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Impact of interdisciplinary education in underserved areas: Health professions collaboration in Tennessee
Impact of Interdisciplinary Education in Underserved Areas: Health Professions Collaboration in Tennessee JOELLEN EDWARDS, P H D , R N * AND PATRICIA SMITH, E D D , R N t
A community-based interdisciplinary health professions education project, involving the Colleges of Medicine, Nursing and Public and Allied Health, was implemented at the undergraduate level at East Tennessee State University from 1990 to the present. The outcomes of this project and the extension of the project into graduate health profession programs are described. Committed leadership, effective communication, and genuine community involvement are identified as essential to the success of communitybased, interdisciplinary health professions training programs. (Index words: Community-based education; Community involvement; Interdisciplinary education; Outcomes)J Prof Nurs 14:144-149, 1998. Copyright © 1998 by W.B. Saunders Company
NTERDISCIPLINARY, community-based education and practice for health professionals is believed to be the way of the future for health care delivery systems. Few institutions promote interdisciplinarity, however, relying instead on traditional segregation ofheahh professions students by discipline and hierarchical arrangements in hospital-based practice. Few examples of interdisciplinary, community-based education and practice exist, and many questions are unanswered about this unique approach to learning and practice (W.K. Kellogg, 1992; Pew Health Professions Commission 1995). Can interdisciplinary teamwork among faculty and students promote improved health status in populations? Are communities better off when they join with academic institutions to educate health professions students? Do students learn what they need to know to survive and succeed in a changing practice environment? Do students who learn in a community-based, interdisciplinary setting in an underserved area choose a similar setting for their practice? These questions will be addressed as
I
*Dean, College of Nursing, East Tennessee State University, Johnson City, TN. tAssociate Dean, Graduate Programs and Research, College of Nursing, East Tennessee State University, Johnson City, TN. Address correspondence and reprint requests to Dr Edwards: East Tennessee State University, College of Nursing, Campus Box 70617, Johnson City, TN 37614-0617. Copyright © 1998 by W.B. Saunders Company
8755-7223/98/1403-0007503.00/0 144
they have been experienced in the efforts of the East Tennessee State University (ETSU) Division of Health Sciences to create interdisciplinary, community-based education for nursing, medical, and public and allied health students. These unique educational strategies, aimed to improve health status in two rural communities, have been supported as part of the W.K. Kellogg Foundation Community Partnerships for Health Professions Education initiative.
The Setting ETSU is a comprehensive, regional academic institution with nearly 12,000 students that awards undergraduate through doctoral degrees. The Division of Health Sciences was established in 1989 to bring together the resources of the Colleges of Medicine, Nursing, and Public and Allied Health to fulfill the specific health mission of the university. ETSU is located in northeast Tennessee in the beautiful Blue Ridge Mountains. The northeast region of the state is comprised of eight counties, most of which are designated as full or partial health professions shortage areas. The partner communities are two rural counties, Hawkins and Johnson, that are part of this underserved region. These counties are located 1 hour or more away from the main campus in Johnson City.
The Community Partnership Projects The Division of Health Sciences and their partner communities were one of seven sites selected for award of the W.K. Kellogg Foundation Community Partnerships for Health Professions Education grants in 1991. The projects were based on the premise that an adequate primary care system can improve health status and save health care dollars. The purpose of the projects was to move health professions education out of the hospital into the community and away from discipline-specific training toward interdisciplinary collaboration for significant portions of the educational experience. Full partnership among the commu-
JournalofProfessionalNursing, Vol 14, No 3 (May-June), 1998: pp 144-149
145
IMPACTOF INTERDISCIPLINARYEDUCATION
nities, the academic institutions, and the disciplines were expected. The first project, funded from 1991 to 1996, addressed the integration of undergraduate medical, nursing, and public and allied health education into communities. The undergraduate effort has become part of the culture of the Division of Health Science, with up to 25 per cent of nursing and medical students, and slightly fewer public health students, enrolling each year in interdisciplinary, communitybased courses. Core content critical to all health professionals is taught by a team of interdisciplinary faculty in an experiential learning format. Community board members exert significant influence over the student experiences to assure that they are appropriate to the setting and meet real community needs. This program continues, even though funding is over, through the commitment of faculty and administration to this approach to health professions education. The second project, currently funded and under way, addresses the same issues at the graduate level. Family practice residents, master's-level family nurse practitioner students, and graduate public and allied health students share community-based, interdisciplinary experiences that meet health needs in rural, underserved areas. Challenges and Opportunities Nursing, medical, and other health professions education, while all aiming to accomplish the common goal of improved health status for people, has arisen from very different traditions (Edwards, 1997). Issues of socioeconomic class, gender, and race have influenced the development of educational structures that segregate the disciplines. These issues are particularly salient to nursing and medical education (Doering, 1992; Fagin, 1992; Melosh, 1982). The origin of educational patterns, graduate for physicians and hospital "training" for nurses, as well as the reinforcement over time of a hierarchical arrangement of authority and subservience are ghosts from the past that can influence present relationships in educational and practice settings. Even the core values of nursing and medicine, although each supporting the same broad goal, are different. Wolf (1989) proposed that medicine tends toward responsibility for others, whereas nursing adopts a vision of facilitating selfresponsibility for health; that medicine values most the preservation of human life as the ultimate goal, whereas nursing supports the idea of quality and wholeness in life as the prime value.
In addition to the academic disciplines, communities bring their own cultures and values to the table. Health professionals have tended to assume a dominant rather than supportive role in bringing services to communities (Osborne & Gaebler, 1992). Divergent views within the community and between community members and health professionals pose challenges to a true community-based approach. Bringing these cultures and histories together to share the power of collaboration is a unique challenge in creating interdisciplinary learning programs (Richards, 1996). The opportunities afforded by interdisciplinary education in communities, where people (who occasionally become patients) live their lives, is that the strengths of all disciplines and the vision of community members can be brought together to the benefit of the whole. This multifaceted team approach has the potential to meet a broad range of health needs as they are defined by the community. Community members require that students learn to view themselves as part of a larger world outside hospital walls. This experience as part of a group of diverse individuals working toward a common goal creates providers aware of their social responsibility as health professionals in their community. This approach can potentially save health care dollars as team members work to their full potential and scope of practice in a manner that is valued and acceptable to the community. The challenges and opportunities of interdisciplinary, community-based education are summarized in Table 1. Outcomes of the Undergraduate Phase of the Partnership Outcomes in various areas have been tracked and analyzed throughout the undergraduate program years. Significant benefits to students, institutions, communities, and the public good through policy changes can be seen. TABLE 1. Challenges and Opportunities of Community-Based Education Challenges
Opportunities
Historical social & professional traditions
Equality and partnership between professionals and community Core content in interdisciplinary service-learning format Identification of common goals and mutual understandings Team approach that benefits the whole
Divergent educational patterns
Core values differ Segregation of disciplines and community
146
EDWARDS AND SMITH STUDENT OUTCOMES
Medical, nursing, and public and allied health students have graduated from the community partnerships program track. A constant worry of program innovators is whether or not graduates of nontraditional programs will meet traditional licensure standards. No significant difference was found between graduates of the community-based interdisciplinary program track and their traditional counterparts on board or licensing examinations. Positive differences were found in the students' physical assessment and communication skills and in the ability to think critically in clinical situations. Students also expressed a better understanding of the role and contribution of team members from other disciplines. They reported placing high value on the early and intensive clinical experiences in the partner communities. The perceived value of working with community members was also expressed by students from all disciplines. O f the initial program graduates, all medical students chose a primary care residency. O f the nursing graduates, 80 per cent are working in public health, home health, small rural hospitals, or long-term care facilities in health professions shortage areas.
Positive differences were f o u n d . . . in the ability to think critically in clinical situations. INSTITUTIONAL OUTCOMES
Nine of the original 13 interdisciplinary communitybased courses have been revised and maintained, with up to 25 per cent of entering health professions classes admitted to the track. An interest in interdisciplinary education has been sparked across the campus, with four graduate courses now in place that are interdisciplinary in nature and undergraduate courses evolving across diverse departments within and outside the Division of Health Science. Although not every traditional medical student gets as intensive a community-based experience as the "Kellogg" students, all now undertake a generalist clinical rotation in a community site early in their educational program. The entire Bachelor of Science Nursing program has moved to a community-based format, with increased options for interdisciplinary study.
Decisions about the application of travel funds, faculty work load, and interdisciplinary credit hour allocation within nontraditional programs within the university administrative structure have supported the success of this model. The value of faculty efforts has been recognized through the full support of community service and community-based research in the promotion, tenure, and reappointment process. The example and success of the partnership program has sparked a renewal of the university's commitment to the region through deep community involvement in many areas.
COMMUNITY OUTCOMES
Communities have benefited from their participation in partnership with ETSU. The visibility and involvement of health professions students in small rural areas has provided role models for the youth of the partner counties. Over the 5-year period, an overall increase of 53 per cent of high school students from the partner communities entering college at ETSU has occurred, with the largest enrollment growth in the health sciences. Employment in clinics associated with ETSU and the community-based program has provided approximately 20 sustainable jobs in health care or educational support in the region. The economic impact on the two counties is significant and represents university commitment to be part of the community. The availability of health promotion, screening, and illness prevention programs as well as clinical preventive services is unrivaled in any rural area because of the students' involvement. Students and faculty are present in schools, industries, health care agencies, community events, and local organizations offering a wide range ofheahh education and services. Although no direct cause and effect can be claimed, it is interesting to note a significant decrease in number of deaths from all causes and from cardiovascular deaths in both partner counties over the 5-year period of involvement. At the same time, the number of deaths in these two categories increased in the state and in the six other counties in the region (Florence & Goodrow, 1996). The high level of wellness activities and comprehensive primary care provided by students and faculty members surely influenced these positive changes. Access to health services has been greatly increased. Three primary care clinics associated with the project provide services in the counties. Together, more than 18,000 primary care encounters for acute, chronic, or
IMPACT OF INTERDISCIPLINARY EDUCATION
preventive services took place in the interdisciplinary, nursing, and medical clinics in the past year alone. PUBLIC POLICY OUTCOMES
The collective public good has been enhanced by the activities of the community partnership through demonstration of approaches to primary care education and practice that improve access to care. The portion of graduate medical education funding associated with TennCare, Tennessee's managed medicaid program, has been rechanneled directly to colleges of medicine rather than to hospitals. Requirements for expenditure of the funds support primary care at the medical residency level. This is one of the first efforts in this direction in the country and may eventually open the door for graduate nursing education funds as well. The state legislature passed a bill requiring commercial insurance companies to reimburse for nurse practitioner services. Although problems continue to arise with managed care organizations that pose barriers to nurse practitioner reimbursement, the passage of the bill was a step in the right direction toward full participation in the health care delivery system by all team members. A move by the Board of Medical Examiners to limit access to nurse practitioner care by revising the supervision requirements for medical preceptors was quelled through intensive statewide efforts by nurses. The leadership and success of the community partnership project at ETSU contributed to the documentation of these changes for the public good. The undergraduate phase outcomes are summarized in Table 2. All of the difficulties inherent in innovation and challenging tradition have been encountered in the implementation of this project. Yet, the positive outcomes for students, the institution, the communities, and the public at large of the undergraduate program set the stage for deeper collaboration and potential impact at the graduate level. The Graduate Phase
During the second phase of the project, the concepts of interdisciplinary learning and community involvement were extended to the graduate level at ETSU. The Graduate Health Professions Education (GHPE) project focuses on a series of interdisciplinary educational experiences for family practice residents, family nurse practitioner students, and graduate students in environmental health, communicative disor-
147 TABLE 2.
Outcomes: Undergraduate Phase ETSU Community Partnership
Students Equal success with traditional students on {icensing and professional examinations All medical graduates chose primary care residency Eighty per cent of nursing graduates chose practice in rural underserved areas Institution Interdisciplinary, community-based track continued after funding Changes in medical, nursing, and public health curricula Recognition of service and community-based research in promotion and tenure Communities Fifty-three per cent increase in college entrance in partner counties Access to primary care increased Improvement in death rates from all causes and from cardiovascular deaths Public policy TennCare GME funds channeled to medical colleges to support primary care Nurse practitioner reimbursement bill passed 1996 Abbreviations: ETSU, East Tennessee State University; GME, Graduate Medical Education.
ders, and public health. The partnership opportunity has been expanded to the region, including northeast Tennessee, southwest Virginia, and northwest North Carolina. The GHPE vision is to develop provider teams who will be better prepared to work with one another and with communities. These graduates, along with community members, will be better able to address issues of access, cost, and quality in primary care. The specific goals of the project include the following: 1. increase the number of suitably educated primary care health professionals with a clear understanding of their responsibility to the larger community; 2. increase access to care throughout the region by promoting delivery of care by multidisciplinary teams of health professionals; 3. reduce the legal and regulatory barriers to health professions education, health care practice, and access to care; and 4. create sustaining organizational structures that link communities, hospitals, and health professions training programs with financial support for community-based education. The interdisciplinary experiences planned include graduate seminars, collaborative practice, community projects, and field experiences that let students interact
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EDWARDS AND SMITH
with a wide range of"best practices" in primary care in the region. The graduate seminars began in the fall semester of 1996. A half-day luncheon forum provided opportunities for students to interact with each other in small groups as they explored topics pertinent to their practices. During the first seminar, students were oriented to the project, introduced to each other, and asked to shared their own personal goals for the learning experiences. Collaborative practice was the focus of the second seminar and featured an exemplar provider team in the region. The physician, nurse practitioner, and social worker discussed the ways in which they relate to each other within the practice and how each contributes to meeting client needs. Small, interdisciplinary groups used a case study to determine how the ideas presented by the speakers could be applied in their own practices. Other seminar topics planned for the coming year include a 2-day seminar on managed care with an emphasis on client and provider issues, measuring quality care, health promotion and disease prevention interventions in primary care, and practice management issues.
• . . there must be committed and knowledgeable leadership at the highest l e v e l . . .
practice sites. They will explore the health care needs, priorities, and resources of their respective communities and become involved in a service learning project or other organized community outreach experience. All projects will be based on community needs and coordinated with local health care providers and organizations. Public health students will become directly involved in the planning and implementation of the community projects. Finally, a series of "best experiences" will be integrated into the learning plan. Visits to primary care sites--such as school-based clinics, occupational health centers, homeless clinics, migrant health programs, prison health, and others--are designed to broaden the students' understanding of the impact of community-oriented primary care.
Lessons Learned... Undergraduate to Graduate Phase
What has been learned from the undergraduate phase that can be applied to the GHPE project and used by others interested in creating interdisciplinary, community-based programs? The lessons learned were many, but the most important pertained to committed leadership, communication, and community involvement.
COMMI'H'ED LEADERSHIP
At the heart of the project is the collaborative practice experience in rural and other underserved settings. The goal is to develop a regional health professions training network of muhidisciplinary practice sites. Potential physician and nurse practitioner preceptors whose practice meets the criteria to be considered collaborative are targeted as training sites for the student teams. In most instances, a resident and family nurse practitioner student will be assigned to the practice for long-term team involvement on a weekly basis. Later in the project, the teams will work together in a more intensive format during the family nurse practitioner internship course and the medical resident community medicine rotation. In selected settings, an appropriate public and allied health graduate student will join the team to work on a related project. In addition to learning how to care for clients within a collaborative practice environment, the student teams will build a community focus in their
First and foremost, there must be committed and knowledgeable leadership at the highest level of the university and the academic units involved as well as those faculty directly involved in teaching students. Changing academic policies and procedures, modifying student schedules, and changing teaching formats are formidable tasks. Even more formidable is the personal and professional risk inherent in challenging history and tradition on a daily basis. Leaders must believe in the concept of the program and be willing to speak and act on that belief every single day. In the ETSU project, the three health science deans, the graduate program directors, and three lead faculty (two of whom were instrumental in the success of the undergraduate effort) comprise the formal leadership structure within the university for the GHPE project. The executive director of the university's Office of Rural and Community Health, established during the undergraduate phase, continues to provide the day-today structure and operational support for both phases of the project.
IMPACT OF INTERDISCIPLINARY EDUCATION
149
COMMUNICATION
TABLE 3.
Second, if real change is to occur, there must be widespread understanding and appreciation of the goals and challenges of the project. Communication must penetrate the breadth and depth of the academic and community organizations. Frequent meetings, for both operational tasks and the refreshing of commitment to the vision of the project, are necessary. Opportunities for faculty, administrators, community members, and students to meet together are time consuming but are critical to the success of the effort. One helpful communication strategy has been to create "memos of understandings" from meetings or student sessions that are reviewed periodically. In the memos of understanding, key points of the discussion as well as the outcomes of the discussion are noted. Far more than minutes alone, this strategy allows all constituents to agree on what was said or planned during sessions. They are effective in keeping everyone moving forward, up-to-date, and on target.
Expected Outcomes: Graduate Phase ETSU Community Partnership
Graduates choose to practice in rural and/or underserved health professions shortage areas Graduates integrate a community focus into their practice Graduates are prepared to practice in interdisciplinary teams Community-academic relationships are strengthened Access to primary health care is increased Health care is of higher quality and more cost-effective due to team approaches to care Sustained fiscal support for community-based, interdisciplinary health professions is obtained
munity members, but they can be the success or failure of the project. The physician and nurse practitioner preceptors, as community providers, are critical to the success of the endeavor. Preceptors should be offered training, feedback, and appreciation in various ways for their contribution to the students' success. Expected Outcomes From the Graduate Phase
COMMUNITY INVOLVEMENT
The third lesson is to assure genuine and active community involvement in all aspects of the project from the very beginning. In the ETSU project, community members direct the program through their representation (51 per cent) on the Executive Board and as they become involved in channeling the learning experiences and community projects of students. Meetings, travel, and telephone conversations require intensive time commitments from busy c o m -
The GHPE project is expected to produce the outcomes depicted in Table 3. Although the outcomes of the GHPE project are yet to be realized, the potential benefits are many. The operational experience and outcomes of the undergraduate phase, the commitment of university and community leaders and participants to the goals of the project, and the benefit to the whole health care system makes 'the outlook strong for success.
References
Doering, L. (1992). Power and knowledge in nursing: A feminist poststructuralist view. Advances in Nursing Science, 14, 24-33. Edwards, J. (1997). Collaboration between nursing and medicine in community-based settings. In J. McCloskey & H. Grace (Eds.), Current issues in nursing (5th ed.). St. Louis, MO: Mosby. Fagin, C. (1992). Collaboration between nurses and physicians: No longer a choice. Nursing and Health Care, 13, 354-363. Florence,J., & Goodrow, B. (1996). Morbidi{y and mortality in two East Tennesseecounties, 1991-1996. A report provided to East TennesseeState UniversityKelloggProgram. Melosh, B. (1982). Work culture and conflict in American nursing: The physician's hand. Philadelphia: Temple University Press.
Osborne, D., & Gaebler, T. (1992). Community-owned government: Empowering rather than serving. Re-inventing government: How the entrepreneurial spirit is transforming the public sector. Redwood City, CA: Addison-Wesley. Pew Health Professions Commission (1995). Critical challenges: Revitalizing the health professions for the twentyfirst century. San Francisco. Richards, R. (1996). Building partnerships: Educating health professionals for the communities they serve. San Francisco: Jossey-Bass. W.K. Kellogg Foundation (1992). Community partnerships: Redirecting health professions education toward primary care. Battle Creek, MI: Kellogg Foundation. Wolf, B. (1989). Nursing identi W The nursing-medicine relationship.Denver, CO: Denver Bookbinding.
A community-based interdisciplinary health professions education project, involving the Colleges of Medicine, Nursing and Public and Allied Health, was implemented at the undergraduate level at East Tennessee State University from 1990 to the present. The outcomes of this project and the extension of the project into graduate health profession programs are described. Committed leadership, effective communication, and genuine community involvement are identified as essential to the success of communitybased, interdisciplinary health professions training programs. (Index words: Community-based education; Community involvement; Interdisciplinary education; Outcomes)J Prof Nurs 14:144-149, 1998. Copyright © 1998 by W.B. Saunders Company
NTERDISCIPLINARY, community-based education and practice for health professionals is believed to be the way of the future for health care delivery systems. Few institutions promote interdisciplinarity, however, relying instead on traditional segregation ofheahh professions students by discipline and hierarchical arrangements in hospital-based practice. Few examples of interdisciplinary, community-based education and practice exist, and many questions are unanswered about this unique approach to learning and practice (W.K. Kellogg, 1992; Pew Health Professions Commission 1995). Can interdisciplinary teamwork among faculty and students promote improved health status in populations? Are communities better off when they join with academic institutions to educate health professions students? Do students learn what they need to know to survive and succeed in a changing practice environment? Do students who learn in a community-based, interdisciplinary setting in an underserved area choose a similar setting for their practice? These questions will be addressed as
I
*Dean, College of Nursing, East Tennessee State University, Johnson City, TN. tAssociate Dean, Graduate Programs and Research, College of Nursing, East Tennessee State University, Johnson City, TN. Address correspondence and reprint requests to Dr Edwards: East Tennessee State University, College of Nursing, Campus Box 70617, Johnson City, TN 37614-0617. Copyright © 1998 by W.B. Saunders Company
8755-7223/98/1403-0007503.00/0 144
they have been experienced in the efforts of the East Tennessee State University (ETSU) Division of Health Sciences to create interdisciplinary, community-based education for nursing, medical, and public and allied health students. These unique educational strategies, aimed to improve health status in two rural communities, have been supported as part of the W.K. Kellogg Foundation Community Partnerships for Health Professions Education initiative.
The Setting ETSU is a comprehensive, regional academic institution with nearly 12,000 students that awards undergraduate through doctoral degrees. The Division of Health Sciences was established in 1989 to bring together the resources of the Colleges of Medicine, Nursing, and Public and Allied Health to fulfill the specific health mission of the university. ETSU is located in northeast Tennessee in the beautiful Blue Ridge Mountains. The northeast region of the state is comprised of eight counties, most of which are designated as full or partial health professions shortage areas. The partner communities are two rural counties, Hawkins and Johnson, that are part of this underserved region. These counties are located 1 hour or more away from the main campus in Johnson City.
The Community Partnership Projects The Division of Health Sciences and their partner communities were one of seven sites selected for award of the W.K. Kellogg Foundation Community Partnerships for Health Professions Education grants in 1991. The projects were based on the premise that an adequate primary care system can improve health status and save health care dollars. The purpose of the projects was to move health professions education out of the hospital into the community and away from discipline-specific training toward interdisciplinary collaboration for significant portions of the educational experience. Full partnership among the commu-
JournalofProfessionalNursing, Vol 14, No 3 (May-June), 1998: pp 144-149
145
IMPACTOF INTERDISCIPLINARYEDUCATION
nities, the academic institutions, and the disciplines were expected. The first project, funded from 1991 to 1996, addressed the integration of undergraduate medical, nursing, and public and allied health education into communities. The undergraduate effort has become part of the culture of the Division of Health Science, with up to 25 per cent of nursing and medical students, and slightly fewer public health students, enrolling each year in interdisciplinary, communitybased courses. Core content critical to all health professionals is taught by a team of interdisciplinary faculty in an experiential learning format. Community board members exert significant influence over the student experiences to assure that they are appropriate to the setting and meet real community needs. This program continues, even though funding is over, through the commitment of faculty and administration to this approach to health professions education. The second project, currently funded and under way, addresses the same issues at the graduate level. Family practice residents, master's-level family nurse practitioner students, and graduate public and allied health students share community-based, interdisciplinary experiences that meet health needs in rural, underserved areas. Challenges and Opportunities Nursing, medical, and other health professions education, while all aiming to accomplish the common goal of improved health status for people, has arisen from very different traditions (Edwards, 1997). Issues of socioeconomic class, gender, and race have influenced the development of educational structures that segregate the disciplines. These issues are particularly salient to nursing and medical education (Doering, 1992; Fagin, 1992; Melosh, 1982). The origin of educational patterns, graduate for physicians and hospital "training" for nurses, as well as the reinforcement over time of a hierarchical arrangement of authority and subservience are ghosts from the past that can influence present relationships in educational and practice settings. Even the core values of nursing and medicine, although each supporting the same broad goal, are different. Wolf (1989) proposed that medicine tends toward responsibility for others, whereas nursing adopts a vision of facilitating selfresponsibility for health; that medicine values most the preservation of human life as the ultimate goal, whereas nursing supports the idea of quality and wholeness in life as the prime value.
In addition to the academic disciplines, communities bring their own cultures and values to the table. Health professionals have tended to assume a dominant rather than supportive role in bringing services to communities (Osborne & Gaebler, 1992). Divergent views within the community and between community members and health professionals pose challenges to a true community-based approach. Bringing these cultures and histories together to share the power of collaboration is a unique challenge in creating interdisciplinary learning programs (Richards, 1996). The opportunities afforded by interdisciplinary education in communities, where people (who occasionally become patients) live their lives, is that the strengths of all disciplines and the vision of community members can be brought together to the benefit of the whole. This multifaceted team approach has the potential to meet a broad range of health needs as they are defined by the community. Community members require that students learn to view themselves as part of a larger world outside hospital walls. This experience as part of a group of diverse individuals working toward a common goal creates providers aware of their social responsibility as health professionals in their community. This approach can potentially save health care dollars as team members work to their full potential and scope of practice in a manner that is valued and acceptable to the community. The challenges and opportunities of interdisciplinary, community-based education are summarized in Table 1. Outcomes of the Undergraduate Phase of the Partnership Outcomes in various areas have been tracked and analyzed throughout the undergraduate program years. Significant benefits to students, institutions, communities, and the public good through policy changes can be seen. TABLE 1. Challenges and Opportunities of Community-Based Education Challenges
Opportunities
Historical social & professional traditions
Equality and partnership between professionals and community Core content in interdisciplinary service-learning format Identification of common goals and mutual understandings Team approach that benefits the whole
Divergent educational patterns
Core values differ Segregation of disciplines and community
146
EDWARDS AND SMITH STUDENT OUTCOMES
Medical, nursing, and public and allied health students have graduated from the community partnerships program track. A constant worry of program innovators is whether or not graduates of nontraditional programs will meet traditional licensure standards. No significant difference was found between graduates of the community-based interdisciplinary program track and their traditional counterparts on board or licensing examinations. Positive differences were found in the students' physical assessment and communication skills and in the ability to think critically in clinical situations. Students also expressed a better understanding of the role and contribution of team members from other disciplines. They reported placing high value on the early and intensive clinical experiences in the partner communities. The perceived value of working with community members was also expressed by students from all disciplines. O f the initial program graduates, all medical students chose a primary care residency. O f the nursing graduates, 80 per cent are working in public health, home health, small rural hospitals, or long-term care facilities in health professions shortage areas.
Positive differences were f o u n d . . . in the ability to think critically in clinical situations. INSTITUTIONAL OUTCOMES
Nine of the original 13 interdisciplinary communitybased courses have been revised and maintained, with up to 25 per cent of entering health professions classes admitted to the track. An interest in interdisciplinary education has been sparked across the campus, with four graduate courses now in place that are interdisciplinary in nature and undergraduate courses evolving across diverse departments within and outside the Division of Health Science. Although not every traditional medical student gets as intensive a community-based experience as the "Kellogg" students, all now undertake a generalist clinical rotation in a community site early in their educational program. The entire Bachelor of Science Nursing program has moved to a community-based format, with increased options for interdisciplinary study.
Decisions about the application of travel funds, faculty work load, and interdisciplinary credit hour allocation within nontraditional programs within the university administrative structure have supported the success of this model. The value of faculty efforts has been recognized through the full support of community service and community-based research in the promotion, tenure, and reappointment process. The example and success of the partnership program has sparked a renewal of the university's commitment to the region through deep community involvement in many areas.
COMMUNITY OUTCOMES
Communities have benefited from their participation in partnership with ETSU. The visibility and involvement of health professions students in small rural areas has provided role models for the youth of the partner counties. Over the 5-year period, an overall increase of 53 per cent of high school students from the partner communities entering college at ETSU has occurred, with the largest enrollment growth in the health sciences. Employment in clinics associated with ETSU and the community-based program has provided approximately 20 sustainable jobs in health care or educational support in the region. The economic impact on the two counties is significant and represents university commitment to be part of the community. The availability of health promotion, screening, and illness prevention programs as well as clinical preventive services is unrivaled in any rural area because of the students' involvement. Students and faculty are present in schools, industries, health care agencies, community events, and local organizations offering a wide range ofheahh education and services. Although no direct cause and effect can be claimed, it is interesting to note a significant decrease in number of deaths from all causes and from cardiovascular deaths in both partner counties over the 5-year period of involvement. At the same time, the number of deaths in these two categories increased in the state and in the six other counties in the region (Florence & Goodrow, 1996). The high level of wellness activities and comprehensive primary care provided by students and faculty members surely influenced these positive changes. Access to health services has been greatly increased. Three primary care clinics associated with the project provide services in the counties. Together, more than 18,000 primary care encounters for acute, chronic, or
IMPACT OF INTERDISCIPLINARY EDUCATION
preventive services took place in the interdisciplinary, nursing, and medical clinics in the past year alone. PUBLIC POLICY OUTCOMES
The collective public good has been enhanced by the activities of the community partnership through demonstration of approaches to primary care education and practice that improve access to care. The portion of graduate medical education funding associated with TennCare, Tennessee's managed medicaid program, has been rechanneled directly to colleges of medicine rather than to hospitals. Requirements for expenditure of the funds support primary care at the medical residency level. This is one of the first efforts in this direction in the country and may eventually open the door for graduate nursing education funds as well. The state legislature passed a bill requiring commercial insurance companies to reimburse for nurse practitioner services. Although problems continue to arise with managed care organizations that pose barriers to nurse practitioner reimbursement, the passage of the bill was a step in the right direction toward full participation in the health care delivery system by all team members. A move by the Board of Medical Examiners to limit access to nurse practitioner care by revising the supervision requirements for medical preceptors was quelled through intensive statewide efforts by nurses. The leadership and success of the community partnership project at ETSU contributed to the documentation of these changes for the public good. The undergraduate phase outcomes are summarized in Table 2. All of the difficulties inherent in innovation and challenging tradition have been encountered in the implementation of this project. Yet, the positive outcomes for students, the institution, the communities, and the public at large of the undergraduate program set the stage for deeper collaboration and potential impact at the graduate level. The Graduate Phase
During the second phase of the project, the concepts of interdisciplinary learning and community involvement were extended to the graduate level at ETSU. The Graduate Health Professions Education (GHPE) project focuses on a series of interdisciplinary educational experiences for family practice residents, family nurse practitioner students, and graduate students in environmental health, communicative disor-
147 TABLE 2.
Outcomes: Undergraduate Phase ETSU Community Partnership
Students Equal success with traditional students on {icensing and professional examinations All medical graduates chose primary care residency Eighty per cent of nursing graduates chose practice in rural underserved areas Institution Interdisciplinary, community-based track continued after funding Changes in medical, nursing, and public health curricula Recognition of service and community-based research in promotion and tenure Communities Fifty-three per cent increase in college entrance in partner counties Access to primary care increased Improvement in death rates from all causes and from cardiovascular deaths Public policy TennCare GME funds channeled to medical colleges to support primary care Nurse practitioner reimbursement bill passed 1996 Abbreviations: ETSU, East Tennessee State University; GME, Graduate Medical Education.
ders, and public health. The partnership opportunity has been expanded to the region, including northeast Tennessee, southwest Virginia, and northwest North Carolina. The GHPE vision is to develop provider teams who will be better prepared to work with one another and with communities. These graduates, along with community members, will be better able to address issues of access, cost, and quality in primary care. The specific goals of the project include the following: 1. increase the number of suitably educated primary care health professionals with a clear understanding of their responsibility to the larger community; 2. increase access to care throughout the region by promoting delivery of care by multidisciplinary teams of health professionals; 3. reduce the legal and regulatory barriers to health professions education, health care practice, and access to care; and 4. create sustaining organizational structures that link communities, hospitals, and health professions training programs with financial support for community-based education. The interdisciplinary experiences planned include graduate seminars, collaborative practice, community projects, and field experiences that let students interact
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with a wide range of"best practices" in primary care in the region. The graduate seminars began in the fall semester of 1996. A half-day luncheon forum provided opportunities for students to interact with each other in small groups as they explored topics pertinent to their practices. During the first seminar, students were oriented to the project, introduced to each other, and asked to shared their own personal goals for the learning experiences. Collaborative practice was the focus of the second seminar and featured an exemplar provider team in the region. The physician, nurse practitioner, and social worker discussed the ways in which they relate to each other within the practice and how each contributes to meeting client needs. Small, interdisciplinary groups used a case study to determine how the ideas presented by the speakers could be applied in their own practices. Other seminar topics planned for the coming year include a 2-day seminar on managed care with an emphasis on client and provider issues, measuring quality care, health promotion and disease prevention interventions in primary care, and practice management issues.
• . . there must be committed and knowledgeable leadership at the highest l e v e l . . .
practice sites. They will explore the health care needs, priorities, and resources of their respective communities and become involved in a service learning project or other organized community outreach experience. All projects will be based on community needs and coordinated with local health care providers and organizations. Public health students will become directly involved in the planning and implementation of the community projects. Finally, a series of "best experiences" will be integrated into the learning plan. Visits to primary care sites--such as school-based clinics, occupational health centers, homeless clinics, migrant health programs, prison health, and others--are designed to broaden the students' understanding of the impact of community-oriented primary care.
Lessons Learned... Undergraduate to Graduate Phase
What has been learned from the undergraduate phase that can be applied to the GHPE project and used by others interested in creating interdisciplinary, community-based programs? The lessons learned were many, but the most important pertained to committed leadership, communication, and community involvement.
COMMI'H'ED LEADERSHIP
At the heart of the project is the collaborative practice experience in rural and other underserved settings. The goal is to develop a regional health professions training network of muhidisciplinary practice sites. Potential physician and nurse practitioner preceptors whose practice meets the criteria to be considered collaborative are targeted as training sites for the student teams. In most instances, a resident and family nurse practitioner student will be assigned to the practice for long-term team involvement on a weekly basis. Later in the project, the teams will work together in a more intensive format during the family nurse practitioner internship course and the medical resident community medicine rotation. In selected settings, an appropriate public and allied health graduate student will join the team to work on a related project. In addition to learning how to care for clients within a collaborative practice environment, the student teams will build a community focus in their
First and foremost, there must be committed and knowledgeable leadership at the highest level of the university and the academic units involved as well as those faculty directly involved in teaching students. Changing academic policies and procedures, modifying student schedules, and changing teaching formats are formidable tasks. Even more formidable is the personal and professional risk inherent in challenging history and tradition on a daily basis. Leaders must believe in the concept of the program and be willing to speak and act on that belief every single day. In the ETSU project, the three health science deans, the graduate program directors, and three lead faculty (two of whom were instrumental in the success of the undergraduate effort) comprise the formal leadership structure within the university for the GHPE project. The executive director of the university's Office of Rural and Community Health, established during the undergraduate phase, continues to provide the day-today structure and operational support for both phases of the project.
IMPACT OF INTERDISCIPLINARY EDUCATION
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COMMUNICATION
TABLE 3.
Second, if real change is to occur, there must be widespread understanding and appreciation of the goals and challenges of the project. Communication must penetrate the breadth and depth of the academic and community organizations. Frequent meetings, for both operational tasks and the refreshing of commitment to the vision of the project, are necessary. Opportunities for faculty, administrators, community members, and students to meet together are time consuming but are critical to the success of the effort. One helpful communication strategy has been to create "memos of understandings" from meetings or student sessions that are reviewed periodically. In the memos of understanding, key points of the discussion as well as the outcomes of the discussion are noted. Far more than minutes alone, this strategy allows all constituents to agree on what was said or planned during sessions. They are effective in keeping everyone moving forward, up-to-date, and on target.
Expected Outcomes: Graduate Phase ETSU Community Partnership
Graduates choose to practice in rural and/or underserved health professions shortage areas Graduates integrate a community focus into their practice Graduates are prepared to practice in interdisciplinary teams Community-academic relationships are strengthened Access to primary health care is increased Health care is of higher quality and more cost-effective due to team approaches to care Sustained fiscal support for community-based, interdisciplinary health professions is obtained
munity members, but they can be the success or failure of the project. The physician and nurse practitioner preceptors, as community providers, are critical to the success of the endeavor. Preceptors should be offered training, feedback, and appreciation in various ways for their contribution to the students' success. Expected Outcomes From the Graduate Phase
COMMUNITY INVOLVEMENT
The third lesson is to assure genuine and active community involvement in all aspects of the project from the very beginning. In the ETSU project, community members direct the program through their representation (51 per cent) on the Executive Board and as they become involved in channeling the learning experiences and community projects of students. Meetings, travel, and telephone conversations require intensive time commitments from busy c o m -
The GHPE project is expected to produce the outcomes depicted in Table 3. Although the outcomes of the GHPE project are yet to be realized, the potential benefits are many. The operational experience and outcomes of the undergraduate phase, the commitment of university and community leaders and participants to the goals of the project, and the benefit to the whole health care system makes 'the outlook strong for success.
References
Doering, L. (1992). Power and knowledge in nursing: A feminist poststructuralist view. Advances in Nursing Science, 14, 24-33. Edwards, J. (1997). Collaboration between nursing and medicine in community-based settings. In J. McCloskey & H. Grace (Eds.), Current issues in nursing (5th ed.). St. Louis, MO: Mosby. Fagin, C. (1992). Collaboration between nurses and physicians: No longer a choice. Nursing and Health Care, 13, 354-363. Florence,J., & Goodrow, B. (1996). Morbidi{y and mortality in two East Tennesseecounties, 1991-1996. A report provided to East TennesseeState UniversityKelloggProgram. Melosh, B. (1982). Work culture and conflict in American nursing: The physician's hand. Philadelphia: Temple University Press.
Osborne, D., & Gaebler, T. (1992). Community-owned government: Empowering rather than serving. Re-inventing government: How the entrepreneurial spirit is transforming the public sector. Redwood City, CA: Addison-Wesley. Pew Health Professions Commission (1995). Critical challenges: Revitalizing the health professions for the twentyfirst century. San Francisco. Richards, R. (1996). Building partnerships: Educating health professionals for the communities they serve. San Francisco: Jossey-Bass. W.K. Kellogg Foundation (1992). Community partnerships: Redirecting health professions education toward primary care. Battle Creek, MI: Kellogg Foundation. Wolf, B. (1989). Nursing identi W The nursing-medicine relationship.Denver, CO: Denver Bookbinding.