Advancing collaboration in health professions education in the general practice domain, developing a national research agenda.

BACKGROUND: Health professions education (HPE) research in the General Practice domain (GP-HPE) is vital for high-quality healthcare. Collaboration among GP-HPE researchers is crucial but challenging. Formulating a research agenda, involving stakeholders, and fostering inter-institutional collaboration can address these challenges and connect educational research and practice. METHODS: We used Q-methodology to explore perspectives on GP-HPE research of participants from all Dutch postgraduate GP training institutes. Participants individually sorted statements based on the relevance of future GP-HPE research for educational practice. Data analysis comprised inverted factor analysis, rotation, and qualitative interpretation of configurations of all statements. The National Meeting on Educational Research took a participatory approach. RESULTS: We included 73 participants with diverse involvement in GP-HPE research. We identified five distinct perspectives, each representing a research focus area for developing and innovating GP education: the clinician scientist, the socially engaged GP, the specific GP identity, the GP as an entrepreneur, and the GP engaged in lifelong learning. DISCUSSION: The resulting five perspectives align with General Practice hallmarks. Q-methodology and a participatory approach facilitated collaboration among stakeholders. Successful inter-institutional collaboration requires a common goal, neutral leadership, participant commitment, regular meetings, audit trail support, process transparency, and reflexivity. Future research should address evidence gaps within these perspectives. CONCLUSION: Using Q-methodology turned out to be valuable for compiling a national research agenda for GP-HPE research. The research process helped to cross boundaries between researchers in different institutions, thus putting inter-institutional collaborative advantage center stage. Our approach could provide a conceivable procedure for HPE researchers worldwide.

Interprofessional education for healthcare professionals. A BEME realist review of what works, why, for whom and in what circumstances in undergraduate health sciences education: BEME Guide No. 83.

AIM: To provide an evidence-informed program theory (PT) for Interprofessional Education (IPE) that adds to the knowledge base of how IPE in undergraduate health sciences education works. METHODS: We undertook a realist review of the literature and synthesis of the evidence combined with stakeholder experience. Our initial program theory (IPT), built around development, delivery and evaluation of IPE interventions, was tested and refined following an in-depth search of the literature and consultation with stakeholders. The literature (2010-2022) was selected based on the realist criteria of relevance and rigor, as well as on conceptual richness of the studies. RESULTS: Our PT is built upon 124 CMOs (Context of IPE interventions, Mechanisms that fired within that context, and IPE Outcomes), from 58 studies. Our PT comprises an array of elements found in the Context, including traits and behavioral displays of students and facilitators, and discusses four Mechanisms (feeling responsible, feeling enthusiastic/excited, feeling safe to take risks, and feeling ready), which are likely to lead to outcomes related to the Interprofessional Education Collaborative (sub)competencies. DISCUSSION: Results were linked to learning theories to further build our understanding. The PT can serve as a guide for the development, delivery, and evaluation of IPE interventions.

EPIS-RI: Indonesian translation, cultural adaptation and construct validation of an interprofessional identity measure.

Interprofessional Education (IPE) as a preparatory stage for Interprofessional collaboration (IPC) is overlooked in some low-and middle-income countries, including Indonesia. One of the driving forces behind IPC is the development of Interprofessional Identity (IPI), which has yet to be assessed in the Indonesian context. Our study aims were translating and culturally adapting the Extended Professional Identity Scale (EPIS) and confirming its construct validity. We invited third-year students from three programs (medicine, nursing, and dietetics) without previous IPE experience to participate in the study. Using Confirmatory Factor Analysis (CFA), we examined the construct validity, analyzed internal consistency, and conducted a Kruskal-Wallis test to identify variations across professions. Of 513 students approached, 335 participated (response rate 65.3%). The CFA showed factor loadings ranging between .59 and .86, while correlations among subscales varied from .55 to .86. All five goodness-of-fit indices were sufficient. The internal consistency of subscales interprofessional belonging, commitment, and beliefs was .82, .84 and .87, respectively, and .90 for the overall scale. Interprofessional belonging and commitment were different among various students (p-value = .009 and .004) and the dietetics students had lower scores than other students. The Indonesian EPIS (EPIS-RI) demonstrated reliability and construct validity.

Interprofessional simulation of acute care for nursing and medical students: interprofessional competencies and transfer to the workplace.

BACKGROUND: Teamwork and communication are essential tools for doctors, nurses and other team members in the management of critically ill patients. Early interprofessional education during study, using acute care simulation, may improve teamwork and communication between interprofessional team members on the long run. METHODS: A comparative sequential quantitative-qualitative study was used to understand interprofessional learning outcomes in nursing and medical students after simulation of acute care. Students were assigned to a uni- or interprofessional training. Questionnaires were used to measure short and long term differences in interprofessional collaboration and communication between the intervention and control group for nursing and medical students respectively. Semi-structured focus groups were conducted to gain a better understanding of IPE in acute simulation. RESULTS: One hundred and ninety-one students participated in this study (131 medical, 60 nursing students). No differences were found between the intervention and control group in overall ICCAS scores for both medical and nursing students (p = 0.181 and p = 0.441). There were no differences in ICS scores between the intervention and control group. Focus groups revealed growing competence in interprofessional communication and collaboration for both medical and nursing students. CONCLUSIONS: Interprofessional simulation training did show measurable growth of interprofessional competencies, but so did uniprofessional training. Both medical and nursing students reported increased awareness of perspective and expertise of own and other profession. Furthermore, they reported growing competence in interprofessional communication and collaboration in transfer to their workplace.

Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes.

BACKGROUND: Collaboration between primary and secondary care (PSCC) is important to provide patient-centered care. Postgraduate training programmes should provide training to learn PSCC. With a design based research (DBR) approach design principles can be formulated for designing effective interventions in specific contexts. The aim of this study is to determine design principles for interventions aimed to learn PSCC in postgraduate training programmes. METHODS: DBR is characterised by multi-method studies. We started with a literature review on learning collaboration between healthcare professionals from different disciplines within the same profession (intraprofessional) to extract preliminary design principles. These were used to inform and feed group discussions among stakeholders: trainees, supervisors and educationalists in primary and secondary care. Discussions were audiotaped, transcribed and analysed using thematic analysis to formulate design principles. RESULTS: Eight articles were included in the review. We identified four preliminary principles to consider in the design of interventions: participatory design, work process involvement, personalised education and role models. We conducted three group discussions with in total eighteen participants. We formulated three design principles specific for learning PSCC in postgraduate training programmes: (1) The importance of interaction, being able to engage in a learning dialogue. (2) Facilitate that the learning dialogue concerns collaboration. (3) Create a workplace that facilitates engagement in a learning dialogue. In the last design principle we distinguished five subcategories: intervention emphasises the urge for PSCC and is based on daily practice, the presence of role models, the work context creates time for learning PSCC, learning PSCC is formalised in curricula and the presence of a safe learning environment. CONCLUSION: This article describes design principles for interventions in postgraduate training programmes with the aim to learn PSCC. Interaction is key in learning PSCC. This interaction should concern collaborative issues. Furthermore, it is essential to include the workplace in the intervention and make adjacent changes in the workplace when implementing interventions. The knowledge gathered in this study can be used to design interventions for learning PSCC. Evaluation of these interventions is needed to acquire more knowledge and adjust design principles when necessary.

Designing the learning of intraprofessional collaboration among medical residents.

BACKGROUND: To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements. METHODS: Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles. RESULTS: The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning. CONCLUSION: This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.

Enabling visibility of the clinician-scientists' knowledge broker role: a participatory design research in the Dutch nursing-home sector.

BACKGROUND: A group of clinician-scientists and managers working within a Dutch academic network, experienced difficulties in clearly defining the knowledge broker role of the clinician-scientists. They found no role clarity in literature, nor did they find tools or methods suitable for clinician-scientists. Clarifying role expectations and providing accountability for funding these knowledge broker positions was difficult. The aim of this research was to design a theory-informed tool that allowed clinician-scientists to make their knowledge broker role visible. METHODS: A participatory design research was conducted in three phases, over a 21-month period, with a design group consisting of an external independent researcher, clinician-scientists and their managers from within the academic network. Phase 1 constituted a literature review, a context analysis and a needs analysis. Phase 2 constituted the design and development of a suitable tool and phase 3 was an evaluation of the tool's perceived usefulness. Throughout the research process, the researcher logged the theoretic basis for all design decisions. RESULTS: The clinician-scientist's knowledge broker role is a knowledge-intensive role and work-tasks associated with this role are not automatically visible (phase 1). A tool (the SP-tool) was developed in Microsoft Excel. This allowed clinician-scientists to log their knowledge broker activities as distinct from their clinical work and research related activities (phase 2). The SP-tool contributed to the clinician-scientists' ability to make their knowledge broker role visible to themselves and their stakeholders (phase 3). The theoretic contribution of the design research is a conceptual model of professionalisation of the clinician-scientist's knowledge broker role. This model presents the relationship between work visibility and the clarification of functions of the knowledge broker role. In the professionalisation of knowledge-intensive work, visibility contributes to the definition of clinician-scientists broker functions, which is an element necessary for the professionalisation of an occupation. CONCLUSIONS: The SP-tool that was developed in this research, contributes to creating work visibility of the clinician-scientists' knowledge broker role. Further research using the SP-tool could establish a clearer description of the knowledge broker role at the day-to-day professional level and improved ability to support this role within organisations.

Competencies to promote collaboration between primary and secondary care doctors: an integrative review.

BACKGROUND: In a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising 'seamless' care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface. METHODS: We conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach. RESULTS: We identified six themes regarding collaborative competencies: 'patient-centred care: a common concern', 'roles and responsibilities', 'mutual knowledge and understanding', 'collaborative attitude and respect', 'communication' and 'leadership'. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration. CONCLUSIONS: This review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.

Professional development arising from multiple-site workplace learning: boundary crossing between the education and clinical contexts.

BACKGROUND: This research explores the value of an inter-organisational jurisdiction, on the professional development of faculty members in their roles of researcher and educator. Faculty members from a Dutch university of applied sciences, who work in both the education and clinical practice contexts, participated in this research. METHODS: Individual semi-structured interview were conducted with nine faculty members, from various academic health professions, on their experiences of professional development arising from working in both the clinical and education contexts. In this exploratory, post-positive interview study, interview transcripts were analysed thematically. RESULTS: Participants reported that working in two organisational contexts, whilst performing two faculty roles that span both contexts, enhances their ability to broker connections between research, teaching and practice. The boundary crossing activities which participants performed, contributed to professional development in all faculty roles. The broker role was not seen as being a unique role which is distinct from research and practice roles. Broker activities were seen as generic and supportive of the roles that bestow academic status and expertise. CONCLUSIONS: To the participants in this research, the relevance of the broker role in professional development is not as evident as the relevance of roles that enhance specialisation and subject specific expertise. They consider broker activities as supportive to the roles of researcher and teacher. The broker role is time consuming, but not yet visible as a distinct professionalisable work-package in its own right. It is also not well defined in literature. A better understanding of the broker role could lead to its development in order to harness its professional development potential tenably across academic roles.

Preventing acute kidney injury in high-risk patients by temporarily discontinuing medication - an observational study in general practice.

BACKGROUND: Elderly, patients with chronic kidney disease (CKD) and patients with heart failure who continue using renin-angiotensin-aldosterone-system (RAAS) inhibitors, diuretics, or non-steroidal-anti-inflammatory drugs (NSAIDs) during times of fluid loss have a high risk of developing complications like acute kidney injury (AKI). The aim of this study was to assess how often advice to discontinue high-risk medication was offered to high-risk patients consulting the general practitioner (GP) with increased fluid loss. Furthermore, we assessed the number and nature of the complications that occurred after GP consultation. METHODS: We performed a cross-sectional study with patients from seven Dutch general practices participating in the Family Medicine Network between 1 and 6-2013 and 1-7-2018. We included patients who used RAAS-inhibitors, diuretics, or NSAIDs, and had at least one of the following risk factors: age ≥ 70 years, CKD, or heart failure. From this population, we selected patients with a 'dehydration-risk' episode (vomiting, diarrhoea, fever, chills, or gastrointestinal infection). We manually checked their electronic patient files and assessed the percentage of episodes in which advice to discontinue the high-risk medication was offered and whether a complication occurred in 3 months after the 'dehydration-risk' episode. RESULTS: We included 3607 high-risk patients from a total of 44.675 patients (8.1%). We found that patients were advised to discontinue the high-risk medication in 38 (4.6%) of 816 'dehydration-risk' episodes. In 59 of 816 episodes (7.1%) complications (mainly AKI) occurred. CONCLUSIONS: Dutch GPs do not frequently advise high-risk patients to discontinue high-risk medication during 'dehydration-risk' episodes. Complications occur frequently. Timely discontinuation of high-risk medication needs attention.

Facilitators and barriers to brokering between research and care by senior clinical-scientists in general practice and elderly care medicine.

BACKGROUND: Clinician-scientists (CSs) are physicians who work in daily care and have an academic role in research or education. They may act as knowledge brokers and help to connect research and clinical practice. There is no data available on CSs' brokering activities and the perceived barriers and facilitators to optimising their role in general practice (GP) and elderly care medicine (EM). AIM: To identify the brokering activities of CSs in these fields and the barriers and facilitators they come across whilst sharing knowledge and connecting people in research and frontline health care. DESIGN AND SETTING: Qualitative interview study among 17 Dutch senior CSs. METHOD: Interview data were audio recorded, transcribed verbatim and thematic interpretative analysis was used to identify themes. RESULTS: CSs facilitate collaboration between researchers and practitioners. They exchange knowledge on both sides, make use of extensive networks and constantly and actively involve care in research and research in care. CSs come across barriers as well as facilitators that influence their brokering activities. Some barriers and facilitators are at the individual level, other are related more to the job context and workplace. CONCLUSIONS: This study reveals barriers to overcome and facilitators to develop related to the brokering role of CSs. To make the best use of CSs, brokering activities and the added value of CSs should be recognised and supported. Awareness of what CSs need to function effectively in demanding work settings could be important for the future impact of the role on the fields of GP and EM.

Educational training requirements for general practice/family medicine specialty training: recommendations for trainees, trainers and training institutions.

High-quality training is a prerequisite to teaching future general practitioners. To inspire and guide all countries to implement General Practice (GP) specialist education and training and bring it to the highest standards, we aimed, within the European context, to produce a collaborative document entitled 'Educational Requirements for GP Specialty Training'. Through an iterative process existing documents from the European Academy of Teachers in GP and Family Medicine (EURACT) and the World Organization of Family Medicine Doctors (WONCA) were collated. Other reports, grey literature about specialty GP training and requirements for trainees, trainers and training institutions were included. State-of-the-art GP specialty training 'core' competences, characteristics and essential features of GP are described. General principles and specified tools for training and assessment are summarised. Recommendations on the duration and place(s) of training and selection of trainees are provided. Trainers should be accredited teachers and quality training institutions are essential. New insights, existing gaps and issues for debate have highlighted areas for further research. This document was produced in the specific context of Europe but its general principles are relevant to GP training in all countries.

What influences on their professional development do general practice trainees report from their hospital placements? A qualitative study.

BACKGROUND: The clinical learning environment is important in GP specialty training and impacts professional development. Uniquely for GP trainees, about half of their training periods occur in a hospital environment, which is not their final workplace. There is still little understanding of how hospital-based training influences GP's professional development. OBJECTIVES: To seek the views of GP trainees on how their hospital experience contributes to their professional development as a GP. METHODS: This international and qualitative study seeks the views of GP trainees from Belgium, Ireland, Lithuania, and Slovenia. Semi-structured interviews were performed in the original languages. A joint thematic analysis in the English language resulted in key categories and themes. RESULTS: From the four themes identified, GP trainees were found to experience additional challenges on top of the service provision/education tensions, which are common to all hospital trainees. Despite these, the hospital rotation component of GP training is valued by trainees. A strong finding of our study is the need to ensure that learning from the hospital placements is placed firmly in the context of general practice, e.g. GP placements prior or parallel with the hospital placements, educational activities resourced by GPs during their hospital experience, encouraging hospital teachers to have greater awareness of the educational needs of GPs, including an awareness of their training curriculum. CONCLUSION: This novel study highlights how hospital placements for GP trainees could be enhanced. Further study could be broadened to recently qualified GPs, which may uncover new areas of interest.

[Observing a resident doing a consultation with a patient: goal determines form]. / Hoe observeer je een aios die een consult doet?

Observation of residents by supervisors is a highly recommended, but underused educational tool in postgraduate medical education. Observation can be performed indirectly (using video recordings of residents performing clinical tasks) or directly (supervisor is present when the resident performs the task). The choice of the observation method depends on aim and context of the observation. In general practice, patients tend to involve the supervisor when the resident performs the consultation. They value such participatory direct observation because they know the supervisor and appreciate their input. For specific residents' learning aims (e.g. consultation efficiency), it may be more useful if the supervisor takes a "fly on the wall" approach. Supervisors wishing to take a "fly on the wall" approach to direct observation need to inform the patient about their role and position themselves outside the patient's field of view. Indirect observation by reviewing video-recorded consultations is an alternative for this purpose.

Teaching and Learning Core Values in General Practice/Family Medicine: A Narrative Review.

General Practice/Family Medicine (GP/FM) is a key discipline within primary health care and so by extension for the whole health care system. An essential condition for effective GP/FM care is a work force that is highly qualified. As society is changing rapidly, a revision of the GP/FM definition is ongoing, in addition to a recent movement of identifying related core values. In this paper, we want to give an overview on how these new paths and perspectives are currently reflected in GP/FM teaching and training. We selected four core values that fit in with possible future visions: person-centered care, continuity of care, cooperation in care, and community-oriented care. By a narrative review, we observed that GP/FM education toward core values is often built around overarching topics. Teaching and learning take place in specific contexts, most of all through placements within communities, primary care settings, or hospital wards. Mixed teaching- and training methods are used combining knowledge, skills, and attitude. Furthermore, collaboration with other health professionals and peers is stressed, in addition to the importance of role models, a holistic focus and the involvement of patients. Since these core values are important within GP/FM and rather few studies on the educational aspects and learning tools were found we advocate encouraging each other more to share good practices, certainly the innovative ones specifically related to GP/FM.

Professional Care Networks of Frail Older People: An Explorative Survey Study from the Patient Perspective.

BACKGROUND: Frail older people living in the community require multidisciplinary care. Despite the fact that patient participation is high on the public agenda, studies into multidisciplinary care mainly focus on the viewpoints of professionals. Little is known about frail older patients' experiences with care delivered by multidisciplinary teams and their perception of collaboration between professional and informal caregivers. OBJECTIVE: To gain more insight into the experiences of frail older patients with integrated multidisciplinary care by mapping the care networks of this patient group and their perception of the interconnection between professional and informal caregivers. METHODS: Survey study to facilitate a care network analysis. Due to the vulnerable health status of the respondents, questionnaires were completed during interviews. Analysis was performed using an iterative process, using both visual and metric techniques. PARTICIPANTS: 44 older persons, considered 'frail' by their general practitioner. SETTING: Four general practices in The Netherlands. RESULTS: The networks of the participants consisted of an average of 15 actors connected by 54 ties. General practitioners were the most common actors in the networks, and were well connected to medical specialists and in-home care providers. The participants did not always perceive a connection between their general practitioner and their informal caregiver. The network analyses resulted in the identification of three subtypes: simple star (n = 16), complex star (n = 16), and sub-group networks (n = 12). CONCLUSIONS: Our findings indicate that the elderly often do not experience the integration of multidisciplinary care as such. This is a real opportunity for MTs to improve their care and to make the patients' experiences better in line with what they are aiming: allowing patients to live at home as healthy and independently as possible for as long as possible. We showed that informal caregivers often form communication bridges between patients and professionals. Having a better knowledge of the patient perspective enables the gaps in professional care networks of frail older people to be filled and facilitates the anticipation of crisis situations.

Inter-professional education and primary care: EFPC position paper.

Inter-professional education (IPE) can support professionals in developing their ability to work collaboratively. This position paper from the European Forum for Primary Care considers the design and implementation of IPE within primary care. This paper is based on workshops and is an evidence review of good practice. Enablers of IPE programmes are involving patients in the design and delivery, providing a holistic focus, focussing on practical actions, deploying multi-modal learning formats and activities, including more than two professions, evaluating formative and summative aspects, and encouraging team-based working. Guidance for the successful implementation of IPE is set out with examples from qualifying and continuing professional development programmes.

Understanding the Broker Role of Clinician-Scientists: A Realist Review on How They Link Research and Practice.

PURPOSE: Clinician-scientists are said to be well placed to connect research and practice, but their broker role has been underexplored. This review sought to gain an understanding of the broker role of clinician-scientists. METHOD: The authors conducted a realist review to describe context-mechanism-outcome (CMO) configurations associated with the broker role of clinician-scientists. CINAHL, PubMed, PsycINFO, Web of Science, and Embase were searched between May and August 2017. Data were analyzed qualitatively; data synthesis focused on assembling CMO configurations. RESULTS: Of an initial 2,241 articles, 9 were included in the final review. Included papers show that clinician-scientists, in their broker role, achieve 2 organizational-level outcomes: an increased volume of clinically relevant, research, and increased evidence application to improve care. They also achieve the individual-level outcome of professional development as a researcher, clinician, and broker. Multidimensional skills and management support are necessary context factors. Mechanisms that contribute to outcomes include balancing economic and scientific interests and performing boundary-crossing activities. Four CMO configurations by which clinician-scientists achieve outcomes in brokering a connection between research and practice were identified. Useful program theories for explaining these are boundary crossing, social network, communities of practice, and diffusion of innovation theory. CONCLUSIONS: The mechanisms found may provide insight for interventions aiming to support clinician-scientists in their broker role. The authors expect that if more attention is paid to learning multidimensional skills and management support for the broker role is strengthened, stronger links between research and practice could be forged.