Student-Led Clinics: Building Placement Capacity and Filling Service Gaps

Student-Led Clinics: Building Placement Capacity and Filling Service Gaps MADELYN NICOLE MICHELE FAIRBROTHER SRIVALLI VILAPAKKAM NAGARAJAN JULIA BLACKFORD LINDY MCALLISTER University of Sydney, Sydney, NSW, Australia Alongside healthcare redesign, clinical placement providers face exigent placement capacity demands. This paper presents the Capacity Development Facilitator (CDF) model, and describes how a CDF supported Sydney hospital addresses physiotherapy placement and healthcare service gaps with Student Led Clinics (SLC), for Transitional Care, Cardiac Rehabilitation, and Pre- Admission, and presents results. A Sydney metropolitan university, trialed the CDF model in 4 Sydney hospitals. The study aims to investigate strategic innovations which increase placement capacity by providing a CDF whose key role is to identify, negotiate and expand placement capacity development opportunities within supported hospitals. Scoping interviews were conducted with physiotherapists, exploring placement characteristics including clinical supervision models and experiences, support, barriers, enablers, and strategic innovations to increase capacity. Data were analysed thematically. Student evaluation surveys were conducted and analysed with descriptive statistics, capturing experiences such as placement structure, support, barriers and enablers. Preliminary findings suggest that: (i) Physiotherapy SLCs can contribute to healthcare redesign service gaps at this CDF supported hospitals and (ii) SLCs potentially support building sustainable placement capacity. Prospectively, study results inform future SLC development, support, and identify barriers. Keywords: Student-led clinic, capacity, innovation, enablers, sustainability, clinical education INTRODUCTION Clinical placements are fundamental for university-based health science students ensuring preparation for employment. Barriers such as staff shortages and challenges such as delivering quality patient care continue to impact sustainable student placement capacity (SPC) across healthcare facilities (Davies, Hanna & Cott, 2010; Siggins Miller Consultants, 2012; Wright, Robinson, Kolbe, Wilding, Davison & May, 2013). Clinical educators (CE) perceive that students increase their workload (Wright et al., 2013) and thereby decrease productivity (Holland, 1997). This presents as a barrier to building SPC. Ladyshewsky (1995) recognised that students increase productivity when collaborative clinical education models are implemented. Student Led Clinic (SLC) literature has also demonstrated increased productivity and SPC (Frakes, Tykes, Miller, Davies, Swanston & Brownie, 2011; Kent, 2011). Reports by Siggins Miller (2012) and Wright et al. (2013), support the need for innovative models to manage capacity issues and placement quality. The CDF is employed by the university. The CDF-SLC model combines three clinical education models: Teacher as Manager Model (Romonini et al., 1991), Peer Learning (Ladyshewsky, 2010), and Critical Companions Model (Titchen, 2001). CDF-SLC networks with managers, CEs, students, healthcare professionals (HCP) and facility services to map service gaps that could be met by students and thus sustain SPC. The CDF mentors CEs to manage student group (4-6 students) and network with staff to provide learning opportunities, complete student clinical assessments, and encourage students to develop sustainable peer learning resources for future placements. Research questions addressed in this paper are: (i) Can SLC increase SPC? (ii) What are the CE and students perceived barriers and enablers to increasing capacity? and (iii) Can SLCs address healthcare service gaps? METHODOLOGY The research was conducted within the physiotherapy department of a 150 bed Sydney hospital. University Human Research Ethics was approved (Project No: 2013/1009). Physiotherapy staff and CDF mapped physiotherapy service delivery gaps that could provide sustainable student placements over the academicclinical year. Low risk-high volume patients in an aged care Temporary Stay Unit (TSU), cardiac rehabilitation 1

and pre-admission were focused on. From this, planning commenced to develop SLC in TSU (SLC TSU ). No additional infrastructure or set-up costs were required. Allied health (AH) services are not funded in TSU and referrals are considered low priority against acute ward referrals. Most patient admissions are greater than 2-3 months, resulting in family/carer complaints regarding inadequate service provisions. Currently, seven physiotherapists and thirteen students have participated in this study. Clinical placements blocks run consecutively back-to-back for the academic year. Placement blocks discussed will be referred to as Block 1, Block 2 and Block 3. Over the 3x5 week placement blocks, during the period 27 January to 9 May 2014, thirteen students (undergraduate and graduate entry masters) rotated through SLC TSU. SLC TSU commenced in Block 1, 2014. Students rotated weekly through SLC TSU, and were orientated and facilitated with patients for 1-3 days by CE and CDF. SLC TSU does not require the provision of one-to-one supervision. Students managed 12-20 patients, and were supported by ward nursing staff. CEs were available by pager. CDF support was provided through weekly onsite visits and reflective journal tasks. Seven CE interviews and thirteen student surveys were conducted by the CDF, the principal author of this study, at the end of each 5-week block. Four primary CEs and three assisting CEs participated in the interviews. Thirteen students completed the surveys. Table 1 lists the topics of the interview and survey. The purpose of the interviews and surveys was to explore placement barriers and enablers, supervision models and experiences. The CDF collated and completed a content analysis of the responses. TABLE 1. Topics for CE Interview and Student Survey Administrative & Clinical Load Placement Structure & Model Enablers & Barriers Perception of Satisfaction, Stress, Department Support, University Support o CE: Perception of CE Role o Students: Perception of CE & placement RESULTS For the purposes of this paper, results will focus on the SLC TSU. During the 15 weeks of this project, the results support that SLC increase SPC and meet hospital physiotherapy service gaps. Capacity Table 2 compares the increase in student capacity for the Block 1 to Block 3 placement period from 2012 to 2014. Compared to the same three block period in 2012, SPC increased by 280% (14 students) in 2014. TABLE 2. Student Placement Capacity for Block 1 to Block 3 placement period from 2012 to 2014 at site of study Student Capacity Total Increase Capacity since 2012 2013 2014 2012 Block 1-3 (gross) Block 1 3 4 7 Block 2 0 3 6 14 students Block 3 2 4 6 (280% increase) Total: Block 1-3 5 11 19 DATA SOURCE: University Clinical Database Meeting Physiotherapy Service Gaps In NSW hospitals, Transitional or TSUs are federally funded. As LHDs are state funded, there is no allocated budget supporting AH services in TSUs. With the implementation of SLC TSU at this study site, TSU patients have access to physiotherapy services. Additionally, during the Block 1-3 period (2014), the hospital introduced mandatory falls screening by physiotherapists for all at-risk patients. Students in SLC TSU conducted falls screening as there is no funded physiotherapist to deliver this service. 2

Barriers and Enablers Table 3 list the barriers encountered by CEs as identified from the analysis of interviews at this site to sustain SPC. Staff interaction, team dynamics and caseload complexity were reported. CEs also reported a reluctance to allocate students to SLC TSU when the student demonstrated poor attitude, knowledge, responsibility or commitment. Table 4 list the enablers encountered by CEs as identified from the analysis of interviews at this site to sustain SPC. Common enablers included support, quality of care provided by students and communication between CEs and students. CEs reported that student participation in SLC TSU services enabled students to successfully develop graduate skill-competencies required for employment. All students successfully attained competency for their clinical placement. TABLE 3. Barriers identified from interviews and surveys Block 1 to Block 3 Theme Sub-theme Sample Quotes Clinical Placement Clinical Educator Role Site Staffing Student Characteristics Poor attitude, responsibility or commitment to placement & patients Theoretical application knowledge Not presenting for placement Supervision & assessment of students Managing underperforming students Risk Management Confidence Stress Time for CE responsibilities Workload (Clinical/Administration) Caseload complexity Short-staffed Managing periods of leave High proportion of part-time staff Staff dynamics Managing clinical & administrative caseload with students Award interpretation for CEs & placement coordinators PT Students represent our service in TSU a poor attitude and commitment close down the open lines of communication the same supervision is not available in TSU remains a barrier if students do not remain focused and committed to patient care and interaction. In my 11 years we are not taught to teach we are expected to do this role as a clinician... This is a big issue for me and I almost quit my job last year because of this extra stress. Time restraints due to own complexity of caseload restricts available time for adequate feedback sessions Student dropping-out required reshuffling of clinical workloads & rotations and change in team dynamics. Student services (TSU) have been appreciated by staff & patients in some cases it has created a culture and impression that physio would be a regular occurrence this does become an issue when students aren t here. A complaint was made by a patient s family regarding no physio when students aren t around 3

TABLE 4. Enablers identified from interviews and surveys Block 1 - Block 3 Theme Sub-theme Sample Quotes Model Impact Staff Support Student experience Staff/Student Satisfaction Patient care & service provision This is a great model of education that needs to roll-out across other health & education providers. Students learn their own boundaries and practical & theoretical skills that prepare them for their future careers. Clinical Educator Role Supportive networking & communication Imparting knowledge/expertise Workforce development Identifying and working with student weaknesses. Then working with them in an open manner to overcome this. I think I m patient; allowing student to think on their feet and make mistakes but provide assistance on how to find the right knowledge. Patients & Family Feedback Quality care & service provision Participation... overheard family members telling their loved one that exercise is really important so it seems families really value the student physio input Staff Feedback Satisfaction with patient care & service provision Supportive Feedback from TSU staff... very positive... praised the students on their professionalism and appreciate the extra activities that they provide the patients... NUM in particular has been very supportive and appreciated the classes... Student Contribution & Feedback Supported & satisfied with experience Feel valued & part of team Professional identity & role responsibility I felt very responsible and proud as well when TSU NUM and senior nursing staff of TSU referred me one of the patients in TSU. I think the student physio service will be really effective once handovers week to week flow well. DISCUSSION Despite perceived barriers, the results of the CDF-SLC model presented demonstrate that SLC can increase SPC and address physiotherapy service gaps in aged-care at the study site. Setting up SLC TSU by addressing barriers and enablers. Prior to setting up SLC TSU, the CDF, physiotherapy manager and staff canvassed clinical placement needs, enablers, barriers and support required to enable sustainable SPC. Responses mirrored results from a qualitative HETI study (Lloyd, 2012) and Wright et al., (2013), including balancing heavy clinical workloads, short staffing, staff leave support during placements, and limited funding to service gaps. The department had positive enablers to drive SPC such as a supportive manager who participated in Hospital Healthcare Redesign (ARCHI, 2014) initiatives, and encouraged staff professional development. Additionally, SLC TSU incurred no infrastructure costs and patients were readily available, allowing the service to commence as soon as students were allocated. 4

Building placement capacity The CDF-SLC model presented in this paper has demonstrated that SLC have the potential to increase SPC. Despite being a small facility, SLC TSU increased SPC by 280%. SLC TSU is not a traditional one-to-one supervision model, thus enabling capacity for additional students. Addressing physiotherapy service gaps SLC TSU provides a daily ward-based physiotherapy service for patients that was not previously available and referrals are not longer required. Students have experienced working interprofessionally with nursing staff to develop interprofessional teamwork and communication skills. Students also have had the opportunity to build communication skills with the families of TSU patients. The findings of this study are supported by SLC research (Kent, 2011, Frakes et al., 2011, Wright et al., 2013), which include: (i) Providing patients with access to healthcare services; (ii) Building placement capacity; and (iii) Providing interprofessional student training opportunities. CONCLUSION The study is limited by its small sample size and duration to date. There is potential for SLC TSU to expand into an interprofessional SLC, as infrastructure and patients who could benefit from interprofessional care are readily available. Barriers to this are that other AH CEs work part-time or across facilities and still utilise traditional CE models. The CDF-SLC model presented may provide a pathway for AH CEs to explore as a means to support SPC demands. Results suggest that physiotherapy CDF-SLC can support sustainable placement capacity and address physiotherapy healthcare service provision. Study results inform SLC development and identify barriers. Future plans are in place to further investigate this model s impact on patient outcomes and further include other students to increase AH SPC. Future research of the CDF-SLC model will include: (i) Investigation of quality of services provided by students within SLC through patient/carer satisfaction surveys; (ii) Systematic collection and analysis of quantitative service data relating to occasions of service and length of stay to reflect improvements in service provision; (iii) Investigation of further capacity and sustainability over the academic year by developing additional partnerships within the hospital, as SLC TSU has the potential to expand into an interprofessional SLC. This will involve scoping nursing and interprofessional staff to identify needs and patient service quality measures. REFERENCES Australian Resource Centre for Health Care Innovations (ARCHI) 2014. The Centre for Healthcare Redesign (CHR). http://www.aci.health.nsw.gov.au/centre-for-healthcare-redesign Davies R., Hanna, E., & Cott, C. (2010). They put us on our toes : Physical Therapists Perceived Benefits from and Barriers to Supervising Students in the Clinical Setting. Physiotherapy Canada. 63 (2) 224-232. Frakes, K.A., Tyack, Z.F., Miller, M., Davies, L.A., Swanston, A., Brownie, S. (2011). The Capricornia Project: Developing and implementing an interprofessional student-assisted allied health clinic. Clinical Education & Training (ClinEdQ), Queensland Health. Brisbane, Australia. Health Workforce Australia (2011). Mapping Clinical Placements: Capturing Opportunities for Growth, Demand (University) Study. Holland, K.A. (1997). Does Taking Students Increase Your Waiting Lists? Physiotherapy. Volume 83, Issue 4, April 1997, Pages 166 172. Kent, F. (2011). Peninsula Clinical Placement Network Student Led Clinic Project. Final Report Phase 1. Peninsula Health. July 2011. Ladyshewsky, R. (1995). Enhancing service productivity in the acute care inpatient settings using collaborative clinical education model. Physical Therapy. 75 (6) 53-63 Ladyshewsky, R. (2010). Building Competency in the Novice Allied Health Professional through Peer Coaching. Journal of Allied Health, Summer 2010, Volume 39, Number 2. J Allied Health 2010; 39:e77 e82. Lloyd, B. (2013). Barriers to and Enablers of Workplace Learning: A Qualitative Study of Allied Health Professionals within NSW. HETI Stakeholder Communiqué February 2013. www.heti.nsw.gov.au Romonini, J., & Higgs, J. (1991). The teacher as manager in continuing and professional education. Studies in Continuing Education. 13:1, 41-52. 5

Titchen, A. (2001). Critical companionship: A conceptual framework for developing expertise. In J. Higgs & A. Titchen (Eds.) Practice knowledge and expertise in the health professions. (pp. 80-90). Oxford: Butterworth Heinemann. Siggins Miller Consultants (2012). Promoting Quality in Clinical Placements: Literature review and national stakeholder consultation, Health Workforce Australia, Adelaide. Wright, K., Robinson, A., Kolbe, A., Wilding, C., & Davison, W.R. (2013). Untapped capacity for clinical placements in the Riverina ICTN: Does it exist, where is it, and can it be used? Project Final Report. Centre for Inland Health, Charles Sturt University, NSW. Copyright 2014 Madelyn Nicole, Michele Fairbrother, Srivalli Vilapakkam Nagarajan, Julia Blackford & Lindy Mcallister The author(s) assign to the Australian Collaborative Education Network Limited, an educational non-profit institution, a nonexclusive licence to use this article for the purposes of the institution, provided that the article is used in full and this copyright statement is reproduced. The author(s) also grant a non-exclusive licence to the Australian Collaborative Education Network to publish this document on the ACEN website, and in other formats, for the Proceedings of the ACEN National Conference, Gold Coast 2014. Any other use is prohibited without the express permission of the author(s). 6