Leveraging a contextually sensitive approach to rural geriatric interprofessional education

Abstract

Interprofessional Education (IPE) has been recognized on an international and national level as an effective method of preparing health professionals for practice while also improving health system outcomes. In particular, recent research highlights that geriatric IPE initiatives can be mutually beneficial both to learners and older adults in rural communities. Despite this trend, IPE initiatives continue to produce mixed results. Although some scholars have acknowledged that IPE initiatives need to consider the complexity of healthcare contexts, there is a dearth of research that considers the diversity of rural communities or rural older adult health. This paper proposes that leveraging contextually sensitive rural gerontological health research marks a next step in IPE development.

Introduction

Interprofessional Education (IPE) is a prominent mechanism in healthcare to enhance health professional collaboration, while improving both patient and health system outcomes.¹ Defined as education or training that fosters the cooperation of multiple types of health professionals, IPE initiatives aim to illustrate how working together can contribute to the better care of patients and their caregivers.¹ This approach has been proposed as especially valuable in rural communities where geriatric IPE initiatives are highlighted as being mutually beneficial for learners and older adults^2
–4 and where relatively few practitioners are called upon to support the growing numbers of aging rural residents.^5

–10 Although IPE has gained recognition on a national and international level, the mixed effectiveness of IPE initiatives has acted as a barrier to adequately prepare health professionals for practice,^6,11

–15 especially with older adults in rural settings.^3,16 Despite contemporary scholars emphasizing the importance of aligning IPE initiatives with complex healthcare contexts,^17

–21 a gap still remains regarding how to develop effective rural geriatric IPE initiatives.³ This paper aims to close this gap by first reviewing the IPE movement that supports the symbiotic relationship between IPE initiatives and rural older adult care and then examining how contextually sensitive rural gerontological health research can enhance IPE initiatives. Although rural geriatric IPE models have been developed both nationally²² and internationally,^2,3 we make the argument in this paper that a more contextually sensitive approach to rural geriatric IPE marks the next step in assisting health science and medical training institutions to better prepare health leaders to work with older adults in rural communities.

Interprofessional education

The majority of international and national research recognizes IPE as an effective method of addressing the contemporary challenges associated with modern healthcare service delivery.^1,4,14 Internationally, the World Health Organization⁴ has identified that IPE initiatives are a fundamental method to address the global health workforce crisis as well as a practical means of managing epidemics, natural disasters, and chronic conditions. Other international bodies have linked IPE with health system improvement and have acknowledged IPE as an essential element to prepare health professionals for collaborative practice.^1,14 In Canada, a similar trend evolved. Catalyzed by the Romanow Report,²³ federal and regional mandates, policies, research, and resource allocation were transformed to better support IPE initiatives.^6,14 In addition, national bodies, such as the Health Council of Canada and the Canadian Institutes of Health Research, formally identify the benefits of IPE^6,24 and have established a national IPE framework highlighting the core competencies needed for effective education in interprofessional care.¹⁸

The burgeoning interest in IPE has resulted in research that emphasizes the positive outcomes of IPE on participants and practice. An abundance of studies indicate that IPE initiatives enhance interprofessional communication and team work,^1,2,14,18,25 assist with role clarification of health professionals,^4,18 increase personal confidence and competence in interprofessional practice,^{6,13,14,17,24,25} and provide a valuable opportunity to learn from and foster respect between interprofessional team members.^{1,2,4,13
–15,17,18,24,25} In addition, scholars have proposed that IPE allows members of different professions to engage in collaborative problem solving and joint decision-making that centralizes the patient within healthcare practice.^{1,13,18,20,24,25} This approach has been linked to improved health outcomes^1,4,12,26 and patient safety,^4,26 while reducing overall healthcare costs.^1,4,26 These positive results have helped to support the interprofessional movement in healthcare practice, leading to the transformation in the way health professionals are educated in health science and medical training institutions.

Interprofessional education in rural communities

Significant attention has been paid to earmark rural communities as ideal settings for practical IPE experiences due to smaller, more integrated systems.^{1,6,11,13,17,24} Challenged by fewer formalized resources and services, scholars propose that a generalist approach is taken by healthcare staff in response to specific demands in rural communities such as heavy workloads and the scarcity of rural clinicians.^{1,13,17,19,24} Indeed, Drolet et al. describe a Canadian IPE initiative at Thompson Rivers University (British Columbia) that illustrates how rural health professionals can mutually support each other through shared responsibility and joint decision-making. Rural communities are presented as ideal settings to learn about interprofessional practice due to the overlapping, flexible, and blurred professional roles that are not typical in specialized urban settings.^1,13,17,25 Scholars outline that rural communities can expose learners to team environments with enhanced communication and cooperation between different disciplines, resulting in mutual respect between professionals through enhanced conflict resolution skills and changes in the attitudes of learners about interprofessional practice.^1,2,11,15 In addition, IPE research indicates that rural communities are inherently small and close-knit which creates an ideal context for patient-centred models of practice with highly integrated healthcare teams.^1,2,13,15,27 It has then been proposed that rural communities act as an ideal setting for interprofessional care, engaging learners in IPE experiences that can enhance their competency in practice.

The relationship between IPE initiatives and health in rural communities is also presented as symbiotic in the literature. Indeed, Grafton et al. maintain that there is a strong interdependent relationship between healthcare and rural communities.²⁸ Through interactions with learners as a result of IPE, community members have benefited from opportunities for capacity building, continuing education, and exposure to new methods of care.^11,24 In addition, scholars note that rural communities introduce learners to the unique challenges of rural healthcare while also debunking negative stereotypes about working in rural settings.^2,11 The benefit of rural exposure on learners is then presented as two-fold. First, IPE participants are challenged to create culturally, socially, and fiscally responsible care plans that fit the needs of rural patients.^1,6,11,15 Second, the experiences and socialization of learners in rural settings has been linked to increased confidence, competence, and appreciation of rural health practice,^24,25 which has resulted in improved recruitment and retention of health professionals in rural communities.^{2,4,11,13
–15,17,19,24,25} Highlighting the advantages of this reciprocal relationship has, thus, been prominent in studies on IPE, which support health education reform to enhance IPE experiences in rural communities.

Interprofessional education and rural gerontological health

Many scholars observe that rural IPE initiatives are particularly valuable when combined with a geriatric component. This is due to the fact that older patients often have more complex needs that require an interprofessional approach.^2,3,16,29,30 Such is especially the case in rural communities, where older adults are more likely to have chronic conditions and co-morbidities³⁰ which are further exacerbated by low socioeconomic status and weak social support networks.³ The World Health Organization emphasizes that IPE initiatives can more effectively support the health complexities of rural older adults, which leads to increased patient satisfaction, improved access to care, and decreased patient complications. Since a lack of health team collaboration can pose a significant risk to older adult patients, it has been proposed that rural IPE initiatives that centralize around the geriatric population can emphasize to learners the importance of an interprofessional approach.^2,3,16 For example, Brewer outlines that in Warsaw, New York, slightly modifying traditionally provided education placements to include a rural geriatric component helped to address the negative stereotypes of working with older adults and provided opportunities for learners that fostered a more holistic method of interprofessional care. Due to the high proportion of older adults who require care in rural communities, IPE initiatives that are focused on rural gerontological health have then been presented as mutually beneficial.^2,3,16,30

The need to contextualize IPE

Despite the plethora of studies in support of IPE, some scholars argue that IPE initiatives are not universally effective. Lapkin et al. indicate that learner outcomes such as improved communication, decision-making, and attitudes towards other professionals differ greatly between studies due to learner-specific factors such as gender and the learners’ profession. In addition, very few studies have shown the transferability of IPE learning outcomes on clinical practice over the long-term, indicating that more work is needed to adequately prepare health professionals for practice,^6,11

–15 especially with older adults in rural communities.^3,16

As such, a shift is transpiring in IPE research to better reflect the complexities of context. In particular, the literature has begun to acknowledge that IPE initiatives require continuous improvement to adapt to the multi-leveled, ever-changing healthcare system that is influenced by environmental, institutional, and professional contexts.²⁰ Cox et al. note that the mixed results of IPE learner outcomes is then, in part, due to the many cofounding variables in complex healthcare settings that lead to the ineffectiveness of IPE initiatives. In considering these developments, we observe that leveraging contextually sensitive rural gerontological health research has the potential to expand this approach beyond healthcare settings^31
–33 by aligning IPE initiatives with the complexities of older adult health in rural communities. Drawing on key arguments in geographical gerontology and geographically informed rural aging studies^5,34 this line of inquiry identifies the interdependence of aging, health, and rurality by uncovering the multiple interconnected factors that influence older adult health in rural contexts.^31
–33 Advocating for the need to create dynamic interventions, this literature proposes that initiatives must remain flexible to adapt to the ever-changing needs of older adults as they age and the idiosyncrasies of life in rural areas.^31
–33 Leveraging this literature will then foster rural geriatric IPE initiatives in health science and medical training institutions that will better prepare health professionals for practice by establishing a more contextually sensitive approach.

Recognizing the unique nature of rural contexts and older adult health

Over the past quarter century, significant inroads have been made by rural aging scholars to address the homogenization of rural communities. In particular, contemporary rural studies have critiqued research that continues to frame rural contexts in direct contrast to urban settings.^7
–9,35 These rural/urban dualities romanticize the close-knit connections in rural communities while constructing rural in contrast to advanced urban centres.^35,36 This view of rural communities contributes to simplistic deficit-focused understandings of rural contexts that fail to reflect the strengths and the engagement of residents that combine to actively construct rural communities.^8,37,38 Key rural aging studies challenge the prevailing view that rural contexts are best conceptualized, defined or researched through the same methods used in urban settings.^35,36 This urban centrism is prominent in health professional education where standard curriculums embrace urban-focused paradigms which rarely reflect the training needed to competently practice in rural communities.²² New models of IPE must then be constructed to reflect the heterogeneity of rural communities, adapting IPE experiences to the unique context of each rural setting.

Inherent in this approach is recognizing how diverse rural contexts shape older adult health. In particular, health is constructed by the social, demographic, economic, political, and environmental factors that are distinctive to each rural community.²² This requires health services to be aligned with the complex interconnected factors that impact health on a micro, meso, and macro level^7,22 and challenges previous research that homogenizes rural communities as effective settings for geriatric IPE initiatives. Establishing this more comprehensive understanding of rural older adult health, program planners at health science and medical institutions can uncover the multiple factors that enhance and impede IPE and specifically tailor initiatives to fit the needs of older adults and the communities in which they live. For instance, a rural community where the primary industry has been linked to the low socioeconomic status and high prevalence of chronic obstructive pulmonary disease in the local older adult population will likely benefit from IPE initiatives that centralize around these local needs, rather than a more generalized training program. This involves focusing on the social determinants of health of the older adult population that goes beyond formal health services,¹⁰ recognizing IPE learning as holistic rather than solely health focused. Health professional education must then reflect an awareness of the historical, social, political, and economic contexts that foster cross-cultural and community interpretations of health that are unique to each rural community.^7,36 This will ensure that geriatric IPE initiatives are better aligned with the distinct local context in which they are employed and, therefore, lead to more effective training opportunities for health professionals.

If this alignment is to have longevity, it is essential that geriatric IPE initiatives also reflect the dynamism of rural communities to ensure that they can adapt with the unique contextual shifts that shape older adult health. This requires reflection on how elements such as social inequalities, migration patterns, globalization, urban sprawl, loss of industry, employment recessions, advancements in technology, voluntarism, so on, influence the health of older adults differently over time.²² Since these shifts can contribute to what Skinner and Winterton refer to as “contested spaces of rural aging,”^5,34 it is essential to recognize how older adults must negotiate their health in response to competing policies, discourses, practices, and values in rural communities.³² Leveraging this knowledge to improve IPE in health science and medical institutions, it is essential that initiatives remain flexible to respond to shifting contested rural environments to ensure that health professionals are adequately trained for the realities of rural geriatric practice. For example, an increase in retirement migrants to a rural area may shift municipalities to focus on age-friendly initiatives. This in turn may take away from resources that aid young families and deter the migration of young health professionals to the local area. A rural geriatric IPE initiative that is designed in response to this local conundrum may then focus on mechanisms to improve health professional recruitment and retention as an element to improve rural geriatric care. In turn, this will create rural geriatric IPE initiatives that align with the needs of local communities and better prepare health professionals to work with older adults rural settings.

Essential to this more flexible approach is appreciating the fundamental role of rural residents in constructing successful IPE initiatives. In particular, rural older adult experiences of aging and health shape and are shaped by the rural communities in which they live.^5,9,37 Reflecting on the normative behaviours, social relationships, values, attitudes, and religion of older adults is then essential to understand unique rural contexts.^8,34 This appreciation of older adults involves respecting the intersectionality of rural older adults that underlines how socioeconomic status, race, gender, disability, and sexual orientation contribute to diverse rural experiences.²² To be effective, health professionals need to be familiar with rural culture and become integrated in and committed to the local community.⁷ This approach will result in initiatives that are co-produced with community members and values local knowledge and input.^7,36 Fostering contextually sensitive IPE initiatives will then more adequately prepare health professionals in health science and medical training institutions for the demands of caring for the rural older adult population.

Conclusion

Acknowledging unique and dynamic rural communities can contribute to a more comprehensive understanding of context and align geriatric IPE initiatives with the multileveled, complex, and dynamic places in which they are situated. Although some emerging scholarship has recognized how the heterogeneity of rural environments can lead to the mixed results of IPE initiatives,^1,4,17 education planners continue to negate the interdependencies of complex rural contexts and older adult health in designing IPE experiences. In a similar thread, community connection, local knowledge, and champions have been deemed fundamental for effective rural health service provision,¹⁹ yet most geriatric IPE initiatives continue to ignore that IPE must be adapted to the unique local contexts in which they are employed.⁴ Further studies need to be conducted to uncover the barriers of IPE planners in constructing geriatric IPE initiatives that fit inter-rural contexts. Initial ways to expand on this field of study, for instance, could be a meta-analysis as well as longitudinal studies to highlight the benefits of this approach.

Even though core competency models for IPE have been created,^18,39 it is argued that new rural centric models are needed to value unique rural contexts and their interrelationship with older adult health. This will result in models of IPE that no longer focus on the deficits of rural gerontological health but capitalize on the strengths and local resources that are available in each community to support effective geriatric IPE initiatives. This reflection on inter-rurality will address simplistic views of local communities as universally suitable to support IPE initiatives and instead recognize the most appropriate settings in which geriatric IPE initiatives can be employed. This will act as a catalyst to increase the number of effective rural geriatric IPE programs available in Canada and ensure that healthcare professionals are adequately prepared to work with older adults in rural practice. The contextually sensitive approach to geriatric IPE advocated for in this paper will have a significant impact on a national level; however, the practicality of this approach may also have noteworthy international implications. Although rural geriatric IPE programs are emerging around the globe,^2,3,22 fostering a contextually sensitive approach represents the next step in the field of IPE development to ensure health science and medical training institutions adequately prepare their students to work with older adults in diverse rural communities.

Footnotes

Acknowledgment

We thank Dr. Kirsten Woodend, RN, MSc, PhD, Dean of Trent/Fleming School of Nursing for her valuable introduction to Interprofessional Education literature.

ORCID iD

Laura I. L. Poulin

References

Walker

Cross

Barnett

. Mapping the interprofessional education landscape for students on rural clinical placements: an integrative literature review.Rural Remote Health. 2018;18(2):208–225.

Brewer

. An interdisciplinary geriatric component for a rural summer experience. Rural Remote Health. 2010;10(1550):1–6.

Toner

Ferguson

Sokal

. Continuing interprofessional education in geriatrics and gerontology in medically underserved areas. J Contin Educ Health Prof. 2009;29(3):157–160.

World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice. 2010. Available at: http://apps.who.int/iris/bitstream/handle/10665/70185/WHO_HRH_HPN_10.3_eng.pdf;jsessionid=E6FFDAE00E92BF4553C18F8EA5978BF1?sequence=1. Accessed January 10, 2019.

Skinner

Winterton

. Interrogating the contested spaces of rural aging: implications for research, policy and practice. Gerontologist. 2018;58(1):15–25.

Crossley

Morgan

Lanting

Dal Bello-Haas

Kirk

. Interdisciplinary research and interprofessional collaborative care in a memory clinic for rural and northern residents of western Canada: unique training ground for clinical psychology graduate students. Australian J Psycholog. 2008;43(4):231–238.

Hash

Jurkowski

Krout

. Aging in Rural Places: Programs, Policies, and Professional Practice. New York, NY: Springer Publishing Company; 2014.

Keating

Swindle

Fletcher

. Aging in rural Canada: a retrospective and review. Can J Aging. 2011;30(3):323–338.

Scharf

Walsh

O’Shea

, Ageing in rural places. In: Shucksmith

Brown

, eds. Routledge International Handbook of Rural Studies. Oxon, OX: Routledge; 2016:50–61.

10.

Skinner

Hanlon

Ageing Resource Communities: New Frontiers of Rural Population Change, Community Development, and Voluntarism. New York, NY: Routledge; 2016: 1–219.

11.

Charles

Bainbridge

Copeman-Stewart

Kassam

Tiffin

. Impact of an interprofessional rural healthcare practice education experience on students and communities. J Allied Health. 2008;37(3):127–131.

12.

Cox

Cuff

Brandt

Reeves

Zierler

. Measuring the impact of interprofessional education on collaborative practice and patient outcomes. J Interprof Care. 2016;30(1):1–3.

13.

Hays

. Interprofessional education in rural practice: how, when and where. Rural Remote Health. 2008;8(939):1–5.

14.

Lapkin

Levett-Jones

Gilligan

. A systematic review of the effectiveness of interprofessional education in health professional programs. Nurse Educ Today. 2013;33(2):90–102.

15.

Mpofu

Daniels

Adonis

Karuguti

. Impact of an interprofessional education programme on developing skilled graduates well-equipped to practise in rural and underserved areas. Rural Remote Health. 2014;14(3):223–235.

16.

Weil

Milbrath

Sharp

, et al. Interdisciplinary partnerships for rural older adult transitions of care, quality in ageing and older adults. 2018;19(4):232–241.

17.

McNeil

Mitchell

Parker

. The paradoxical effects of workforce shortages on rural interprofessional practice. Scand J Caring Sci. 2015;29(1):73–82.

18.

Canadian Interprofessional Health Collaborative. A National Interprofessional Competency Framework. 2010. Available at: https://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf. Accessed July 10, 2019.

19.

Parker

McNeil

Higgins

, et al. How health professionals conceive and construct interprofessional practice in rural settings: a qualitative study. BMC Health Serv Res. 2013;13(500):1–11.

20.

D’Amour

Oandasan

. Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. J Interprof Care. 2005;19(2):1356–1820.

21.

Williams

Cutchin

. The rural context of healthcare provision. J Interprof Care. 2002;16(2):107–115.

22.

Kulig

Williams

. Health in Rural Canada. Vancouver, British Columbia, Canada: UBC Press; 2012.

23.

Romanow

RJ.

Building on Values: The Future of Health Care in Canada. Saskatoon, Saskatchewan, Canada: Commission on the Future of Health Care in Canada; 2002.

24.

Drolet

Christianson

Clark

. The BRIDGE Community Consultation Project: building rural interprofessional discussions and group experiences. Rural Remote Health. 2011;11(1676):1–7.

25.

Medves

Paterson

Chapman

, et al. A new interprofessional course preparing learners for life in rural communities. Rural Remote Health. 2008;8(1):836–843.

26.

Tsou

Shih

. A comparative study of professional and interprofessional values between health professionals and associations. J Interprof Care. 2015;29(6):628–633.

27.

Spencer

Woodroffe

Cross

Allen

. ‘A golden opportunity’: exploring interprofessional learning and practice in rural clinical settings. J Interprof Care. 2015;29(4):389–391.

28.

Grafton

Troughton

Rourke

. Rural community and healthcare interdependence: an historical, geographical study. Can J Rural Med. 2004;9(3):156–163.

29.

McKenzie

Lasater

Delander

Neal

Morgove

Eckstrom

. Falls prevention education: interprofessional training to enhance collaborative practice. Gerontol Geriatr Educ. 2016;38(2):232–243.

30.

World Health Organization. World Report on Ageing and Health. World Health Organization. 2015. Available at: https://apps.who.int/iris/bitstream/handle/10665/186463/9789240694811_eng.pdf;jsessionid=0F9488BF9604C55A005AFE8FF06196B4?sequence=1. Accessed July 10, 2019.

31.

Herron

Skinner

. Rural places and spaces of health and healthcare. In: Crooks

Andrews

Pearce

, eds. Routledge Handbook of Health Geography. Oxon, OX: Routledge; 2018:267–272.

32.

Hanlon

Poulin

LIL

. Making way for a critical gerontology of rural health. In: Skinner

Winteron

Walsh

, eds. Rural Gerontology: Towards Critical Perspectives on Rural Ageing. New York, NY: Routledge; 2020. In Press.

33.

Pruchno

. Aging in context. Gerontologist. 2018;58(1):1–3.

34.

Skinner

Andrews

Cutchin

. Geographical Gerontology: Perspectives, Concepts, Approaches. New York, NY: Routledge; 2018.

35.

Shucksmith

Brown

. Routledge International Handbook of Rural Studies. New York, NY: Routledge Taylor & Francis Group; 2016.

36.

Ramp

Kulig

Towshend

McGowan

. Health in Rural Settings: Contexts in Action. Lethbridge, AB: University of Lethbridge; 1999.

37.

Cloke

Marsden

Mooney

, eds. Handbook of Rural Studies. London, United Kingdom: Sage; 2006.

38.

Joseph

Cloutier-Fisher

Ageing in rural communities: vulnerable people in vulnerable places. In: Andrews

Phillips

, eds. Ageing and Place: Perspectives, Policy and Practice. London, United Kingdom: Routledge; 2005:133–146.

39.

Verma

Paterson

Medves

. Core competencies for healthcare professionals: what medicine, nursing, occupational therapy, and physiotherapy share. J Allied Health. 2006;35(2):109–116.