Teaching About Partnerships Between Patients and the Team: Exploring Student Perceptions

Abstract

Health profession educators are responding to shifting approaches where patients are increasingly recognized as partners in an interprofessional care process. To foster competencies related to partnerships between patients and the team, educators have advanced the role of patient partners; however, an appreciation of resulting student learning is in its early stages. First-year students from 9 programs interacted with patient partners and participated in a Reader’s Theater that explored partnerships with patients in an interprofessional team. Students completed reflective assignments; an inductive thematic analysis explored student learning. The following 4 overarching themes were recognized: developing insights through patient perspective, promoting partnerships with patients, recognizing attitudes that promote therapeutic relationships, and advocating for the patient to be a team member. Accompanying subthemes provide enhancement of each of the identified themes. Students discussed the effect of poor collaboration, identified attitudes that promote collaboration, and expressed the value of advocacy for patient partnership. An enriched appreciation of student learning will guide educator engagement of patient partners in both health professional and interprofessional curricula.

Introduction

Many health care settings are recognizing patients as partners in the care process. To prepare students to embody this value and to understand this important shift in the culture of care delivery, health profession educators have been exploring approaches where patient partners participate in the learning process. In interprofessional contexts, patient partners have been engaged in the design, delivery, and evaluation of learning activities. Although there is growing agreement on the value of privileging the patient voice, an appreciation of the nature of resulting student learning is still progressing.

Interprofessional education (IPE) occurs when students from health and social service programs learn together with the goal of cultivating a collaborative approach to enhance patient-centered care (1). Although the patient is understood to be a member of the health care team, the typical approach to IPE learning activities places a stronger focus on the interaction of team members from various professional programs, addressing team dynamics, roles of professions, communication strategies, and collaborative care plans (2). Yet, the desired goal of IPE is collaboration among all team members, including patients and family members, ultimately fostering patient-centered, or rather patient-partnered, care.

Although the terms patient-centered care and patient partnerships are often used interchangeably, nuances in these concepts address varying understandings. Following a narrative review regarding patient-centered care in medical and nursing literature, authors described 3 emerging themes: patient participation and involvement, relationship between the patient and health professional, and the context where care is delivered (3). Key attributes of a more nuanced understanding of partnership in health care address relationship but also include power sharing, shared decision-making, negotiation, and patient autonomy (4, 5). Here, the implied goal is to foster empowerment of patients, often with the anticipation that they assume greater self-management of health concerns. Health providers must consider the nature of the relationship, exploring approaches to sharing knowledge and power to enable patient empowerment. Yet, health care providers can struggle with the tension between a more traditional paternalistic approach and the move toward ensuring patients are fully informed and engaged members of the team, participating actively in decision-making (6).

Although health profession education programs address patient-centered care in their profession-specific curricula, the focus is typically on the relationship between the individual health care provider and the patient (7); however, educating about partnerships between the patient and health care team is rarely described. With the evolution to team-based practice and patient desire for greater engagement, health-care providers ought to consider the nature of patient partnership. In turn, educational programs should address approaches to foster evolving skills needed to empower patients to participate as partners. One approach is to structure learning opportunities where students interact directly with patients, reflecting on their lived experiences and learning from their suggested strategies (8, 9). Evidence of greater levels of engagement of patients is emerging, particularly with respect to involvement on research teams and a growing role in teaching/co-teaching in the health professions. Where patient involvement in teaching is described (10 –13), a greater emphasis has been placed on the process of delivery rather than impact on student learning or practice (14).

Understanding the nature of student learning resulting from interactions with patients is valuable. In search for a deeper understanding, investigators have turned to the analyses of reflective writing, focus groups, questionnaires, and online discussions (15 –19). Key emerging themes from these analyses include acknowledgement of the value of learning from patients in both profession-specific and interprofessional contexts, and an appreciation of patient circumstances and needs. However, little is known about how students understand the nature of partnerships in a team context.

Theoretical Considerations

Co-constructed learning, as described by the theory of social constructivism (20), is particularly relevant within the context of interprofessional learning with patient partners where understanding of teamwork and partnership skills are evolving. Additionally, the authors draw on transformative learning (21,22); here, disorienting dilemmas, such as some of the experiences shared by patient partners, serve as stimuli to encourage learners to challenge their assumptions and beliefs, fostering reformulation of meaning schemes and perspectives.

This study aimed to explore student learning about partnerships between the health care team and the patient in an interprofessional learning activity with health profession students where patient partners are fully engaged and their voice is privileged.

Methodology

Context

The University of Toronto has a requisite Interprofessional Education (IPE) curriculum where health profession students from 11 programs learn about, from and with each other to develop collaborative competencies to enable optimal health care delivery. Students participate in 8 requisite core activities and a specified number of electives. In one of the core IPE activities for first-year students, Patient Partnerships in a Team Context, students explore partnerships between the patient and team members and consider the role of the patient on the team. Students are assigned to mixed profession groups where they learn with and from a patient partner (individuals with lived experience as a patient) and use a Reader’s Theater approach to engage with a verbatim script created to explore the notion of partnerships. The script was developed following the transcription of interviews with 5 patients and 3 health care providers addressing the topic of partnerships. Students select the voice of one of the informants, read the corresponding selections, and explore notions raised in the facilitated small group discussions. Each facilitator follows the learning plan in the Facilitator Guide referring to a list of questions to inform discussion following interaction with the patient partner and the reading of each scene in the script. Topics include the impact of chronic health conditions, differing perspectives, competing priorities, communication, and collaboration. A detailed description of the learning activity, script development, and activity is published elsewhere (9). Following completion, students prepared a one-page written reflection.

Patient partners are recruited from the community and trained to share experiences regarding partnerships, as well as to participate as small group facilitators. Workshops target approaches to educating students in the context of the IPE curriculum, to sharing their story/experiences, and to facilitation of group discussions.

Study Design

Investigators used an inductive thematic analysis to explore health profession student learning regarding partnerships as recorded in the written reflections. The authors studied the reflections to code, identify emerging themes, and to consider possible meanings. Ethics approval to conduct this study was obtained from The University of Toronto’s research ethics board.

Participants

A total of 904 first-year students from 9 of the health profession programs (Medical Radiation Sciences, Medicine, Nursing, Occupational Therapy, Pharmacy, Physical Therapy, Kinesiology, Social Work, and Speech-Language Pathology) participated in the interprofessional learning activity. Only students from Medicine, Nursing, Pharmacy, and Occupational Therapy were required to complete the reflective assignments. Of this group, 550 students signed and returned consents.

Data Analysis

The data set consisted of the submitted reflections of the 550 participating students. Braun and Clarke’s thematic analysis process was used to identify, analyze, and report on the themes in the data set (23). The 2 researchers familiarized themselves with the data set by repeatedly reading the reflections. The researchers read a set of reflections together, coded them independently, and then discussed a common approach to coding. Once both researchers consistently identified similar codes, the second author engaged in a more detailed coding process by systematically reviewing the data set. Both authors met regularly to discuss the codes identified and the process of coding. NVivo 11 was used to support coding. Saturation was reached once 260 reflections were coded.

Once authors identified codes, they collated them into potential themes and checked to determine whether the emergent themes resonated in the data set. They explored external heterogeneity and internal homogeneity once themes were identified. Following discussion and review of the data set, the authors achieved consensus on the final themes. The authors attempted to minimize the effect of assumptions and preconceptions during the research process by regularly recording and considering potential influence of their impressions.

Results

The qualitative analysis of the reflective writings revealed 4 key themes with accompanying subthemes. Broader themes included (a) developing insights through patient perspective; (b) recognizing attitudes that promote therapeutic partnerships; (c) promoting partnerships with patients; and (d) advocating for the patient to be a team member.

Theme 1: Developing Insights Through Patient Perspective

This theme included recognizing expertise of the patient and understanding the impact of poor collaboration. Collectively, these themes represent the perceived value of learning about the patient and understanding the impact of the experience from the individuals who know this best.

Although students struggled with the concept of patient expertise, they did acknowledge that the patient has insight that should be considered in the therapeutic relationship. This comment reflects the tensions in group discussions:

Our group had a very interesting debate around this topic. Some thought that while the patient may be an expert in how they are feeling during the disease state, they may not necessarily be an expert in the actual pathology of the disease. However, some other members argued that the patient is the sole expert of their disease state and that health care professionals are resources that are available to them…Patients/clients will likely have insight into what methods of treatment will be the most effective for them, as their health priorities are important in reaching their best health outcome” Student 112

By being engaged with the patient partners, students recognized the impact of poor collaboration and communication among team members on the patient. For example, these students reflected on the experiences shared by the patient partner.

It was an eye-opening experience because it drove home the point that real suffering was caused by lack of team communication with both health care providers and between the patient and the team. Student 37

Theme 2: Promoting Partnerships With Patients

Subthemes addressed acknowledging complexity of partnerships between health care team members and patients, recognizing strategies to promote communication, and encouraging shared decision-making.

Students described the ideals of establishing partnerships with patients but recognized the challenges associated with doing so in practice scenarios.

However, it became clear to us that establishing such partnerships is really easier said than done. While acting out the script that showcased different patients’ and health care professionals’ perspectives on chronic disease and the role of patient/client partnership, I was particularly concerned by how drastically different the patient’s perspective of their therapeutic encounter was when compared to the health care professionals themselves. Student 18

Upon recognizing the complexities, students reflected on the strategies to promote communication to enable the partnerships. Strategies they suggested included determining how much information the patient is prepared to take in, identifying oneself and the purpose of the interaction, using patient-centered language, and eliminating jargon and language that could be confusing. However, the most frequently cited strategies could be summed up as active listening and providing opportunity to ask questions.

On my next clinical placement I will remember to constantly be actively listening, to ask the patient what they need from the interaction, and to ask them what frustrations or difficulties they’ve had navigating the health care monster and how those difficulties can be best addressed. Student 27

Students described how developing a relationship with patients and providing adequate information was essential to enable shared decision-making.

The core component of involving a patient as a partner in their treatment, I believe, is ensuring that they have all the information to make their own decisions. This should be done by delivering the information in a manner that is understandable by the patient, as we discussed today. Student 13

Additionally, valuing the patient as part of the health care team contributes to a desire to engage them more in decision-making.

It was also interesting to see that patients are much more engaged in their care. They no longer want to be told what to do, instead they want to collaborate with their health care provider and develop realistic goals. I believe that as a health care professional, it is important to acknowledge this change in patient mentality and no longer think of ourselves to be superior to the patient. Instead of giving the patient instructions, we should work as a profession to guide patients in making the most educated and appropriate health care choices. Student 135

Theme 3: Recognizing Attitudes That Promote Therapeutic Relationships

Two subthemes informing this notion include recognition of one’s own limits and curbing desensitization to suffering. As part of the first subtheme, students reflected on issues of pride and humility needed to recognize limits to own expertise when considering interactions with patients.

Another theme that emerged was the importance of staying humble. Several care providers in the scenarios discussed that oftentimes, the biggest barrier to patient partnerships is the health care provider’s pride; when providers take too much pride in their own knowledge and skills, they forget to take the time to listen to the patient as well as the opinions of their colleagues. Student 185

Students recognized that despite their perhaps more idealistic thinking early in their education as health care practitioners, they were not immune to attitudes that could hinder therapeutic relationships. Awareness fostered by self-reflection is essential.

Yet there I was, arrogantly thinking that these things would never happen to me. But considering how often it has happened in the past, and happened to people who I am sure were all as well-meaning as we are in our first year of health care education, I am sure that it can happen to me as well. This is something that I will stay diligently aware of from now on. Student 48

Theme 4: Advocating for the Patient to Be a Team Member

This theme included subthemes of enabling the patient for an empowered response and collaborative advocacy. Students reflected on discussions with the patient partners and considered the value of empowering the patient to be active members of the health care team. They recognized some of the barriers that have impeded this level of engagement in the past but expressed their need to foster empowerment in the health care relationship, as the following quote illustrates.

In the past, medicine had a patriarchal or hierarchical structure, where physicians and other health care providers were placed on a higher level than that of patients. However, medicine has shifted to a patient-centered approach to improve the efficacy of care and empower patients to take responsibility of their health and health-related decisions. Many patients still believe that the initial power differential still exists. It is our duty, as health care providers, to inform patients of their role in the health care relationship. Student 78

Additionally, students recognized that barriers to empowering patients to see themselves as members of the health care team can also be impacted by the systematic changes and coordinated teamwork.

I noticed that the patient educator [partner] had great insight into partnerships. She highlighted the importance of advocating for one self and making herself part of the team. I learned that the patient should be empowered to advocate for oneself. But in addition, the patient educator [partner] emphasized that it would be easier if teamwork was facilitated. Student 120

Discussion

This study explored health profession students’ learning following an interprofessional activity addressing team partnerships. Through analysis of the reflective assignments, 4 themes and corresponding subthemes were identified. While some themes were confirmed by similar descriptions in the literature, others emerged as new concepts, particularly as they pertained to the notion of partnerships.

Students generally accepted that the patient should be part of the team but wrestled with what this meant and how it should be achieved. They recognized the value of empowering the patient to believe they were a part of the team and act accordingly by taking on responsibilities related to communication and shared decision-making. Some students acknowledged potential challenges when working with individuals from vulnerable populations, and that they and the team had a responsibility to provide additional support.

What has been discussed less is student appreciation of the impact of poor team collaboration. Within the context of IPE, students are typically exposed to the need for collaboration among team members as an important underpinning for providing holistic management of patients’ health concerns, for enhancing quality of patient care, as well as when addressing team communication in safety-related issues (2,24). As students engage with patient partners, they have the opportunity to learn more about how a lack of collaboration affected them and their perception of care provided by the team.

Students paused to reflect on attitudes that promoted relationships, specifically the impact of pride, and conversely humility, on therapeutic partnerships. Humility considers qualities such as respect, receptiveness to varying worldviews, motivations that are oriented to others, and integrity (25). Students noted the need to consider their own pride in their interactions, as well as acknowledgement of their own limitations, fostered through the important skill of self-reflection. Although attitudes like humility may be challenging to alter, transformative learning theory suggests that reflection on experiences that may be perceived as “disorienting dilemmas” serve to foster meaning-making and potential transformation of values.

Students reported the value of advocating for the patient to be a partner with the team. Although patient-centeredness is commonly addressed, in practice settings, team activities may isolate patients; for example, team meetings where decisions are made for the patient are often held without the patient present (26). Where patients are empowered to participate and engage in shared decision-making with the team, their preferences and expectations are recognized, thus enhancing effectiveness of clinical interventions and treatment outcomes. In the disability movement, the rallying cry of “Nothing about me without me” has been raised. An extension of such an approach in care environments has implications for practice and corresponding health profession education.

Limitations

Student responses were limited by the selection of patient partners engaged in the learning activity. Although their narratives and experiences are authentic, they do not represent a composite of the patient experience and should be regarded as a symbolic representation only (27). Additional interviews would have provided greater insights into the student learning process.

Conclusions

In a health care context, patients are increasingly acknowledged as members of the team, yet the conceptualization and operationalization of this notion is still being discussed and developed, both in education and practice environments. In this study, first-year health profession students learned about the concept of partnership through engaging in an interprofessional learning activity and interacting with the experiences of the patient. The analysis of written reflections noted that students valued the opportunity to develop new insights from the patient as well as through discussions with their peers from other professional programs. They wrestled with how partnerships were understood as well as how their own attitudes and advocacy efforts influenced that partnership.

This study represents an analysis of learning at an early stage in the health profession student educational process. Further investigation along the trajectory of learning will support and guide educator efforts to provide experiences that transform approaches to partnerships and ideally produce enduring results translated to future practice settings.

Author Biographies

Sylvia Langlois is an Associate Professor in the Department of Occupational Science and Occupational Therapy, Faculty of Medicine, and the Faculty Lead IPE Curriculum and Scholarship, Centre for Interprofessional Education, University of Toronto. She has a keen interest in promoting patient engagement in health profession education and in learning associated with interprofessional curricula offered to health profession students.

Kamna Mehra is a Post-Doctoral Research Fellow at the Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Canada.