In Canada there is increasing awareness that a number of populations are underserved by the health system. While access to health services is a right of every Canadian as guaranteed by the Canada Health Act 19841, living in rural areas is shown to have adverse effects on access to health care, quality care, rights of patients, patient and provider satisfaction, and most importantly, on patient health outcomes1-3. While the entire health system in Canada is under a great deal of stress, this is, however; most evident in rural communities3,4. According to the British Columbia Rural Academic Health Project's provincial consultation report, 'health programs need to give communities an empowering leadership role' in relation to matters of healthcare services5.
This article discusses the BRIDGE project: Building Rural Interprofessional (IP) Discussions and Group Experiences. The BRIDGE project was created among Thompson Rivers University faculty, practitioners and community members to explore IP education (IPE) in the Interior of British Columbia, Canada. This group created the project through a collaborative team-building award granted by the British Columbia Rural and Remote Health Research Network (BCRRHRN) of the Michael Smith Foundation of Health Research.
The role of interprofessional education
The Health Council of Canada describes IPE as learning together to promote understanding of each other's discipline, collaborative problem solving and decision-making for the benefit of patients and developing required competencies for collaborative practice6. Interprofessional education has never been more essential for those working in Canada's rural and remote areas; healthcare professionals rely on each other's skills and knowledge, and tend to be more resourceful due to the limited local resources available to them7. Collaboration among healthcare professionals, researchers, and key stakeholders is required to promote community-based research and program development related to access to healthcare services for rural communities and IP collaborative practice8. However, due to isolation and a challenging work environment, it is difficult to attract and retain healthcare professionals in rural areas. Studies have shown that changing the way health professionals are educated is a key component of achieving change and ensuring that health professionals have the necessary knowledge and training to work effectively in IP teams within the evolving rural healthcare system3,9-11.
According to the literature reviewed, gaining IP practice experience is necessary for students in healthcare and allied healthcare disciplines. Studies demonstrated the importance of preparing students in an IP manner, and educational programs with a structured IP curriculum provide students with the opportunity to learn and practice from each other's discipline, which leads to the provision of quality patient care services12-14. Students gain a more complete understanding of the role of other professions in the healthcare team through IP. In order for students to build IP collaborative skills, they need to be involved in team decision-making and problem solving with each other and community practitioners because this can contribute to a positive and successful learning experience for all3,4,9,14,15. During IPE experiences, students must collaborate and work together in a process known as 'team preceptoring'. Team preceptoring is a reciprocal process with individuals of two or more disciplines learning from each other16. In addition, IPE involves collaboration among students, faculty and others, across many different levels, including site or practice areas. Administrative support involves leaders who can communicate a vision of collaborative practice, motivate practitioners and staff to participate, and create a working environment that nurtures IP practice14.
Faculty need to work together in order to role model for students the collaborative process. Practitioners, agency staff, decision-makers, and organizational managers must also participate in implementing IPE in the healthcare setting14,16. An example of a project that not only successfully demonstrated the necessary components of IPE, but also offered a positive rural experience is the IP Rural Program of BC (IRPbc) that brought together key stakeholders in the community as well as 'partners from government, post-secondary institutions, and health service organizations in rural communities' to build inter-professional teams of students, practitioners, and communities that offered an IP collaborative experience in rural BC communities4.
Medves et al found that learning in the clinical setting is the best way to gain knowledge, experience and clinical decision-making skills that are conducive to collaborative practice17. According to Craddock et al, students who had IPE experiences developed professionally due to the exchange of knowledge and skills and enhanced personal confidence10. Because IPE requires hands-on experience, the best place for students to learn about this form of collaboration is through field education or practicum placements in the rural setting18,19.
Students who learn through IPE and practice in rural settings not only have greater knowledge, skills, and appreciation of rural practice, but also learn about rural life and the health impacts of those living in rural communities. Students learn about rural life, rural health issues, and are exposed to particular community needs. This can also be of significant benefit for rural communities where the IPE students practice. Medves et al evaluated students' inter-professional and experiential learning in rural settings and found that the experience provided valuable experience, knowledge and skills of other disciplines in for preparation for rural practice17. Having rural IP experiences can also encourage students to pursue rural practice as a career choice3,4,7,9,17,20. Daniels et al asserted 'the importance of rural training as part of health professional education...and maintaining rural training programs is an effective educational strategy to build a rural health professional workforce' (p67)15.
The context in the Interior of British Columbia
The Interior Health Authority (IHA) is the second largest geographic area in British Columbia, covering almost 217 000 km2. The IHA consists of 4 health service delivery areas, including urban, rural and remote areas of East Kootenay, Kootenay Boundary, Okanagan, and Thompson Cariboo Shuswap. The IHA provides a full range of health services to approximately 733 000 residents, with the majority of those residents living in communities with populations of 10 000 or less. Thompson Rivers University (TRU) is geographically situated in the Southern Interior of British Columbia in the City of Kamloops. The TRU is a university which has traditionally served the educational needs of students from the surrounding communities that are considered rural, and provides certificate, diploma, undergraduate and graduate programs on campuses in Kamloops and Williams Lake, as well as through distance education in Canada and internationally.
The project utilized a community-based participatory action research (CBPAR) approach to involve those most affected, and to change or influence a social situation21. Community-based participatory action research is a planned, systematic approach to issues relevant to the community of interest, requires community involvement, and makes a lasting contribution to the community22. The project had two components: (i) using focus group discussions to learn about rural healthcare experiences and the supports required in facilitating IP education; and (ii) the development and implementation of a CBPAR workshop for rural health and social work participants at a conference on rural health that was held in one of the two communities.
The project members conducted two focus group discussions on rural health and what supports may be required to facilitate IP field placements. The CBPAR methodology is best situated to facilitate community participation, to understand important community health problems, and to facilitate communication and interaction between participants. Allied health professionals were encouraged to talk to one another by asking questions, exchanging anecdotes and commenting on each others' experiences with practicum students and points of view. The discussions were particularly useful for exploring people's knowledge and experiences, and gaining their opinion on the state of health in their community. Open-ended questions were used to encourage participants to explore the issues of importance to them and to understand the nature of IP practice in each community.
In addition, documentation was reviewed and a relevant academic literature on IP practice and education, rural practice, and field education was conducted. The participants were invited by the local health and community service agency representing a variety of allied health professionals. Participants were selected from on the basis of being rural health practitioners who had the potential to host an IP placement in their agency. There were six participants in one focus group and eight participants in the second focus group. Each focus group discussion was organized in a community service agency. It was not possible to tape record the meetings; however, the discussion meeting was facilitated by at least two faculty members and key words and memos were recorded. After the meeting a full debriefing was held and the notes of the meeting were transcribed and analyzed.
Finally, consistent with the focus on building partnerships, a CBPAR workshop was developed and implemented at a rural health conference in the region. This workshop provided information on CBPAR, including stages of research and levels of participation. Through a case study, participants explored the development of a research question. Eleven participants attended and rated the topic of CBPAR as either good or very good and found the information was both useful and relevant to many different disciplines.
The focus group discussions elicited: participants' perspectives of rural issues, what services were being offered, how the organizations work together, their experiences with students, and their vision for future student placements. Many of the issues that arose during the discussions had been present in the literature reviewed. For example, participants expressed that recruitment and retention of healthcare professionals was an ongoing challenge. The impact of centralized services meant that some healthcare services were 'parachute' services, meaning health professionals came to the communities once each month from urban areas. These parachute services created a gap in follow up because the services were not readily available locally. Practitioners identified that professional and personal boundaries were hard to balance in a smaller community. Previous studies have documented similar challenges regarding boundary issues for family physicians, a lack of services and professional supports7,20,23. Participants shared a concern about the lack of supports for student travel and accommodation in this region. Previous research has found that financial incentives such as 'loan forgiveness' and free accommodation can be positive influences on recruiting and retaining healthcare professionals in rural communities15,24.
The discussions demonstrated some of the positive aspects of living in a smaller community that foster collaboration among health professionals. This may be a result of the professional isolation that participants expressed, yet they reported relying on each other for professional support. The participants reported that they tended to be generalists in practice. As one participant stated, 'the roles tend to blur at the margins as people just do what has to be done in a mutually supportive way'. The participants agreed that their communities offered broad learning opportunities and all were eager to have students. They stated that students often provide a 'fresh perspective' and bring enthusiasm that help practitioners feel 're-energized'. In the literature reviewed, it was found that students and rural practitioners learn and practice together, creating positive experiences that may increase the potential for retaining and recruiting healthcare providers4,9,15,17.
With the partnership created between the rural communities and TRU; taking into account participants' views, the field placement coordinators at the university began to explore how they might coordinate potential IPE opportunities for their students. This planning process proved to be more difficult than anticipated. Time was a factor in trying to plan a pilot rural IPE experience and coordinate the timetables of students from social work, nursing and human service programs. The coordination also involved trying to gain the support and commitment of decision-makers and stakeholders in the academic departments and health authority. During the planning process for IPE placements, the project members found that people were either too busy or unable to coordinate a common meeting.
The project developed collaborative partnerships between rural communities and the university that identified the needs and priorities to build capacity for IP placements in two rural communities in the Interior of BC. The rural practice sites learned first-hand about the constraints of post-secondary education and the complexities of practice education. In the process the faculty members learned about the challenges and opportunities available for students and practitioners in rural communities. The project increased understanding of each partner's situation, improved communication, and developed trust. Collaboration created a new partnership for future activities between the rural communities and TRU. Through this collaborative process, partnerships were formed as a means to improve the health status of individuals and for community empowerment in matters of health and wellness.
The project demonstrated that there needs to be concerted effort and commitment from not only the rural community, but also from the academic institution and the health authority in order to develop an IPE program. It has been stated that such projects do have value, but to be sustainable they must be incorporated into the conventional post-secondary education for training future healthcare professionals6. Collaborative practice for the health and wellbeing of rural communities and their citizens is vital. Unfortunately, inter-professional education continues to be lacking in many Canadian post-secondary institutions today.
The authors thank the British Columbia Rural and Remote Health Research Network (BCRRHRN) of the Michael Smith Foundation of Health Research for their financial support. The authors acknowledge the contributions to this project of community partner Jack Keough and research students Jennifer Radmacher, Monika Wroz and Allysa Gredling.
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