An Interprofessional Yearlong Geriatrics Fellowship Program for Advanced Practice Nursing and Social Work Students : Nurse Educator

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An Interprofessional Yearlong Geriatrics Fellowship Program for Advanced Practice Nursing and Social Work Students

Glassburn, Susan PhD, LCSW; Frank, Kathryn PhD, RN; Fulton, Jan PhD, RN; Westmoreland, Glenda MD; Garrison, Emilie BA; Roth, Sarah MPH; Litzelman, Debra K. MD

Author Information
doi: 10.1097/NNE.0000000000001212

Abstract

According to the US Census Bureau, adults 65 years and older are expected to double from 46 million in 2015 to more than 98 million by 2060, and those 85 years and older will triple to 20 million by 2060. By 2034, there will be more older adults than children.1 The percentage of older adults with comorbidities is increasing, with 8 of 10 older adults having multiple chronic conditions requiring ongoing management and the potential for functional limitations and decreased quality of life.2 Health care practice is evolving into patient-centered, team-based models requiring interprofessional (IP) collaboration to achieve the triple aim of health care: better patient experiences, better health outcomes, and lower costs.3 The American Geriatrics Society identified the importance of IP care for older adults, noting the complex health needs of older adults require expert clinical care and care coordination from an entire team of health professionals, family, and other caregivers, regardless of setting.4 In addition to assessment, diagnosis, and treatment of medical conditions, team-based care should include care coordination, patient and family education, patient preferences for care goals, and discernment about what matters most in promoting a better quality of life for each patient. Managing multiple chronic conditions involves considerable clinical complexity, and an IP team is well suited for this holistic care approach.5,6 Educational curricula in gerontology should focus substantively on developing students' ability to work in IP teams.7

While IP team-based care is best practice for older adults with complex needs, universities are challenged to prepare students for working in teams. Barriers to IP practice include lack of IP team training opportunities, lack of knowledge about other professionals' scope of practice, professional cultures and stereotypes, and liability issues. Additional logistical issues, such as scheduling time for faculty collaboration and coordinating student class schedules, are formidable barriers to adding IP clinical experiences to the curriculum.8

To address this need for training in IP geriatric care, the Indiana University Geriatric Workforce Enhancement Program (GWEP) designed the Geriatric Interprofessional Fellowship Experience to provide master of nursing adult/gerontology primary care nurse practitioners (NPs), adult/gerontology clinical nurse specialists (CNSs), and master of social work (MSW) students with an opportunity to develop clinical expertise in managing older adults within a team care environment. The 3 aims of this IP geriatric training project were to increase students' knowledge of age-related changes and health problems experienced by older adults, develop students' clinical competencies in providing patient-centered health care for older adults, and assess the perceived usefulness of fellowship activities for preparing students to practice within an IP team caring for older adults. This article presents the findings of the project and discusses recommendations for future replication or enhancement of existing programs.

Methods

The fellowship was designed as a 2-semester (1 academic year) immersion experience providing learners with advanced knowledge and clinical skills for managing older adults within an IP team care environment. Each fellow received a monetary stipend in the form of a scholarship toward their tuition costs and a certificate upon completion. The institutional review board for the university approved the study of GWEP fellowship activities and associated outcomes. Using a competitive application process, 5 advanced practice nursing (APN) and 5 MSW students were selected as fellows for a total of 10 fellows per year for a 3-year period (n = 30). Medical residents participated in monthly case conferences and seminars but were not offered fellowships due to scheduling conflicts with residency programs. Fellows were placed in geriatric clinical settings and services including inpatient, outpatient, home-based, primary care, and long-term care. Project aims were achieved using several learning activities including online educational modules, clinical experiences, monthly IP seminars, interactive case studies, community-based experiences, and quality improvement (QI) projects.

Online Learning Modules

Five online learning modules with pre/posttests were created by the faculty as a part of this project to introduce fellows to common age-related changes and health problems experienced by older adults including myths about aging, falls and fall prevention, depression, dementia, and medication management/polypharmacy. On the basis of year 1 evaluation, additional modules were created and added, including working with community-based organizations, principles of IP education (IPE), and safe use of opioids. To assess learning, fellows completed multiple-choice pre/posttests consisting of approximately 10 questions for each module and a year-end self-report using a Likert-type scale to identify the degree to which the content in the modules was reinforced or expanded upon during the fellowship.

Supervised Clinical Experiences

Fellows completed clinical experiences designed to meet their school's curricular requirements. APN fellows completed 360 of required 525 clinical hours in the fellowship; MSW students completed all required 640 hours in the fellowship. For the clinical experiences, fellows applied knowledge, practiced clinical skills, and participated in IP team meetings under the supervision of a qualified preceptor. A competency checklist was created by the program based on published nursing and social work geriatric competencies and school requirements and was used to direct activities and monitor progress toward independent practice.9–12 Broad categories of competencies were developed with more specific competencies tailored to fit each professional role, with the understanding that each student is guided to practice within that profession's scope (see Table, Supplemental Digital Content 1, Categories of Clinical Competencies, available at: https://links.lww.com/NE/B119). Emphasis was placed on achieving competency in the areas emphasized in the modules, including dementia, depression, falls, and medication management. Preceptors were oriented to GWEP goals at the beginning of the project and were supported as needed by project faculty. Preceptors completed formative and summative evaluations of fellows' clinical performance, engagement with older adults, contribution to interdisciplinary team meetings, and application of knowledge from the learning modules and monthly seminars.

Monthly IP Seminars

Fellows attended monthly seminars that reinforced knowledge, reflected on clinical experiences, fostered IP teamwork, facilitated leadership development through didactic presentations by clinical experts, process discussions, interactive case studies and care planning with medical residents, and selected professional development topic discussions. To foster collaboration in leadership, paired APN and MSW fellows were assigned to colead either a process discussion or a case study. A faculty member provided consultation for each pair to review best practices in leading group discussions. Each seminar was evaluated by the fellows, with faculty adjusting seminar topics to reflect fellows' learning needs. These seminars did fulfill the values/ethics, roles/responsibilities, and IP communication competencies from the IPE Collaborative.9

Interactive Case Studies

Interactive case studies were derived from medical records using a teaching electronic health record, a modified version of a real electronic health record.13 These cases were de-identified patients who received care at a local safety-net hospital. Fellows were assigned to review the cases, complete assignments, and discuss care plans in an IP team of APN fellows, MSW fellows, and internal medicine residents completing a geriatrics rotation.

Community-Based Experience

Students completed a 1-day experience with staff of the local Area Agency on Aging dedicated to empowering older adults and their caregivers to achieve the greatest possible independence. Fellows attended an orientation overview of the agency's services and shadowed staff as they coordinated plans for in-home services, assisted with transportation and meal services, and advocated for services for older adults.

Quality Improvement Projects

Fellows completed a QI project addressing a clinical care need related to older adults and anchored in a clinical setting. Using the plan-do-study-act (PDSA)14 format, fellows planned, implemented, and evaluated the project. Fellows applied leadership skills in directing the project and partnering with team members in the setting.

Results

The majority of fellows were female (83%), younger than 40 years (63%), and White (73%). MSW fellows were slightly younger, with 30% between the ages of 20 and 29 years compared with 6% of APN fellows. Twenty-six percent of APN fellows were between the ages of 30 and 39 years. Complete demographics can be found in participant demographics and are displayed in Table 2, Supplemental Digital Content, Demographics (available at: https://links.lww.com/NE/B120).

Aim 1: Increase Knowledge of Age-Related Changes and Health Problems

Fellows were introduced to the care of older adults with didactic content presented in online modules and reinforced through the various fellowship activities. For each module, fellows' pre- and posttest scores remained the same or improved. The knowledge scores for the dementia module had lower baseline scores and the greatest improvements. The social work students improved more on the depression and medication management modules than the NP-Gero students. Using mid- and end-of-year surveys, fellows self-reported their knowledge and skill related to the key topics of depression, dementia, falls, medication management, and IP care for older adults. The topics for which self-reported knowledge increased the most were fall prevention (mid-year average score 72% vs end-year average score 97%) and medication management (mid-year average score 86% vs end-year average score 100%) (see Table 3, Supplemental Digital Content, Fellows Improved Knowledge, available at: https://links.lww.com/NE/B121).

Fellows reported the monthly seminars were useful in reinforcing knowledge, with 88% rating the seminars as very useful. Fellows identified the didactic sessions on the prevalence of delirium, treatable causes of dementia, types of memory loss, and prevention of dementia as particularly useful. Fellows also reported high levels of satisfaction with the interactive case studies but found the electronic teaching medical record difficult to use.

Aim 2: Develop Clinical Competencies for Geriatric Practice

The competency checklist served to guide learning by encouraging preceptors to find opportunities for fellows to achieve the full complement of competencies. Preceptors reported fellows being enthusiastic and engaged in the clinical experiences. Fellows overwhelmingly rated clinical experiences as critical to knowledge and skill development, consistently rating the experiences highly satisfactory. Qualitative comments reinforced the ratings. Qualitative feedback was reviewed by 2 of the authors using qualitative descriptive analysis, which seeks to give voice to the experiences and meanings of participants in everyday language.15 One MSW fellow stated, “...interactions with patients made it easier to learn new concepts and apply these skills to working with older adults.” An NP fellow reported that “the most positive aspect for me throughout the experience was the clinical sessions and interacting hands-on with the patients while also learning from the team.” A CNS fellow reported that the clinical experiences allowed her to discover “what a clinical nurse specialist does in the hospital setting and how we can work with staff to ensure the needs of geriatric patients are not missed.” An MSW fellow's comment is representative of many,

The most beneficial aspect of my experience was getting hands-on, face-to-face experience with older adults ... my experience allowed me to work independently during the last semester, so I was able to actually use the knowledge and techniques I had gained ... this experience has made me much more confident, knowledgeable, and ... has solidified my passion for working with older adults in a health care setting.

Aim 3: Assess Perceived Usefulness of IP Team Learning

Fellows provided qualitative feedback at the end of the fellowship about the experience of learning and working in IP teams. Fellows identified IP team care as one of the most important learning activities in the fellowship. Feedback about IP educational learning fell into 2 categories: learning from each other in team meetings and collaborating with team members to improve patient care.

Theme 1: Learning From Each Other in Team Meetings

Fellows reported feeling included in team meetings by experienced practitioners in different professional roles, and team meetings helped them understand the depth and complexity of caring for older adults. The power of team collaboration was mentioned multiple times in comments such as “I was able to learn most from other perspectives and insight from other workers.” An MSW fellow said that “team meetings were the best part of the clinical experience.” An NP fellow said that “having all the disciplines in one room discussing the patients was wonderful and provided a well-rounded treatment plan for them.” Another NP fellow noted how transformative it was to watch teamwork in action during meetings: “I was able to really observe IP practice in a positive and constructive environment.”

Theme 2: Collaborating With Team Members to Improve Patient Care

GWEP fellows engaged in several activities to prepare them for work in IP teams, including supervised clinical experiences, monthly IP seminars with didactic presentations, interactive case studies, and QI projects. Qualitative feedback was solicited from the fellows on how much patient care was improved through IP collaboration. One CNS fellow stated, “I was able to learn so much from different professions that enabled me to regularly contribute to the discussions and better serve patients during this experience and in the future.” An MSW fellow stated: “The communication with the other professionals had the most positive impact. I was able to share valuable knowledge with others in order to increase awareness about certain risks and resources available” [for the patient].

Discussion

The purpose of this fellowship project was to design and implement an academic yearlong immersion experience for APN and MSW students focused on caring for older adults in an IP team setting. The outcomes of the fellowship demonstrated increased knowledge, clinical skills, communication skills, and appreciation for working in an IP geriatrics team, which is consistent with other literature in geriatrics education.16,17 Designing and implementing the fellowship inside a university structure came with challenges. On the basis of our experience, the following recommendations are offered along with literature that supports those recommendations.

Get Faculty “on the Same Page”

From the beginning, faculty members need to develop trusting and safe collegial relationships. Roles and scopes of practice need to be discussed to clarify performance expectations for students of different professions. One common barrier to IP learning activities is the lack of knowledge of each profession and the unique language used by each.18 For example, student practice experiences are called field placements for social work students, rotations or blocks for medical students, and clinical practicum for nursing students.

Anticipate Scheduling Conflicts

The fellowship was embedded in a large, public university and organized as a collaboration among the schools of nursing, social work, and medicine, each operating independently and offering graduate and undergraduate programs. Incorporating meaningful IPE experiences into 2 or more individual professional schools' already packed curricula is a common barrier.8,19 While each of the health profession schools' accreditation standards reflect the importance of including IPE options in the curriculum, operationalizing this standard is idiosyncratic to each school. Each school has unique requirements for experiential learning, such as supervisor qualifications, practicum hours required, skill level, and specialty content, to name a few. While easier said than done, universities seeking to implement IP learning activities should consider intentional design of a common curricular structure that would interface IPE into each school's curriculum.

Centralize Communication

Communication is essential to success. A designated program coordinator or point person is important for communicating with all involved partners, both internal and external. Coordinator activities should include communications with faculty members, fellows, preceptors, clinical settings, and collaborating agencies; centralized data collection and management for testing and evaluation; scheduling of preceptors and settings, and scheduling of meetings, seminars, and guest speakers. With faculty and fellows based in 3 different schools, a coordinator for communication is essential for a successful initiative.

Prepare Students for IPE to Improve Patient Care

Our qualitative feedback demonstrated that fellows perceived IP collaboration as key to improved patient care. We spent time discussing IP teamwork in our sessions and facilitating collaboration between the fellows. Several studies corroborate the effectiveness of IPE in geriatrics on students' attitudes and appreciation for IP care, including increased positive attitudes toward older adults.8,16,17

Reinforce Learning Through Collaborative Seminars

Regularly scheduled seminars are important for reinforcing learning and collaboration. Scheduling guest speakers in the smaller group setting facilitated questions and reflections about patients encountered in clinical settings. The small group seminars helped facilitate intentional conversations around how professions can collaborate effectively and, perhaps more importantly, facilitated a better understanding of each profession's lens. For example, in discussing case studies, each profession has its own viewpoint, giving rise to discussions about the best approach, and collaborative decision-making about responsibilities for interventions and follow-up.

Structured seminar discussions about new learning were coled by paired nurse and social work fellows, who were coached by a faculty member on how to facilitate the discussion. One important goal of IPE is to help students develop awareness of their own roles and to adopt a collective identity that values the contributions of all team members.17–19

The Critical Role of Preceptors

Preceptors served as teachers, coaches, and mentors. Placing fellows with same-profession preceptors who were expert in care of older adults provided role modeling of the nuances of caring for older adults. Fellows witnessed the preceptors' passion and dedication to the patients and their families, which were frequently referenced in the fellows' written feedback about the clinical experiences. As the fellows developed relationships with their mentors, they began to see themselves in similar clinical roles.

Implementation of a QI Project

QI projects have been used to facilitate collaboration between professions, and competence in QI is important for health care teams to improve patient care outcomes.20 Fellows were assigned to complete a QI project either individually or in groups and in collaboration with a clinical setting with outcomes presented the last scheduled seminar. Teaching professionals QI skills has resulted in increased self-efficacy and positive system changes.21,22 Initially, fellows expressed confusion about the QI project as QI education can bring about tensions in the way different professions engage in this process.22 We discovered that the fellows' understanding and skill in QI varied greatly depending on their school's curriculum. The MSW curriculum emphasized evidence-based practice, whereas the nursing curriculum included core content in QI. In addition, some fellows had gained QI experience while working for hospitals and health care agencies. Faculty provided didactic content and created a step-by-step process for project design. The MSW fellows found identifying and implementing a QI project more challenging than APN fellows. Despite the challenges, including a QI assignment served to empower the fellows as change agents, develop leadership skills, and reinforced the need for collaborative problem-solving.

Promote Prestige

Upon completing the fellowship program, fellows received a certificate of completion at a ceremony and were reminded to highlight the fellowship on their curriculum vitae. For future fellows, faculty will investigate university-level recognition of the fellowship by placing a notation on the official transcript. For this fellowship, due to grant funding, students received a tuition stipend, which served as an incentive for students to apply for the academic yearlong program. Depending on funding, it may not be possible to provide tuition stipends; however, official notation on the transcript would validate the significance of the fellowship and provide a competitive edge for students seeking employment in settings focusing on the care of older adults and their families.

Challenges and Limitations

We created the first IP geriatric fellowship at our university. Rather than beginning de novo collectively, we were required to find ways to insert our new learning experiences into existing curricula. As the program unfolded, we were able to make adjustments, such as seminar topics, clinical settings, preceptor assignments, and QI projects. Scheduling conflicts limited our ability to engage students from additional health professions. Medical residents participated in case studies through the teaching medical record and case study discussion during seminars but did not have the opportunity to develop ongoing relationships with the fellows. Ongoing competency verification by preceptors was poorly facilitated using paper documentation. Fellows and preceptors neglected to review and complete the checklist in a timely manner and frequently forgot to submit to faculty for review. Ideally, all feedback should have been captured electronically for ease of analysis. In addition, the number of fellows (n = 30) limits the generalizability of the statistical analysis of findings. Finally, we could not schedule NP and CNS fellows in one consistent setting, which limited their ability to collaborate with each other outside of the monthly seminars. Barriers to implementation are not insurmountable but do pose unique challenges for every institution based on its own internal and external resources.

Conclusion

An IP gerontology fellowship for APN and MSW students can develop students' knowledge and skills in team-based care for older adults. Funded by HRSA, a Geriatric Workforce Development Grant prepared 15 APN and 15 MSW students for practice, with 65% of graduates reporting working in jobs related to care of older adults after graduation. A faculty collaborative facilitated the design, implementation, and evaluation of the program. Challenges remain for scheduling across schools and multiple clinical settings. We hope a similar fellowship program is feasible for other universities and specialty areas of practice.

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Keywords:

advanced practice nursing; clinical competence; curriculum; fellowship; geriatrics; social work

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