|ORIGINAL RESEARCH ARTICLE
|Year : 2018 | Volume
| Issue : 3 | Page : 155-162
Utilization of an interprofessional integrated clinical education experience to improve medical and physical therapy student comfort in treating patients with disabilities
Emily Garavatti1, Jennifer Tucker2, Patrick S Pabian2
1 Department of Medical Education, College of Medicine, University of Central Florida, Orlando, Florida, USA
2 School of Kinesiology and Physical Therapy, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, USA
|Date of Web Publication||23-May-2019|
Patrick S Pabian
University of Central Florida, 12805 Pegasus Drive Orlando, FL 32816-2205
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of this study is to examine the impact of an interprofessional education (IPE) clinical experience for medical and physical therapy students on students' comfort levels and attitudes toward patients with disabilities. Methods: Forty students were recruited for this study, 20 from the College of Medicine and 20 from the Doctor of Physical Therapy Program at University of Central Florida with 10 students from each program self-selected into a control group or an experimental group. The experimental group attended an IPE clinical experience that included an encounter with a patient with a disability. Students completed standardized inventories on their perceptions of difficult rehabilitation situations, comfort levels, and attitudes prior to, and immediately following, the clinical experience. The control group completed the same standardized assessments. Results: Using the rehabilitation situations inventory (RSI) statistically significant changes in scores from the pre- to the post-intervention (P < 0.001) were observed. In addition, a statistically significant (P < 0.05) improvement in comfort levels was found in five of the six RSI subscales which include staff–staff interactions, families, motivation/adherence, aggression, and sexual situations. Attitudes toward disabled persons (ATDP) and interactions with disabled persons (IDP) failed to find statistically significant changes in respondent scores due to the intervention (P > 0.05). Conclusion: Both medical and physical therapy students reported increased comfort in dealing with rehabilitation situations after attending the IPE clinical experience. This supports the use of clinical encounters with individuals with disabilities as component of education on treating patients with disabilities.
Keywords: Clinical education, disabilities, interprofessional education
|How to cite this article:|
Garavatti E, Tucker J, Pabian PS. Utilization of an interprofessional integrated clinical education experience to improve medical and physical therapy student comfort in treating patients with disabilities. Educ Health 2018;31:155-62
|How to cite this URL:|
Garavatti E, Tucker J, Pabian PS. Utilization of an interprofessional integrated clinical education experience to improve medical and physical therapy student comfort in treating patients with disabilities. Educ Health [serial online] 2018 [cited 2019 Aug 23];31:155-62. Available from: http://www.educationforhealth.net/text.asp?2018/31/3/155/258924
| Background|| |
Individuals with disabilities experience significant challenges in having their health-care needs met, with reports that they are less likely to receive care for a health need than those without a disability., In addition, they experience numerous barriers to receiving adequate health care, with the lack of adequately trained providers identified as the most significant barrier. Health-care professionals' attitudes, knowledge, skills, and comfort providing services are recognized shortcomings that prevent individuals with disabilities from accessing health care. In addition, general practitioners indicate that their lack of training with this sector of the population impacts their ability to provide effective health care for people with disabilities.,
Over the past few decades, health disparities faced by individuals with disabilities in the United States have been recognized and a preliminary plan formulated to address them, but a coordinated or national response has yet to be established. The US Surgeon General has called for improvements in the training of health-care professionals regarding the health-care needs of individuals with disabilities beginning in medical school education. Vermeltfoort et al. found that although the majority of students in occupational and physical therapy programs were willing to work with individuals with intellectual disabilities, 50% reported feeling “not at all prepared” or “a little prepared” and 75% reported inadequate knowledge as the reason for feeling unprepared.
Knowledge, attitudes, and skills have been identified as core competencies to incorporate into disability training. Attitudes toward individuals with disabilities are critical and impact patient care. A study by Tervo, Palmer, and Redinius evaluated the difference in attitudes toward individuals with disabilities between students in several different health professions. They found that nursing students had the least positive attitudes when compared with medical students and allied health professions students and as a combined cohort held less positive attitudes when compared with the general population. This study, like many others, utilized a cross-sectional design and only looked at attitudes in one point in time and does not offer a means to improving these negative attitudes. Research demonstrates exposure to individuals with disabilities results in more positive student attitudes.,, Students with more positive attitudes, as documented by Tervo et al., reported greater comfort when working with individuals with disabilities. Early exposure, a longitudinal curriculum, and experience working with individuals with disabilities  have been found to lead to improvements in student's comfort and attitudes toward treating patients living with a disability.,
Patient care for individuals with disabilities is often challenging as they may present with multiple and complex conditions as well as functional limitations. Consequently, their health-care needs cannot be fully met by one discipline. This complexity of the care provides an exceptional learning opportunity for interprofessional education (IPE).,,,, The World Health Organization defines IPE as “when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.” IPE is regarded as an important component of health profession education reform. It is a requirement for accreditation of both medical schools  and physical therapy education programs in the United States. This requirement offers a unique opportunity to create a curriculum that fulfills learning objectives for both IPE and content on health care for individuals with disability.
There is a gap in the literature examining the impact of an IPE clinical experience involving individuals with disabilities on students' attitudes toward such patients and perceptions of difficult situations. Thus, the aims of this study were to: (1) investigate attitudes of medical and physical therapy students toward patients with disabilities, including their perception of difficult rehabilitation situations and (2) determine if an IPE clinical experience that addresses the health care of individuals with developmental disabilities would change medical and physical therapy students' attitudes and perceptions. We hypothesized that an IPE clinical experience that includes a patient with a disability will improve attitudes and comfort dealing with rehabilitation situations in both medical and physical therapy students. We also hypothesized that the attitudes and comfort will not differ between professions.
| Methods|| |
The study was approved by the University of Central Florida Institutional Review Board. Participants were recruited by E-mail from the University of Central Florida medical education and Doctor of Physical Therapy Programs. Students from the College of Medicine were in their 2nd year of a 4-year curriculum, whereas students from Doctor of Physical Therapy Program were in the beginning of their 3rd and final year. Twenty students were recruited from each discipline (n = 40). Due to commitments of time and travel for the experimental group, volunteers were able to self-select into a control group (n = 20) or experimental group (n = 20). Demographic information of participants can be found in [Table 1] with specific characteristics of the experimental group participant provided in [Table 2].
|Table 1: Demographics and experience level of medical and physical therapy student participants|
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Prior to the intervention, all participants, including control group, were provided instructions to access a secure online survey that was comprised of several inventories including the rehabilitation situations inventory (RSI), attitudes toward disabled persons (ATDP), and interactions with disabled persons (IDP). Both the control and experimental groups completed the survey once before the IPE clinical experience was held. The experimental group attended a 3.5 h IPE clinical experience held at a community-based training facility for adults with developmental disabilities. The event was facilitated by the administrator of the training facility, a faculty member from the College of Medicine, and a faculty member from the Doctor of Physical Therapy Program. Each activity was approximately an hour long; activities included an orientation, a jointly performed neurological examination on a patient with a disability, and a group discussion. The administrator led the orientation session which included a brief orientation to complex care of patients with disabilities, a discussion on health-care disparities experienced by this population, and a time for questions. Following this, medical students were paired with a physical therapy student. All pairs were instructed to perform a neurological examination on an individual with a developmental disability. They were given 10 min to develop a patient encounter plan and 60 min to complete the neurological examination together. The individuals with disabilities presented with varying diagnoses including but not limited to cerebral palsy, muscular dystrophy, Down syndrome, spina bifida, autism, and intellectual disabilities. All patient encounters took place in a semi-private treatment setting within the facility. After the patient encounter, students were gathered for a faculty-led debriefing and discussion. Discussion focused on the experience of working with individuals with disabilities as well as the roles and responsibilities of each profession. At the conclusion of the event, students in the experimental group were provided access to the same surveys a second time to be completed within 24 h following the IPE clinical experience.
The selected measures assessed attitudes toward persons with disabilities and a provider's comfort level when dealing with difficult rehabilitation situations. The data collection instruments were chosen based on published reliability and validity. The RSI  was one of the few scales identified that was specifically designed for health-care workers. It assesses comfort levels in dealing with rehabilitation situations commonly encountered when working with individuals with disabilities. Two scales were selected for measuring attitudes; attitudes toward disabled persons (ATDP) and interactions with disabled persons (IDP). Although these two scales were designed for the general population, they have been commonly used in the literature for populations of health-care professionals.
The RSI developed by Dunn  is intended to measure respondents' perception of difficult rehabilitation situations. The RSI contains 30 Likert scale items and is composed of six subscales (depression, staff–staff interactions, families, motivation/adherence, sexual situations, and aggression). The reliability of the RSI has been shown to be 0.93 for the instrument in its entirety and 0.72–0.84 for subscales. A total score is obtained by calculating the mean overall 30 items. Scores for each of the subscales were computed by summing the score of each item of the subscale and dividing by the total number of items. Higher scores indicate more discomfort, lower scores indicate less discomfort.
The attitudes toward disabled people scale (ATDP) developed by Yuker  is intended to measure attitudes toward disability. The ATDP Form O is composed of 20 Likert scale items. The reliability of the ATDP has been shown to be 0.73–0.89 in other studies., Total scores on the ATDP are calculated by summing all of the items with assigned values of −3 (I disagree very much) and +3 (I agree very much), 5 items were reverse scored (2, 5, 6, 11, and 12). Higher scores on the ATDP indicate that the respondent does not perceive disabled individuals to be different than nondisabled individuals (more positive attitudes). Lower scores indicate that the respondent perceives disabled individuals to be different from nondisabled individuals (more negative attitudes).
The IDP scale developed by Gething  is intended to measure attitudes toward people with disabilities. The IDP is a 20-item Likert scale and it is composed of six subscales (discomfort, coping/succumbing, information, fear, coping, and vulnerability). The IDP has shown the reliability of 0.74–0.86 in other studies., Total scores on these subscales are calculated by summing the score on each item in the subscale; several items were reversed scored (10, 14, and 15). Higher scores indicate the respondents had more negative attitudes toward people with disabilities, and lower scores indicate more positive attitudes.
Statistical analysis was conducted using SPSS 23.0 (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 23.0. IBM Corp., Armonk, NY, USA). Descriptive data are represented in mean and standard deviation or frequencies and percentages, as appropriate. A Cronbach's alpha for reliability of scales for total scores and the subscales was conducted to determine appropriateness of scales. Inferential statistical analyses were conducted to compare groups' means on all scales at baseline and post-intervention. Baseline homogeneity analysis was determined to be a critical step in the analyses due to the non-randomization of control and experimental groups. Therefore, we conducted a two-way, factorial analysis of variance (ANOVA) at baseline, with independent grouping variables being discipline (medicine/physical therapy) and group assignment (control/experimental). To address the primary aim of the study comparing the influence of the intervention on the experimental group, a repeated-measures ANOVA with one between factor (split plot) was conducted. Level of significance was set at P < 0.05.
| Results|| |
Participant demographics as well as quantification of professional and personal experience interacting with patients with disabilities were collected and are presented in [Table 1] and [Table 2]. The reliability for the participant responses on the outcome scales and subscales can be found in [Table 3].
|Table 3: Reliability for rehabilitation situations index attitudes toward disabled people scale and interactions with disabled persons scale|
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To first evaluate the appropriateness for use of the RSI, ATDP, and IDP scales in this study, reliability analyses were conducted for the responses on each of the instruments for all participants [Table 3]. Cronbach's alpha for the responses on each of the scales demonstrated good reliability (RSI α = 0.866; ATDP α = 0.702; and IDP α = 0.792). Therefore, the components within each of the three scales were summed. The total score RSI was utilized to measure participant comfort level in evaluation and treatment of patients with disabilities, the ATDP components were summed and the total score ATDP was utilized to assess participant attitudes toward patients with disabilities, and the IDP components were summed and the total score IDP was utilized to assess participant attitudes in regard to interaction with patients with disabilities.
To examine statistical equivalence of the groups (medical vs. physical therapy students; and experimental vs. control groups), baseline data were examined for homogeneity for each of the scales (RSI, ATDP, and IDP). A two-way, factorial ANOVA was conducted at baseline to examine mean pretest total scores for each scale. At baseline, Levene's test for homogeneity of variance found no differences in the error variance across the groups based on intervention versus control assignment or profession (medicine vs. physical therapy) for each of the scales.
In addition, the mean RSI and ATDP scores did not statistically differ (P > 0.05) between the experimental and control groups or between the professional disciplines [Table 4], [Table 5], [Table 6]. Finally, there was no statistically significant interaction effect of profession and intervention group assignment (P > 0.05). Due to these baseline findings, we proceeded with the within-group analyses to assess the impact of the intervention on student perceptions of difficult rehab situations (RSI) and attitudes toward disabled populations (ATDP).
|Table 4: Medical student and physical therapy student pre- and postintervention scores on rehabilitation situations index|
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|Table 5: Medical student and physical therapy student pre- and postintervention scores on attitudes toward disabled people scale|
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|Table 6: Medical student and physical therapy student pre- and postintervention scores on interaction with disabled persons scale|
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However, the factorial ANOVA found the IDP mean score for the experimental (64.1; standard deviation [SD] = 9.96) and control group (70.15; SD = 9.20) to be statistically different (F1,36=6.63; P = 0.014; partial eta 2 = 0.156). There also was a statistically significant difference in the baseline scores based on profession (F1,36=27.32; P < 0.001; partial eta 2 = 0.431), with the mean score of medical students (73.25; SD = 8.35) being significantly greater than that of the physical therapy students (61.00; SD = 7.38). There was, however, no interaction effect of group and profession (P > 0.05). Therefore, the control group was found to have significantly more negative attitudes than the experimental group, and the medical students had significantly more negative attitudes than the physical therapy students at baseline. These factors will be considered in the interpretation of the effect of the intervention on the IDP scale.
Rehabilitation situation inventory
To analyze changes in comfort level after the patient interaction experience, a repeated measure with a between factor (split-plot) ANOVA was conducted. The split-plot ANOVA found a statistically significant difference in pretest (mean 82.10; SD = 14.51) to posttest (mean 67.60; SD = 18.7) RSI total scores (F1,18=18.89; P < 0.001; partial eta 2 = 0.512). Approximately 51% of the variance in score can be accounted for based on the intervention. There was, however, no interaction effect of intervention and profession (F1,18=2.62; P > 0.05; partial eta 2 = 0.127). In addition, there was no statistically significant difference between the groups based on professional discipline (F1,18=0.649; P > 0.05; partial eta 2 = 0.035). Although the physical therapy students (mean 62.20) possessed a greater comfort level at posttest than medical students (mean 73.00), the differences did not meet statistical significance. Thus, all students responded similarly to the intervention. In addition, a statistically significant (P < 0.05) improvement in comfort levels was found in five of the six RSI subscales which include staff–staff interactions, families, motivation/adherence, aggression, and sexual situations, with an effect reaching as high as eta = 0.412 for aggressive behavior. However, no between-group differences were found (physical therapy [PT] vs. medical doctor [MD] students). Data from the RSI and subscales can be found in [Table 4].
Attitudes toward disabled people scale
To analyze changes in attitudes after the patient interaction experience, a repeated measure with a between factor (split-plot) ANOVA was conducted. The split-plot ANOVA found no statistically significant difference in pretest to posttest ATDP total scores (F1,18=0.126; P > 0.05; partial eta 2 = 0.003). Less than 1% of the variance in score can be accounted for based on the intervention. In addition, there was no interaction effect of intervention and profession (F1,18=0.912; P > 0.05; partial eta 2 = 0.048) and there was no statistically significant difference between the groups based on professional discipline (F1,18=0.133; P > 0.05; partial eta 2 = 0.007). The difference in ATPD scores at posttest between the physical therapy students and medical students also failed to reach statistical difference. Data for the ATDP pretest to posttest can be found in [Table 5].
Interaction with disabled persons scale
To analyze changes in attitudes after the patient interaction experience, a repeated measure with a between factor (split-plot) ANOVA was conducted. The split-plot ANOVA found no statistically significant difference between pretest and the posttest IDP total scores (F1,18=0.006; P > 0.05; partial eta 2 = 0.000). Less than 1% of the variance in score can be accounted for based on the intervention. However, there was a significant interaction effect of intervention and profession (F1,18=8.37; P = 0.01; partial eta 2 = 0.317). There was also a statistically significant difference between the groups' IDP scores based on professional discipline (F1,18=9.23; P = 0.007; partial eta 2 = 0.339). Approximately 34% of the variance in IDP score is accounted for based on profession. Data for IDP scale can be found in [Table 6]. The interaction of the discipline on attitudes with the intervention displayed in [Table 6] demonstrates that the medical students had significantly more negative attitudes prior to the intervention, which significantly improves, while the physical therapy students had more positive attitudes prior to the intervention. Postintervention, the medical student negative attitudes reduced from its original rating, while the PT student scores increased from baseline, resulting in less positive attitudes.
| Discussion|| |
This study sought to evaluate the impact of an IPE clinical experience for medical and physical therapy students on their comfort level with and attitudes toward patients with disability using three validated inventories.
The results suggest that the intervention effectively improved the comfort levels and perceptions attitudes of students in working with patients with disabilities. Students from both disciplines reported statistically significant changes in comfort in the RSI and nearly all of its subscales with moderate effects. This primary finding is consistent with previous literature,,, but as previously discussed, the mechanism by which it was achieved has not been a consistent model in health-care education. We used a novel approach of an IPE clinical experience to improve comfort level and attitudes of medical and physical therapy students toward disabled populations. Our design for the IPE clinical experience was based on several factors. Physical therapy and medical students were included as participants based on the important role each discipline plays on a rehabilitation team. Both professions have shared skill sets for the neurological examination, and both groups will likely treat patients with disabilities in their career. Research demonstrates that students value IPE experiences that involve active engagement and work with students of other professions on a relevant problem, this led us to pair students together to conduct the neurological examination. One of the primary evaluative instruments for this study was the RSI which assesses an individual's perceptions of difficult situations. The IPE clinical experience with the patients with disabilities was able to significantly improve the perceptions in both medical students and physical therapy students. Exposure to this IPE clinical experience explained over 51% of the variance in RSI score. In addition, five of the six subscales (aggression, sexual situations, motivation/adherence, families, and staff interactions) also found statistically significant improvement in perceptions of difficult situations [Table 4]. The other two instruments utilized, the ATDP and IDP, failed to find statistically significant changes in respondent scores due to the intervention. Both of these scales, however, were developed to address attitudes toward disabled individuals. The ATDP is one of the most widely used scales to assess attitudes and is validated. This scale is under scrutiny for being outdated and was originally designed for general population rather than health professionals. Several studies have found that it failed to reveal any difference in attitudes between groups , which was similarly encountered in this study. The IDP was also selected because it had been internationally validated and had good internal consistency, but this scale also failed to reveal any difference in attitudes. Again, this scale was designed for the general population, thus its application to health profession students might not be reliable. There are very few scales that are created specifically for health professionals and not one of those identified are designed for health-care students.
The results of our study are consistent with the current research suggesting that IPE clinical experiences that provide opportunities for interactions with individuals with disabilities increase comfort levels in treating this population.,,, Few studies have attempted to incorporate the different components of interprofessional education and training to work with individuals with disabilities that this study accomplished. Numerous cross-sectional studies have been done examining attitudes of health-care professional students, including occupational therapy students, nursing students, and medical students. Several studies have compared attitudes between health professions such as occupation therapy students and physical therapy students  or medical and social work students. There has been some research on the effectiveness of educational opportunities targeting the improvement of comfort, attitudes, and skills of medical students working with individuals with disabilities. Recent studies have used standardized patients as a method to improve students' interactions with disabled populations.,,, However, none of the aforementioned studies utilized a real patient intervention on site with interdisciplinary teams.
The literature on physical therapy students' attitudes and comfort treating the disabled population is limited. A study conducted by Stachura and Garven found that physical therapy students had relatively negative attitudes at the start of their training and their attitudes were more positive at the end of their training. Gething found that practicing physical therapists held positive attitudes toward individuals with disabilities. Similarly, this study demonstrated high comfort levels and attitudes of physical therapy students, which may be a direct relation to the curricular focus of those physical therapy programs. Conversely, in this study, the medical students trended toward less comfort in interacting with patients with disabilities. This could potentially be explained by the inherent nature of physical therapy being a rehabilitation specialty and whereas rehabilitation is just one of many settings for the practice of medicine. The limited data on the topic of exposure to complex patients during training in one's discipline highlights an area for future research.
| Conclusion|| |
Our study aims to evaluate the effects of an IPE clinical experience on medical student and physical therapy students' attitudes and comfort toward patients with disabilities. Our analysis revealed that both medical students and physical therapy students' comfort was improved following the IPE clinical experience. Physical therapy students demonstrated increased comfort in working with individuals with disabilities as compared to medical students. The reason for this difference is not clear and warrants further research. Our results support that interactions with individuals with disabilities increases comfort and should be a component of graduate health-care education, and this can be accomplished through use of IPE clinical experience.
There were several limitations that were encountered in this study. Students were able to self-select into either experimental or control group, thus the lack of randomization could be a source of error. Since this study was done at one institution and with a relatively small sample size, our findings may have limited generalizability. Student awareness of the research objectives may have allowed for a positive influence of the intervention. Due to the fact that this present study did not possess a true control group, it was not able to account for maturation. In addition, only one IPE clinical experience was held and due to proximal data collection, we do not know if this event will have lasting effects on comfort levels that will carry on into the students' careers. Another limitation was the use of scales that may be outdated and were not specifically designed for health-care workers.
The authors would like to acknowledge Dr. Lisa Barkley, MD, former Assistant Dean for Diversity and Inclusion and Assistant Professor of Family Medicine at University of Central Florida College of Medicine. Dr. Barkley contributed to the organization of the student interaction and data collection for this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]