education program for GPs and practice nurses.

Findings in relation to other studies

기존 연구가 많지는 않지만, 부합하는 결과임

To our knowledge, there is a paucity of literature on interprofessional education specifically pertaining to GPs and practice nurses in primary elderly care [31]. Our results are in line with the limited research on interprofessional learning in primary care and reviews on interprofessional education [14,31,32].

Kirkpatrick모델에서 attitude와 performance가 변화하였음

A study by Pearson & Pandya [31], for example, found that primary care professionals value interprofessional education and the sharing of knowledge and expertise. In keeping with a recent review of Reeves et al. [14] on the effectiveness of interprofessional education, our pilot study shows a change in the attitudes of the participants and their performance in practice: level 1 – 2/3 Kirkpatrick’s model [27]. As mentioned above, the impact of the IPE program on the health care system itself and on patient outcomes was not measured in our pilot and could therefore not be compared with findings in other studies.

IPE프로그램이 성공하기 위해서 넘어야 할 장벽들이 있다.

The participants in this pilot study mentioned some barriers to the success of the IPE program. In the literature, other barriers are also mentioned that hinder the implementation of an interprofessional education program. These barriers include...

the social identity of professional groups,
hierarchical relations between professionals,
lack of time,
workload, and
lack of financial incentives for the education program and for interprofessional collaboration in practice. 

In addition, factors related to the implementation and change process of professionals and practices such as...

the support of senior management,
dynamic leadership,
inclusion of all staff members,
a proactive approach to prevent resistance, and
sustaining change during and after the initial implementation process are important [10,30,33-37].

이러한 문제에도 불구하고 전문직종간의 협력은 보건의료시스템에서 대단히 중요하다. IPE와 IP collaboration의 관계가 명확하지는 않지만, 이 관계를 밝히기 위한 노력은 중요하다.

However, despite these start-up problems, collaboration between professionals is crucial in today’s increasingly complex healthcare system. Although the literature indicates that the link between interprofessional education and interprofessional collaboration is not clear, working on clarifying this link is worthwhile [10,38-41]. There is a need for theory-driven development and implementation of interprofessional education programs, combined with high quality research on the effects of interprofessional education. Future research is necessary to learn more about the effects of interprofessional education on an individual level, i.e. how professionals learn in certain settings and why some are more capable than others; as well as its effects on an organisational level, i.e. how factors such as the organisation of care, financial incentives, costs, and patients outcomes influence the health care system [16,30,33,39-41].

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BMC Med Educ. 2013 Dec 5;13:161. doi: 10.1186/1472-6920-13-161.

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

Oeseburg B1, Hilberts R, Luten TA, van Etten AV, Slaets JP, Roodbol PF.

Author information

Abstract

BACKGROUND:

The Dutch health care system faces huge challenges with regard to the demand on elderly care and the 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) elderly need care and support that takes their daily functioning and well-being into consideration as well. Therefore, health care professionals, especially those professionals working in primary care such as GPs and practice nurses, will be challenged to a paradigm shift in emphasis from treating illness to promoting health (healthy ageing). Interprofessional education is necessary to realise this shift in professional behaviour. Evidence indicates that interprofessional education (IPE) can play a pivotal role in enhancing the competencies of professionals in order to provide elderly carethat is both effectively, integrated and well-coordinated. At present, however, IPE in primary care is rarely utilised in the Netherlands. Therefore, the aim of this pilot study was to develop an IPE program for GPs and practice nurses and to evaluate the feasibility of an IPE program for professionals with different educational backgrounds 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 the Netherlands, Groningen and Drenthe (total population about 1.1 million people), participated in the pilot IPE program. A mixed methods design including quantitative and qualitative methods was used to evaluate the IPE program.

RESULTS:

During the program, tasks and responsibilities, in particular those related to the care plan, shifted from GP to practice nurse. The participants' attitude toward elderly (care) changed and the triage instrument, the practical tool for prioritising preferences of the elderly and discussing their medication use, was considered to have an added value to the development of the care plan.

CONCLUSIONS:

The results of this pilot study show that an interprofessional education program for professionals with different educationalbackgrounds (GPs and practice nurses) is feasible and has an added value to the redefining of tasks and responsibilities among GPs and practice nurses.

PMID:

 

24308766

 

[PubMed - indexed for MEDLINE] 

PMCID:

 

PMC4029384

 

Free PMC Article