Fostering gerontology students’ competence in Interprofessional collaborative practice | BMC Medical Education

Each interview lasted from 45 to 90 min. Of the 16 respondents, nine (56.3%) were male, and 11 (68.8%) had over 10 years’ related work experience. Eleven (68.8%) had completed a masters or doctoral degree, four (25%) a bachelor degree and 1 (6.3%) an associate degree.

Theme 1: need for IPCP

Enhanced holistic and person-centred coordinated care

The respondents consistently mentioned that IPCP represented the key to provision of holistic and person-centred care across acute and rehabilitation hospitals and community and residential care settings. They regarded IPCP as essential to boosting the sustainability of health care, with its importance being most evident in the care of older adults with complex health needs during the different phases of their chronic illness trajectory.

‘Older adults’ health problems may change when they are in hospital and then return home…one health profession may be in charge of their care, e.g. during acute management of the disease, yet another profession’s expertise may be needed to provide holistic care, especially during discharge planning and long-term care planning.’ (Physician A).

The importance of IPCP in enhancing person-centred coordinated care was illustrated by a pharmacist recounting an experience of fall risk evaluation and management for an older adult:

‘Physicians will discuss whether the client requires a surgery to prevent falls, pharmacists will offer advice on what medications could reduce the risk of falls, and nurses will assess the client’s physical fitness and identify measures to prevent falls.’(Pharmacist A).

A collaborative approach to care, drawing on the combined expertise of various professionals, that address older adults’ health and social problems holistically, was evident:

‘Early discharge reduces complications associated with an extended hospital stay.… Careful and robust discharge planning is necessary and should be considered from multiple perspectives, i.e. after input from different health professionals.’(Physician B).

‘Social workers and aged care providers can help to address family dynamics-associated problems and financial distress that the clients might be experiencing. They are experts in mobilising resources that are available in society.’(BScG graduate A).

A social worker argued that IPCP can be applied to many aspects of aged care and is particularly useful in managing older adults with chronic conditions and planning lifestyle changes.

‘A client’s health problems can be complex, and you need different health professions’ expertise to address it.… Clients are often unaware of the association between suboptimal lifestyle and health, for instance, their diets may be unbalanced and they may be receiving inadequate care. Health professionals can identify the root causes of their health problems.’ (Nurse A).

Respondents elaborated on the advantages of IPCP in terms of time, resources and communication which contributed to enhancing person-centred coordinated aged care.

‘(IPCP) saves time and enables better use of resources, for example, no need to repeat assessment with the clients for diagnosis or monitoring’ (Physician 1).

‘(IPCP) promotes communication among different healthcare professions … it facilitates understanding of patients’ needs and referrals’ (Social Worker 1).

A physiotherapist noted that inter-disciplinary health consultation services are offered for newly discharged older adults in the hospital. The team managing the care of clients in the geriatric day hospital communicates with the healthcare team in the hospital about the clients’ health condition and the challenges they may encounter after discharge.

‘The services help the clients to achieve better control of their conditions and thus reduce the likelihood of re-admission.’ (Physiotherapist A).

Shared decision making in care planning

Respondents mentioned that each professional shared their own expertise to promote holistic person-centred care. To achieve this, each member of the team needs to consult and coordinate with other team members for their expertise in developing a holistic care plan for clients.

‘In healthcare, there are always areas that one does not know and requires input from others.… During case conferences, different professionals came together to discuss the best interventions for clients.… As different health professionals may visit the clients on separate occasions, a more holistic picture of the clients’ conditions can be drawn when health professionals exchange their information during a case conference.’ (Pharmacist B).

‘A pharmacist can advise on a better alternative to certain medication, the shelf life of medications, or whether a drug is compatible with another. Nurses invest a substantial amount of time in taking care of their clients and thus know more about their conditions. Social workers can advise on financial support for specific measures to be taken. All of this can help to set achievable goals for the clients via consensus among the professionals.’ (Physician B).

During the process of shared decision making, respondents said the physician usually assumed the role of leading the discussion or case conferences.

‘Each professional represents their own profession’s views on the clients’ care, but still need a person to overlook the case, and often the doctor will be the one, who knows more about the medical management …’ (Physician 2).

However, respondents highlighted that the physician’s role was shifting more towards that of a ‘facilitator’. This was echoed by some respondents’ comments that there should be a person who led the discussions and this person would be the professional who was accountable for the key issues or health complaints of the older adult.

‘In the community settings, nurses or persons who know more about the older adults usually take up the role of a case manager’ (Social Worker 2).

Theme 2: role preparedness, scope and liability

Knowledge about health professions’ scope of practice

Competencies in providing quality and safe care for older adults, interprofessional communication and relations, and teamwork are necessary for the successful IPCP. A physician stated that the successful implementation of IPCP depends on each professional’s understanding of self-strength and weakness.

‘The professionals should know when they should seek advice from others and when to give suggestions to improve the clients’ outcomes.’ (Social worker A).

Several respondents highlighted that adequate knowledge about other professional’s roles and responsibilities are crucial for building trust within an interprofessional team.

‘Inexperienced clinicians may still be exploring their profession and may face difficulties in understanding the functions of other professionals and expressing their views. We need to understand the jargons, philosophies, and expertise of other health professionals to communicate effectively with them.’ (BScG graduate B).

A social worker said that when discussing a case with nurses, he has to tune himself to the nurse’s ‘language’, such as talking about the clients’ diet and elimination, vital signs, blood pressure, and heart rate. These skills are difficult to acquire.

‘Communication is crucial. Different professions may have different professional boundaries that need to be respected, or the collaborative relationship may be ruined.’ (Social worker B).

Each professional presented his/her own professional views on client care, but several highlighted the need for a single person to supervise the case. In this regard, the care coordinator serves as a communication hub and facilitates teamwork by interacting with the clients and interdisciplinary care teams. A BScG graduate said they often take up this role in community settings and perform comprehensive assessment and initiate referrals to ensure the best possible care for the client. They are expected to be equipped with essential medical knowledge and knowledge of other professional’s roles.

Lack of training in interprofessional collaboration

All respondents agreed that the success of IPCP depends on effective and continuous communication among the team members. Conflicts may arise when a member gives opinions that are too offensive, as stated by one respondent. When a member becomes too dominant, the discussion will also be obstructed. Negotiation skills and a mindset for compromise are necessary for IPCP to ensure that a mutually-agreed decision is reached by all team members.

‘Non-governmental organisations often have to purchase the services provided by nurses, physiotherapists, or occupational therapists in a pay-as-you-go approach. Every time a brand-new team is formed with new staff, it takes time for everyone to adapt and familiarise with their teammates. To avoid misunderstanding, one has to be tactful when delivering messages. Communicating in a concise manner and avoiding medical jargons would be desired for ensuring that things run smoothly.’ (BScG graduate A).

‘Those who have worked in community settings often have to deal with clients on their own or with minimal supervision. They have to make decisions even when IPCP is established as other health professionals are unavailable nearby for answering queries. The currently available training for facilitating the collaboration of professionals in such a dynamic team is inadequate.’ (Social worker C).

A physiotherapist commented that the lack of health professionals’ willingness to create more opportunities to IPCP in community settings makes the situation worse.

‘The colleagues who propose or initiate new IPCP services often have to rely on themselves for data searching and planning to convince their supervisors. They have to be savvy about finding a good time to introduce their ideas to the concerned parties. They have to make acquaintance with many parties before implementing the IPCP initiatives. These abilities cannot be acquired in a short time.’ (Physiotherapist B).

Perceived roles and stereotypes

Owing to differences in power and status among aged care professionals, the general public tends to have more trust in physicians than in other health professionals. The authoritative image of physicians is regarded as a deep-rooted stereotype among Chinese.

‘Health professionals other than physicians may feel discouraged as they are given little respect and thus become more reluctant to assume a role with broader responsibilities. The obligation for making the overall decision is often imposed on physicians, who are stereotypically perceived as the gatekeepers in hospitals.’ (Occupational therapist A).

Liability issues

Several respondents commented that the acceptance of IPCP varies among health professionals. The involved parties often raise concerns regarding accountability issues.

‘Liability issues are important.… People may be afraid of what they are responsible for, and if it is not a concern of my profession, it is better to leave it to others.’ (Physiotherapist B).

One respondent expressed concerns that IPCP could be abused, e.g. a party may try to evade its responsibilities and impose them on others. He also stated that physicians and nurses often have to deal with emergency or life-and-death issues, and these conditions cannot be handled by allied health professionals. Therefore, IPCP serves limited functions in some settings.

The degree of accuracy of the provided information is determined by the team members’ competencies, and it may significantly affect the team’s performance.

‘The teammate has to ensure that the information provided to other parties is correct. Once a wrong message is delivered, significant effort is required to rectify it as the message may have already been passed to multiple parties… Besides, a member may hesitate when referring a client to or requesting help from another professional as he/she may not be sure whether this could address the issue. These considerations and experiences could have a negative impact on initiating new collaboration with other health professionals.’ (Social worker D).

Theme 3: strategies for interprofessional education

Using innovative simulation-based teaching and learning strategies

Attaining teamwork synergy requires individual members learning to work separately as well as collaboratively. Respondents consistently mentioned that students from different health professions learn separately. They seldom have opportunities to study a course together or work collaboratively in practice.

‘Innovative teaching strategies, such as role playing or simulation, would help students understand the implicit culture and unspoken rules of the workplace. This would help students to get involved in IPCP upon graduation.’ (Occupational therapist B).

‘Although it is good to introduce innovative teaching and learning strategies to let students know what working with different health professionals is like, there are logistics problems, e.g. ratio of teachers to students in different health professions, teaching room size, and levels of difficulty of the case scenarios.’ (Pharmacist B).

Engaging students earlier in the curriculum

Learning is a process in which each health professional acquires the skills and mindset to participate in IPCP. Several respondents said, ‘It would be better to learn the right concept at the very beginning rather than rectifying it later.’ They stated that understanding the practice of other professionals via IPE during undergraduate study can prevent the formation of wrong perceptions or stereotypes about healthcare professions.

‘Many gerontology students were eager to contribute to team meetings and case conferences during their community practicum. However, some reported inadequate confidence in coordinating care and insufficient ability to serve as advocates of their clients and interact with the team.… More input about high-impact communication skills and leadership skills in care coordination could help enhance their skills in applying interdisciplinary care principles in planning health and social care for older adults and their caregivers.’ (BScG graduate B).

Enhancing interpersonal skills and effective communication

Interprofessional communication skills are essential for maintaining team dynamics.

‘Interpersonal skills are essential to foster IPCP. Interpersonal skills such as being humble, showing courtesy, and expressing gratitude are facilitators for collaboration.’ (Nurse B).

‘An open mind and flexibility are vital as IPCP requires coordination with all involved parties.’ (BScG graduate B).

‘The use of social skills, such as using simple messages and showing respect to others, would allow all parties to build mutual understanding and lead to sustainable collaboration.… One may use euphemism and express opinions but should avoid being unpleasant or offensive to others. One should also avoid explicitly pointing out others’ wrongdoings as it may create hard feelings in others.’ (Physician B).

‘Communication can be as simple and direct as sending text or voice messages via smartphones in daily practice … We are all busy, but short messages could update each other instantly … Sometimes, adding a sense of humour in correspondences is powerful in getting each other closer.’ (Physician A).