561470

research-article2015
PHPXXX10.1177/2373379914561470Pedagogy in Health PromotionSuiter et al.

Article
Pedagogy in Health Promotion: The

Interprofessional Education in Community Scholarship of Teaching and Learning

2015, Vol. 1(1) 3746
2015 Society for Public
Health Contexts: Preparing a Collaborative Health Education
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DOI: 10.1177/2373379914561470
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Sarah V. Suiter, MS, PhD1, Heather A. Davidson, PhD2, Mark McCaw, MSSW, MBA3,
and Kelley-Frances Fenelon, MTS2

Abstract
This pilot study explores an interprofessional, practice-based education initiative that placed students from four different
professions (medicine, nursing, social work, and pharmacy) in a community health clinic day per week for 8 months. The
study was guided by two research questions: (1) How do clinic experiences contribute to students understanding of social
determinants of health? (2) What factors influence the creation of an effective learning environment? To address these
questions, we conducted a qualitative, ethnographic study that included participant observation, focus groups, and textual
analysis. This study allowed us to explore the experiences of students and staff as they interacted in a community-based
clinic setting. We found that the interprofessional, clinic-based experience improved students knowledge- and practice-
based competencies in a variety of areas, including awareness of social determinants of health, skills in securing resources
for patients with financial limitations, appreciation for health education and health promotion in clinical practice, and
experience working interprofessionally. We observed that creating environments that support this kind of student learning
requires time and effort on the part of the clinic staff. We discuss implications of these findings for supporting future
interprofessional, practice-based health education initiatives.

Keywords
community-based organizations, community health, clinical education, interprofessional practice

An ever-increasing body of research demonstrates that a
persons health is affected by numerous social determi-
nants, most of which occur outside of the health care
system (Commission on Social Determinants of Health,
2005), and health care systems must also adapt to address
these factors (U.S. Department of Health & Human
Services, 2000). Among these adaptations is an emerging
emphasis on team-based carecare that is delivered by
intentionally created, usually relatively small work
groups in health care, who are recognized by others as
well as themselves as having a collective identity and
shared responsibility for a patient or group of patients
(Interprofessional Education Collaborative Expert Panel
[IECEP], 2011, p. 2). These teams are often led by a medi-
cal doctor but include other practitioners such as
advanced practice nurses, physician assistants, nurses,
pharmacists, nutritionists, social workers, health educa-
tion specialists, and care coordinators (Agency for Health
Research and Quality, 2012). By employing multiple
types of practitioners to work together to provide coordi-
nated, comprehensive care, these teams are better
equipped to provide care that addresses health needs in
a sufficiently comprehensive manner (Agency for Health
Research and Quality, 2012).
The data supporting positive outcomes related to this
interprofessional model are compelling (Patient-Centered
Primary Care Collaborative, 2012); however, this model
is something of a departure from traditional models of
care both in training and in practice, and it often neces-
sitates forging new partnerships, creating organizational
changes, and equipping providers for team-based work
(IECEP, 2011). In particular, team-based work requires
practitioners within these systems to communicate across
1
Peabody College of Vanderbilt University, Nashville, TN, USA
2
Vanderbilt University School of Medicine, Nashville, TN, USA
3
Siloam Institute of Faith, Health and Culture, Siloam Family Health
Center, Nashville, TN, USA
Corresponding Author:
Sarah V. Suiter, Peabody College of Vanderbilt University, 230 Appleton
Place, Box 90 Peabody, Nashville, TN 37203, USA.
Email: sarah.v.suiter@vanderbilt.edu

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38 Pedagogy in Health Promotion 1(1)
professional disciplines, recognize social determinants
of health, and respond to patients as whole persons
(Klein & Vaughn, 2010). At the same time, there is emerg-
ing evidence that covering topics such as social determi-
nants of health, cultural humility and linguistic
competence, and interdisciplinary approaches to well-
ness in a classroom setting is not enough (Hoover, Wong,
& Azzam, 2012; Soska, Sullivan-Cosetti, & Pasupuleti,
2014; Wieland, Beckman, Cha, Beebe, & McDonald,
2010). Rather, these are skills that are best learned in
vivo, where the nuances, particularities, and challenges
of one person (a health practitioner) working with
another person (a patient) can be practiced and refined
(Holmes, Zayas, & Koyfman, 2012; OToole, Kathuria, &
Mishra, 2005).
Changes are being made across the health system to
equip practitioners with these skills; however, few
approaches show as much promise as those that start
before practitioners are even practitionersnamely,
those that start with students (Greiner & Knebel, 2003;
Thistlethwaite & Moran, 2010). The idea behind such
programs is that it is easier for practitioners to learn
behaviors than to unlearn them, and so medical, nursing,
pharmacy, and social work students are ideal candidates
for instituting change. As a result, there has been a rise in
interprofessional education programs that work to bring
practitioners from different professions together early in
their training and place them in a practice-based setting
(Josiah Macy Jr. Foundation, 2012). The World Health
Organization (2010) defines interprofessional education
as education in which students from two or more pro-
fessions learn about, from, and with each other to help
enable effective collaboration and improve health out-
comes (p. 7). The World Health Organization Study
Group described one of the primary goals of interprofes-
sional education as preparing a collaborative practice-
ready workforce. Inherent to their definition is the idea
that a collaborative practice-ready workforce is one that
is driven by local health needs and local health systems
designed to respond to those needs (p. 12). Although
the needs for such training are clear and have long been
recognized by health professions communities (Institute
of Medicine, 1972, 2001; Pew Health Professions
Commission, 1998), interprofessional education is not
the norm in health professions (Institute of Medicine,
2001). Nevertheless, substantial evidence exists that
interprofessional education is expanding. The IECEP,
composed of representatives from multiple professional
organizations, recently released core competencies for
interprofessional collaborative practice (IECEP, 2011).
These core competencies will surely act to guide the
growth and expansion of interprofessional education;
however, there is still considerable need for understand-
ing how core competencies are implemented and prac-
ticed, what types of environments are particularly suited
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to facilitating interprofessional learning, and how stu-
dents, educators, and organizations can work together to
influence patient experiences and outcomes.
This pilot study explores these issues in a community-
based clinic in a densely populated area of a midsized
city in the southeastern United States that hosts a variety
of students and one four-student team specifically desig-
nated for interprofessional learning. Peace Family Health
Clinic (PFHC), the clinic in which the study was con-
ducted, is a freestanding, faith-based, and volunteer-sup-
ported, primary health care center that provides
affordable health care to persons who are uninsured and
have difficulty accessing health care in traditional set-
tings. Volunteers and health professions students founded
the clinic in 1998 and designed it to be a place that pro-
vided free or low-cost health care to persons who could
otherwise not afford it. Furthermore, they developed a
practice orientation that was and is committed to
resource-sensitive health care, cross-cultural exchange,
and whole-person care.
In practice, resource-sensitive health care entails edu-
cating patients about preventative behaviors, connecting
them with community-based resources, and making a
concerted effort to contain costs while still providing
excellent care. Cross-cultural practice involves having
multilingual staff and volunteers, access to and profi-
ciency with interpreters, and a model of health care pro-
motion and treatment that incorporates cross-cultural
appreciation and understanding. Finally, whole-person
care denotes a way of thinking about patients (as well as
staff and volunteers) as people whose health is affected
by their mind, body, spirit, relationships, and contexts.
In 2012, clinic staff and volunteers had 21,757 patient
encounters: 86% of clinic patients were foreign-born,
and the clinic provided the initial health screenings and
physical examinations for all refugees who were reset-
tled in the county in which the clinic is located. Primary
health care, behavioral health care, case management,
and pharmaceutical services are all provided on-site. The
clinic also has referring privileges with several specialists
in the area. Although the clinic has grown substantially
in its 16 years of existence, the commitment to providing
excellent care to low-income patients, sustained by stu-
dents and volunteers, continues to be the central mission
of the clinic.
PFHC frequently hosts students for medical preceptor-
ships, social work internships, and the other preprofes-
sional clinical experiences; however, this was their first
time hosting an interdisciplinary team of students who
were all participating in the same program designed to
foster and facilitate interdisciplinary learning and inter-
action. The four-student interprofessional team was part
of a multiuniversity program that brought together teams
of students from health professional training programs in
medicine, advanced practice nursing, pharmacy, and
Suiter et al. 39
social work and placed them in a clinic-based setting for
two semesters (8 months) during their first year of their
professional degree program. Prior to beginning their
professional degree programs, students participated in a
2-week orientation that is coordinated and led by instruc-
tors from the four participating universities. Once the
school year begins, students participate in a weekly,
cross-university course that supports their clinic-based
experiences. Students work and learn for day per week
at their clinic sites for the first two semesters of their
respective programs. Students continue working in the
same site during the second year of their programs; how-
ever, this engagement looks somewhat different for dif-
ferent students as they advance. For the students
participating in the interprofessional pilot program, the
clinic placement was the first time they were able to
work together and learn from each other in practice.
Understanding their experiences in this location is ben-
eficial to the universities and the clinic alike, as they con-
tinue to work in order to improve student experiences in
the short term and to improve patient health and experi-
ences through better prepared health practitioners in the
long term. The study was guided by two primary research
questions:
Research Question 1: How do clinic experiences
contribute toward the students understanding of
social determinants of health and whole-person care?
Research Question 2: What factors influence the cre-
ation of an effective learning environment?
Method
To capture student experiences in a systematic and rigor-
ous manner, we conducted a qualitative, ethnographic
study that included participant observation, focus groups,
and textual analysis of student learning journals. Approval
of the Institutional Review Board for the lead university
was sought and gained for this study. All participants
were treated according to standard human subjects pro-
tection regulations. To protect participant and clinic con-
fidentiality, all names in this article are pseudonyms.
Participant Observation
Two research assistants observed the students activities
and interactions during the day each week that the
students were working in the clinic. The research assis-
tants were purposeful in selecting activities to observe
that would give them a full picture of the clinic and the
students behaviors, interactions, conversations, and
other experiences while at the clinic. The research
assistants recorded systematic field notes (Emerson,
Fretz, & Shaw, 1995) that they submitted to the key study
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personnel at different time points throughout the aca-
demic year. Participants were asked to use a grounded
approach (Charmaz, 2006) to participant observation,
meaning that observations were guided by the two
research questions but little structure was provided
beyond those parameters. Because of the exploratory
nature of this project, we intentionally chose a grounded
approach anticipating that we might encounter some
phenomena that would be lost if using a predetermined
set of observational categories.
Staff Focus Groups
One of the authors conducted two focus groups with
clinic staff. Focus group questions covered topics such as
staff perceptions of student burden on staff time, percep-
tions of the benefits that students add to staff and patient
experiences, and perceptions of student development
and growth during their time at the clinic. Focus groups
were audio recorded and transcribed. All names and
identifying information were removed from transcrip-
tions prior to analysis.
Student Journals
As a part of their university curriculum, students were
asked to write weekly journal entries in response to ques-
tions about their experiences in the clinic (e.g., What
was one thing that surprised you during your work in the
clinic this week?). We randomly selected 1 journal entry
per student per month (or a total of 8 journal entries per
student, and 32 total journal entries) and used these
entries as an additional data source to explore how stu-
dents were reflecting on their own experiences.
Analysis
Our data collection time line was designed to follow
the first two semesters of students experiences, so the
data collection phase of the study stopped when the
students first two semesters were complete. We felt that
saturation had been met by this point (or perhaps a bit
before) and did not determine that additional data col-
lection was needed for the purposes of this study. The
authors and research assistants coded all field notes,
focus group transcripts, and student journals in two
iterations. The first phase of coding involved using pre-
determined codes that were guided by research ques-
tions and educational goals established by the clinic
and pilot program to establish broad categories of data
(Charmaz, 2006). The second phase of coding employed
a grounded approach within each of the broad catego-
ries (Maxwell, 1996). Table 1 demonstrates the prede-
termined codes and corresponding grounded codes for
each category.
40 Pedagogy in Health Promotion 1(1)

Table 1. Coding Framework Used in Qualitative Analysis.

Predetermined codes Corresponding grounded codes

Collaborative Barriers, collaboration, communication among providers, establishing boundaries, facilitating factors,
practice-ready inclusion of others, overlap, trusting partners work, valuing nonmedical health intervention
Health care delivery Charting and paperwork, clinic as organization, comparison with other clinics, cost of care, eligibility
system for specialty services, insurance, limits to health care, process of a patient visit, referral processes,
regulations, relationships with other agencies, support systems for patients, technology, waiting time
Respectful Acknowledging, affirming/encouraging, asking questions, confidentiality, extra effort, flexibility, humility,
professionals listening, person-centered, physical touch, respectful disagreement, respecting anothers authority, seeing
others perspective, setting reasonable expectations, sharing information, speaking patients language,
using names
Self-directed learners Asking questions, confidence, drawing conclusions, facilitating factors, info from outside sources, making
suggestions, practicing skills, projects, qualities of students
Culture Community issues, differences among cultures, etiquette, impact on health, impact on service delivery,
impact on treatment seeking, language and communication, learning moments, refugee experiences,
social isolation
Poverty Access to health care, access to meds, complexity of poverty, education, insurance, living situations,
networking with other agencies, occupational situations, public assistance
Whole-person care Clinician sensitivity, culture, economic, illness experience, interdisciplinary care, outside resources,
providerclient relationship, patient empowerment, prevention, physical, mental, social, sexual, spiritual
Other learning Beside manner, class projects, clinical skills, EMR, health policy, historical perspective, how PFHC works,
issues specific to immigrants, lab work, medical knowledge, mental health knowledge, pharmaceutical
knowledge, tricks of the trade
Clinician as educator Coordinating learning activities, creating opportunities, impact on client, knowledge-client behavior,
knowledge-culture, knowledge-health systems, knowledge-illness, knowledge-patient resources,
knowledge-treatment, mentoring, resources required, skills-client relationship, skills-clinical, skills-HER,
skills-health assessments, skills-interpretation, skills-managing work, teachable students
Student value-added Asking questions, barriers to value-added, clinical procedures, communicating between clinician and
patient, communicating between clinicians, energy, extra hands, information gathering, institutional
relationships, paperwork, patient education, patient history, sharpening clinician practice, teaching other
students, translating

Note. EMR = electronic medical record; HER = electronic health record; PFHC = Peace Family Health Clinic.

After analysis was complete, one of the authors devel-
oped a brief report describing the coding scheme and
preliminary findings from the study. She then met with
three of the four interprofessional students, described the
analysis process and the preliminary findings, and asked
the students for their feedback. This process, called
member checking, is an effective strategy for ensuring
validity in qualitative research (Lincoln & Guba, 1985).
Student feedback was overwhelmingly positive, and stu-
dents indicated that their experiences had been captured
accurately. There were times when students provided
additional information, interpretation, or more nuanced
accounts of their experiences. This feedback was
included in the final analysis.
Results
Overall, students and staff reported that hosting an inter-
professional team at the clinic was a positive experience.
Students not only demonstrated and reported general
skills- and knowledge-based learning relevant to their
professions but also emphasized how important the
clinic-based experience was for their awareness of
understanding poverty, culture, and whole-person care.
Furthermore, students gained appreciation for and expe-
rience with interprofessional practice but reported that
achieving true collaboration required organizational
commitment to creating a collaborative and inclusive
environment. Creating this environment, as well as creat-
ing meaningful practice-based learning opportunities in
general, required significant intention on the part of the
clinic staff and leadership. Staff members who interacted
with students reported that having students required
additional time and attention (often scarce resources) on
the clinicians parts, but most thought that the benefits to
students and patients were worth the investment.
Contributions to Student Knowledge and Practice-
Based Competency
Students reported that they received some formal train-
ing on delivering poverty medicine from their school
curricula and other experiences. Their clinic experiences
added to this knowledge as they interacted with patients,
learned about their illness experiences, educated patients
about health behaviors, and worked with them to access

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Suiter et al. 41
resources. Students found that caring for patients with
few material resources required recognizing the com-
plexity of poverty, social determinants of health, and
how to access health-supporting resources outside the
clinic itself. Additionally, they learned that best prac-
tice recommendations are not always feasible for
patients when their home, work, or social environments
are restrictive. Mitchell, the pharmacy student, offered
the following reflection on an exchange he witnessed
between a nurse practitioner and patient with eczema:
The patient had eczema only on one hand. She was a house
cleaner and it was affecting the hand that she used to clean.
So, more than likely the persistent eczema was due to the
harsh chemicals that she used in cleaning houses. The nurse
practitioner suggested that she take a couple weeks off from
work to let her skin heal. I am not sure whether the patient
will follow through with this suggestion, but it showed me
that sometimes a patient may not be able to do what is best
for his/her health due to financial or economic barriers.
These may not always be not being able to afford medical
care, but may also be not being able to take time off of work
to rest and let your body heal. (Student reflection essay,
November 12, 2011)
Along with understanding how poverty affects patient
care and learning how to navigate some of the poverty-
related barriers, students learned the importance of
understanding culture (the patients and their own) in
providing relevant, effective health care and health edu-
cation. As with practicing poverty medicine, serving for-
eign-born patients required additional cultural knowledge
than that required for serving English-speaking, American
patients. The most obvious is how to communicate when
patients and clinicians speak different languages.
Although some staff, volunteers, and students are multi-
lingual, the variety of patients that the clinic serves
ensured that everyone had to navigate the language bar-
rier at some point in their practice. The clinic has several
interpreters who either work or volunteer at PFHC. It also
subscribes to a phone service that allows them to reach
an interpreter in any language at any time. Using inter-
preters (especially those on the phone) is an acquired
skill, and one to which PFHC devoted purposeful train-
ing. Students watched a video on interpretation at the
beginning of their semester at PFHC, and several provid-
ers talked to the students about the challenges of com-
municating with patients. For example, the social worker
described this exchange:
An Egyptian woman needed to go through Medicaid to
access a particular type of treatment, but facilitating the
conversation meant that I had Medicaid on one line, an
interpreter on another and the woman in the room beside me.
Trying to juggle those conversations became nightmarish;
particularly when the Medicaid representative needed the
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patient herself to reply to a question. (Field notes, November
16, 2011)
Students also experienced how culture can affect the
experience of illness, help-seeking behaviors, and ser-
vice delivery. The following anecdote describes just one
example of the many exchanges students observed:
Dr. Williams told us about another of her patients, a Middle
Eastern woman who had been bleeding vaginally for 45
days. Because of cultural taboos surrounding virginity and
vaginal contact, the patientunmarriedwould not allow
the doctor to perform an exam or even look without touching
to try to determine the cause of the bleeding. Dr. Williams
told us that such bleeding could be caused by a wide range
of things, some quite serious, but that almost all of them
would need the patient-forbidden exam for diagnosis. Dr.
Williams was clearly frustrated and stymied but maintained
an understanding of the need to respect the patients beliefs
and cultural system. (Field notes, February 1, 2012)
In this case and in others, respect for beliefs and cul-
tural systems is a component of the clinics commitment
to whole-person care, which is understood to mean
providing care with awareness of multiple aspects of
health and well-being, including physical and mental
health, spirituality, sexuality, relationships, and culture. It
involves knowing how all of these dimensions interact to
influence the life, interests, and concerns of a patient.
Whole-person care as practiced at the clinic requires an
expanded workforce (e.g., having the interprofessional
services of a social worker and a chaplain in a primary
care clinic), additional knowledge (e.g., knowledge
about poverty and culture mentioned above), and extra
effort to attend fully to the needs of the patient. When
asked how their perception of whole-person care had
changed over the course of their time at PFHC, the stu-
dents responded in a way that emphasized the bigger
picture of health as well as their reliance on other
professionals:
Mitchell: I think for me it really helped to work with social
work students, because it helped to learn about the social
work aspect of care. It enabled me to understand that its not
just what theyre (the patients are) experiencing here, but
also what theyre experiencing at home, and other places. I
think that really helped me, just have that different eye to it.
(Additions from member checking, September 12, 2012)
David (medical student): For me it was just the recognition
that there are other professionals out there that will help you
care for someone. I came into it thinking that, you know, if
youre going to be a physician, you have to be aware of this,
this, this and this, and thats still true, but theres a lot of
comfort in knowing that there are other people who are
looking in a focused way at things like the home life and
that kind of thing, so it frees you up to think about other
42 Pedagogy in Health Promotion 1(1)
things. Not that you dont care or youre insensitive or dont
pay attention, but just that somebodys covering it. (Additions
from member checking, September 12, 2012)
In addition to gaining an understanding of health and
health care that is more complex than a physician treat-
ing a patients presenting illness in a clinic-based encoun-
ter, students gained an appreciation for the many different
approaches and time points that can be used to improve
patient and community health. Because of the condi-
tions from which many of the patients were coming, stu-
dents learned that the best health care often involved
educating patients about health-related concepts and
practices and ensuring that the patients had access to the
resources required to engage in health practices.
Creating Learning Environments: Clinicians as
Educators
Creating an environment in which students can learn
and grow as professionals requires considerable effort on
the part of clinic staff who act as educators at the same
time they are interacting with patients. This role can be
rewarding but also taxing. Based on our observations, it
seemed that some clinicians were more suited to this
role than othersit came more naturally to some, and
some seemed to enjoy it, whereas others (even if they
found it valuable) found it more of a burden. Clinicians
who students identified as good teachers employed a
number of strategies when interacting with students in
the clinic setting. While working with patients, clinicians
used strategies such as allowing students to observe
unusual or advanced procedures, providing cultural and
contextual knowledge relevant to the patient, creating
opportunities for students to practice skills, and oversee-
ing them as they practiced. For example, one student
described,
I shadowed a nurse today and learned how to complete an
immunization visit for the incoming refugee screenings. I
administered 2 IM injections and 2 SQ injections. I found it
interesting to learn which shots were administered for
refugees (against what we call childhood diseases) and what
shots werent administered. Penny (the registered nurse)
showed me strategies for efficiency and maintaining clean
technique. I also learned how immunizations are tracked
and records are kept. (Student reflection essay, February 2,
2012)
In another example, a clinic nurse educated the social
work student on the nature of Burmese names while pre-
paring the student to do an intake interview with a
Burmese patient:
Jill instructed Melissa on the nature of Burmese names: They
dont have a first and last name in the same way. Jill used
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Melissas name to demonstrate: It would be like saying Mel
and Issa for your first and last namesIssa, Mel? (Jill imitated
how odd it would be for a Burmese person to hear their
name disordered into our Western standard of last name,
first name). (Field notes, March 2, 2012)
In addition to working directly with patients, clinic staff
involved students in staff meetings during which clinic
staff discussed patient cases. During our member check-
ing exercise, the students emphasized the importance of
being included in staff meetings:
I would add that they (the clinic staff) included us in their
lunch meetings (where the staff discussed clients), so we got
to see them interact and sort of debrief cases, too. So not just
debrief ourselves, but also watch the staff do that. (Addition
from member checking exercise, September 12, 2012)
Outside of patient encounters, clinicians took the time to
understand student goals and mentor them accordingly:
Mitchell told Dr. Gray that he was interested in learning
Spanish, and Dr. Gray suggested an intensive Spanish
language program that she did in Costa Rica for a month.
Mitchell talked about his interest in community health
(undergraduate minor) and Dr. Gray suggested a specific
pharmacy residency program that focuses on community
health. (Field notes, February 29, 2012)
Finally, clinic staff coordinated activities and opportuni-
ties for the students themselves to work as a team.
Explaining how important this was to their relationships
with each other and their ability to learn about other
health professionals, the students offered,
Mitchell: We worked together on stuff, we followed each
other, we called on each other
Kelsey (nursing student):I think our clinicians here expected
that.
Mitchell: Yeah, they facilitated that. When we had a
projectthat was one thing that I thought was great
about PFHCwe would have the Q and A, but they set
aside time for us to work together and work on projects
and be a team. That and the weekly debriefs where we
shared and learned from each other. And like at the
beginning where we were paired, that helped us learn to
work together and get used to working together . . .
because then we would walk to each other even when
we werent paired together, like we would seek each
other out.
There are likely other clinician activities such as plan-
ning, reading, and preparing for students that the research
assistants did not observe while following students. These
activities also take time and resources that might other-
wise be devoted to patient care. Despite the resources
required to host students, however, most clinic staff
Suiter et al. 43
reported that having students present benefitted patients
in direct and indirect ways.
Student Influences on Patient Care
Focus group discussions revealed that PFHC clinicians
felt that students added value to the clinic, and research
field notes corroborated these feelings. Students added
tangible benefits such as serving as an extra set of hands,
communicating between clinicians, communicating
with patients, completing paperwork, gathering informa-
tion from outside sources, conducting patient histories,
and providing patient education. Students with clinical
skills were able to help with giving shots, drawing blood,
taking blood pressure, and other basic services. Students
noted that as they and clinic staff became more comfort-
able with one another, they were asked to do more activ-
ities, and they felt that their practical value to the clinic
increased over the course of the year.
In addition to these tangible contributions, staff talked
about intangible benefits of having students in the clinic.
Having students around to ask questions, be enthusiastic,
and observe often spurred clinicians to sharpen their
own practices. For example, one staff member said,
You are more purposeful in your actions when your student
follows you because you are more aware of your actions.
The process that you go through in taking a patient back to
the doctor and getting them ready to see the doctor, if you
have a person over your shoulder asking you Why or
How, it really makes you stop and think How do I do
this? What is the best way to do this? (Staff focus group,
February 29, 2012)
Along with the immediate value that students added
to patient experiences in the clinic, there was ample evi-
dence that students were gaining skills and knowledge
that could positively influence the ways in which they
provided care to patients in the future. In particular, their
clinic experiences allowed them to learn to work and
collaborate interprofessionally, and gave them more
knowledge about health care delivery as a system as
opposed to patient encounters only.
Interprofessional Work and Collaboration.The strongest evi-
dence of preparing a collaborative practice-ready work-
force was actual collaboration among students.
Collaboration happened when visiting with patients,
working on assignments, and meeting with clinicians.
Throughout the school year, students taught each other,
asked each other questions, and consulted each other on
projects, patient cases, and decisions. Students learned
to rely on each other for their respective types of skills,
knowledge, and perspectives.
Creating a space where collaborative practice could
happen was something the clinic encouraged and was
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well equipped to do. The type of patient seen at the
clinic, and the clinics commitment to whole-person
care, requires that staff be interprofessional and value
interprofessional practice. Staff members were quick to
recommend the same types of collaboration from the
students. For example, when treating a family that was
infested with lice (a problem that required not only
pharmaceutical intervention but also changes to the
familys living space), staff encouraged a social work
student and a pharmacy student to work together in edu-
cating the family regarding how to get rid of the lice.
During their intervention, the students collaborated in
their explanation of lice treatment and killing those on
clothes, in the house, and elsewhere and addressed the
familys questions.
PFHC staff also modeled collaborative behaviors for
students, including having good processes and prac-
tices of communication among clinicians, purposefully
including other clinicians in patient care and decision
making, trusting other clinicians work, and establish-
ing boundaries of scope and responsibility. As a result
of their time in the clinic, students were also able to
appreciate the fine line between when overlap of activi-
ties by different providers is helpful and beneficial for
the client and when it results in duplication and ineffi-
ciency. The following exchange between David, the
medical student, and the clinic social worker demon-
strates how there can be disagreement on collaboration
versus duplication even in the very same patient
encounter:
David observed that the process could be repetitive, but that
it could be a good thing. He gave an example of a patient
saying forty-five but heard by an initial interviewer as four
to five, a miscommunication that was corrected because of
multiple patient interviews by different staff members or
students/volunteers. Rachel instructed, It can be good to
say, I know youve been asked these questions already.
David observed that hed be frustrated with such a process.
Rachel replied, Its all about how you ask the questions. It
can take more than one person asking to get a solid
response. (Field notes, November 2, 2011)
Understanding these and other potential conflicts
between effective patient care and efficient business
practices that affect health care delivery systems are
among the goals that the interprofessional program has
for its students. The students saw the impact of several
health care delivery systems firsthand in the clinic.
Understanding Health Care Delivery Systems.Through activi-
ties such as shadowing a patient for the entirety of his or
her visit, observing clinicians trying to access outside
resources for their patients, and learning about the clinic
as a business, students improved their knowledge of
health care beyond the patient encounter.
44 Pedagogy in Health Promotion 1(1)
During their clinic placement, students had the oppor-
tunity to shadow a patient during his or her visit, starting
from the minute the patient walked in the door of the
clinic and ending when he or she walked out. Students
reported that this was one of the most beneficial exer-
cises they completed in terms of helping them learn
about not only the clinic in particular but also health
care delivery systems in general. Because clinicians typi-
cally only see patients at select time points during the
patients engagement with the health care delivery sys-
tem, it can be difficult to develop a full picture of what
this journey looks like. Mitchell, the pharmacy student,
who worked part-time as a pharmacy tech, observed that
until shadowing a patient, he had no idea how long
patients could wait to see a doctor. He described,
I was surprised by how much time a patient spends waiting.
I hadnt realized how long a visit can take, and I feel like I
have a much greater appreciation for how frustrated some
patients can be upon leaving, (working in a retail pharmacy,
I know that many patients take their frustrations about their
physician visit out on us!) and I feel like I can have a much
better empathy toward them. (Student reflection essay,
January, 30, 2012)
Students also learned about the different aspects of
health care delivery system and how to navigate them to
best serve their patients. These aspects included learning
about referral processes, the costs of care and different
ways to finance it, understanding and interacting with
insurance companies, the impact that technologies (both
medical and information) have had on health care, and
networking with other agencies for additional client
resources. The following description illustrates the com-
plicated interplay of knowledge and resources required
when trying to access medications for clients with no
insurance and limited financial means.
The pharmacist and the students had thought that a
prescription would make the most sense and be the most
financially viable because it would be cheaper and covered
by insurance. The nurse practitioner informed them that the
family wouldnt have Medicaid until the following week
and that Medicaid may not even cover that particular
treatment. If we know how much it costs, Catholic Charities
can help cover the cost, the NP said, working to find a
means of access to the treatment for the family. The
caseworker echoed her concern that Medicaid has denied
that type of coverage before. To double-check, the
pharmacist began to look up treatment coverage on the
Medicaid website. (Field notes, March 2, 2012)
Finally, clinic staff were purposeful in educating the
students about the business of running a nonprofit
clinic. The clinics chief executive officer came to talk
to students about the rules and regulations that accom-
pany being a nonprofit organization, the challenges of
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fundraising, and some of the particularities of being a
faith-based organization and what that means for work-
ing with government agencies, hiring staff, and serving
patients. David, the medical student, reflected on it in
one of his journal entries:
I was surprised by the impromptu half-hour interaction we
had with the clinics CEO, because I was not expecting
how to make money for your non-profit to be on the
curriculum for the day. It made me think about some of my
own opinions about nonprofit organizations providing
stopgap measures for systemic insufficiency. (Student
reflection essay, November 11, 2011)
This, among other examples, illustrates the many ways
Siloam served as a laboratory for students seeking to
learn and understand complex human experiences in the
context of complex human systems.
Discussion
If there was one underlying theme that emerged from our
work, it was the value of multilevel, multisystem, multi-
professional approaches to care. Students and practitio-
ners alike felt that these approaches were more effective
and more humane. That these experiences were mark-
edly different from other educational experiences the
students had had raises the questions of what makes the
clinic and the interprofessional approach different, and
why integrated approaches are not more ubiquitous.
As noted by participants in this study, as well as other
scholars working to understand, support, and promote
interprofessional practice, collaboration requires more
than mere good intentions (Korazim-Korsy, Mizrahi,
Bayne-Smith, & Garcia, 2014). It requires learning new
professional languages, new processes, and new rules of
engagement (IECEP, 2011; Korazim-Korsy et al., 2014).
This study indicated that interprofessional collaboration,
particularly in community-based settings that engage
diverse patient populations in resource-poor settings,
requires choosing organizational design that promotes
collaboration. Although there are many small efforts the
clinic made along these lines, the three primary features
identified by our research were an ethic of inclusion and
inherent value of all members, workflow design features
that enabled and required collaboration, and a willing-
ness to allow time for learning and instruction.
The ethic of inclusion and value of all members
applied to patients as well as professionals and stu-
dents. Evidence such as promoting copractice and
knowledge sharing among students from different pro-
grams (e.g., medicine and social work) is cited above.
Additionally, it was not unusual for the clinic director
(a physician) to openly name and dispel preconceived
notions of professional hierarchy (especially among
professions). He frequently used a body metaphor to
Suiter et al. 45
describe the relationships among different practitioners,
saying that though each part has a different role, all
parts are equally necessary in their own right and to one
another. This type of symbolism and rhetoric worked to
create an environment in which an inclusive vision drove
and informed practice (Trice & Beyer, 1993).
Workflow design features included an open floor plan
that facilitated constant interaction among professionals
(and professionals and students) as well as a patient pro-
cess that dictated involvement from multiple types of
practitioners at each visit. Although there were times
when this practice seemed redundant, as mentioned by
the medical student above, it also meant that clinic staff
were consistently practicing humility by admitting the
limits of their own knowledge and professional training
(Metzl & Hansen, 2014) and relying on one another to
ensure best practice.
Finally, the allowance of time for clinicians to prepare
for students, as well as include them in their work
throughout the day, was especially rare for service-based
environments in which efficiency and profitability often
go hand in hand. Further investigation into this phenom-
enon is needed; however, the authors hypothesize that
this seemingly different valuation of time is at least some-
what made possible by the clinics financial model. The
model not only includes some Medicaid billing (and
would thus drive an efficiencyprofitability model) but
also relies heavily on other sources of income and
resources (private donations, some state funding, and a
substantial volunteer base) that allow for more flexibility
in terms of how much time providers spent with students
and patients alike.
Conclusion
This qualitative study allowed us to explore the experi-
ences of students, staff, and patients as they interacted in
a community-based clinic setting over the course of a
school year. We found that the interprofessional, clinic-
based experience provided an opportunity for students to
develop practice-based knowledge and skills, as well as
to learn about how complex issues such as poverty, cul-
ture, and whole-person care affect community health
practice. We also found the students positive experience
was directly linked to the amount of time and energy
clinic staff put into activities such as teaching, mentoring,
including students in special opportunities, and requiring
students to work together on treatment-related projects.
Finally, we found that the presence of students often led
clinicians to be more thoughtful and attentive to their
own practice, leading to potentially better patient care.
As with all studies, this study was able to uncover
some useful and important findings, even as it was lim-
ited in uncovering others. The relatively small student
group meant that our observations were limited to four
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students in a very particular environment. The study
could have been strengthened by observing multiple
groups of students in the same environment over time, or
by observing the same group of students in a different
environment. Additionally, this study relied heavily on
observation and self-report in an environment where
participants were subject to strong norms regarding lan-
guage and behavior. Indeed, in some ways, these norms
were themselves a focus of the study; however, it is pos-
sible that the data reflect some degree of social desirabil-
ity bias regarding participants feelings toward one
another. The findings and limitations of this study indi-
cate a number of additional questions regarding prac-
tice-based, interprofessional learning that are suitable for
further research. Exploring patient perceptions of student
involvement could elucidate staff members claims that
having an observing student present makes them more
focused and attentive. Comparing interprofessional
learning with traditional student placements would be
useful in understanding the benefits and drawbacks of
interprofessional education from a pedagogical perspec-
tive. Expanding this study to include interprofessional
students located at other clinic sites could reveal which
learning experiences were specific to this clinic and
which are more ubiquitous to experiential learning in the
health field. Answering these and other questions should
guide and inform the education of health professionals
so that students are best equipped to contribute to a col-
laborative practice-ready workforce focused on local
needs, and help change the systems that support com-
munity health.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This work was supported in part by the Vanderbilt Clinical and
Translational Science Award Grant UL1 TR000445 from the
National Center for Advancing Translational Sciences/National
Institutes of Health. The Vanderbilt Program in Interprofessional
Learning is supported in part by a grant from the Josiah Macy Jr.
Foundation.
References
Agency for Healthcare Research and Quality. (2012). Defining the
patient centered medical home (PCMH). Retrieved from
http://www.pcmh.ahrq.gov/portal/server.pt/community
/pcmh__home/1483/pcmh_defining_the_pcmh_v2
Charmaz, K. (2006). Constructing grounded theory: A practi-
cal guide through qualitative analysis. Thousand Oaks, CA:
Sage.
46 Pedagogy in Health Promotion 1(1)
Commission on Social Determinants of Health. (2005).
Towards a conceptual framework for analysis and action
on the social determinants of health. Geneva, Switzerland:
World Health Organization.
Emerson, R., Fretz, R., & Shaw, L. (1995). Writing ethnographic
fieldnotes. Chicago, IL: University of Chicago Press.
Greiner, A. C., & Knebel, E. (Eds.). (2003). Health professions
education: A bridge to quality. Washington, DC: The
National Academies Press.
Holmes, D., Zayas, L. E., & Koyfman, A. (2012). Student objec-
tives and learning experiences in a global health elective.
Journal of Community Health, 37, 927-934.
Hoover, C. R., Wong, C. C., & Azzam, A. (2012). From primary
care to public health: Using problem-based learning and the
ecological model to teach public health to first year medical
students. Journal of Community Health, 37, 647-652.
Institute of Medicine. (1972). Educating for the heath team.
Washington, DC: National Academy of Sciences.
Institute of Medicine. (2001). Crossing the quality chasm.
Washington, DC: National Academies Press.
Interprofessional Education Collaborative Expert Panel.
(2011). Core competencies for interprofessional collabora-
tive practice: Report of an expert panel. Washington, DC:
Author. Retrieved from http://www.aacn.nche.edu/educa-
tion-resources/ipecreport.pdf
Josiah Macy Jr. Foundation. (2012). Annual report: Accelerating
interprofessional education. Retrieved from http://
www.macyfoundation.org/docs/annual_reports/macy_
AnnualReport_2012.pdf
Klein, M., & Vaughn, L. M. (2010). Teaching social determi-
nants of child health in a pediatric advocacy rotation: Small
intervention, big impact. Medical Teacher, 32, 754-759.
Korazim-Korsy, Y., Mizrahi, T., Bayne-Smith, M., & Garcia,
L. (2014). Professional determinants in community col-
laborations: Interdisciplinary comparative perspectives
on roles and experiences among six disciplines. Journal of
Community Practice, 22, 229-255.
Lincoln, Y. S., & Guba, E. (1985). Naturalistic inquiry. Beverly
Hills, CA: Sage.
Downloaded from php.sagepub.com at Gazi University on January 19, 2016
Maxwell, J. (1996). Qualitative research design: An interactive
approach. Thousand Oaks, CA: Sage.
Metzl, J., & Hansen, H. (2014). Structural competency:
Theorizing a new medical engagement with stigma and
inequality. Social Science & Medicine, 103, 126-133.
OToole, T., Kathuria, N., & Mishra, M. (2005). Teaching profes-
sionalism within a community context: Perspectives from
a national demonstration project. Academic Medicine, 80,
339-343.
Patient-Centered Primary Care Collaborative. (2012). Benefits
of implementing the primary care patient-centered medi-
cal home: A review of cost and quality results. Retrieved
from http://www.pcpcc.net/files/benefits_of_implementing
_the_primary_care_pcmh_0.pdf
Pew Health Professions Commission. (1998). Recreating health
professional practice for a new century: The fourth report
of the Pew Health Professions Commission. San Francisco,
CA: Author.
Soska, T., Sullivan-Cosetti, M., & Pasupuleti, S. (2014). Service
learning: Community engagement and partnership for
integrating teaching research, and service. Journal of
Community Practice, 18, 139-147.
Thistlethwaite, J., & Moran, M. (2010). Learning outcomes for
interprofessional education (IPE): Literature review and
synthesis. Journal of Interprofessional Care, 24, 503-513.
Trice, H., & Beyer, J. (1993). The cultures of work organiza-
tions. Upper Saddle River, NJ: Prentice Hall.
U.S. Department of Health & Human Services. (2000). Healthy
people 2010: With understanding and improving health
and objectives for improving health (2nd ed.). Washington,
DC: Author.
Wieland, M., Beckman, T., Cha, S., Beebe, T., & McDonald,
F. (2010). Resident physicians knowledge of under-
served patients: A multi-institutional survey. Mayo Clinic
Proceedings, 85, 728-733.
World Health Organization. (2010). Framework for action
on interprofessional education & collaborative practice.
Retrieved from http://whqlibdoc.who.int/hq/2010/WHO_
HRH_HPN_10.3_eng.pdf