Interprofessional Training in Mental Health: a possible challenge.

ABSTRACT

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Background: Mental health approaches require interprofessional actions. However, education on mental health is traditionally uniprofessional and is performed in specialized scenarios which reinforces the belief that mental health is only a concern for specialists. This is the reason why the first interprofessional mental health rotation in Colombia was designed and launched. The aim of this paper is to describe that process and the rotation itself. Material and method: This work describes the steps for the design and implementation of an interprofessional rotation on mental health. which involve medicine and psychology students. Results: The structure of the rotation is detailed. It contains both a clinical component and a simulated one, and diverse methodologies for learning and assessment. Conclusions: This interprofessional rotation is a useful strategy in the learning process of specific competences in mental health, and it facilitates acquisition of skills for teamwork.
Key words: mental health, medical education, psychology, clinical medicine.

INTRODUCTION

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Education  on  mental  health  has  traditionally been uniprofessional. This approach collides with  the  reality  of  patient  care  practice,  in which interdisciplinary and interprofessional work is essential. Nurses, psychiatrists, general practitioners, psychologists, occupational therapists, and social workers are the healthcare professionals who most frequently work in mental health(1,2).  Despite this, the importance of joint work between professions is not visible during education and training. Additionally, work in mental health requires specific competencies and skills to manage intense emotional situations and approach complex problems. Given the quality requirements in healthcare, there currently exists a worldwide call for interprofessional education.(3,4)

Interprofessional  education  is  the  participation of students from two or more professions in a collaborative practice through which they learn to work together to obtain better outcomes(5,6). Initiatives to advance this purpose(7-12)   have been brought forward in mental health syllabi  both in undergrad and graduate programs(1). This initiatives contemplate diverse alternatives including joint seminars(11,12), formation in specific topics(10), classes with the concurrence of various professions(8), and the inclusion of service users as partners in work teams(7). Some initiatives include educational models  such  as  the  Leicester  model(1,8,9),  based on Kolb’s learning theory (concrete experience, reflexive observation, abstract conceptualization, and active experimentation).(1,8)

Research on interprofessional education in metal health have, in general, positive outcomes(6). However, in Colombia, as in other Latin-American countries, the characteristics of training sites do not favor the process of interprofessional education and supervision that guarantee the acquisition of the necessary competencies to approach people with mental illnesses or symptoms(13). Particular local characteristics lead to more specialized attention stages and have reduced the scope students get of action fields and contexts in which mental health practice could be favored. This includes ignoring primary attention, and promotion and prevention activities.

The previously described items uncover three difficulties: a) Non-existent interprofessional formation in mental health in Colombia, b) The available learning environments have limitations for  the  acquisition  of  competencies  and  skills, and c) The training and formation is carried out in  specialized  facilities  that  limit  the  approach of different pathologies and disregard normal emotional responses.

The development of a new rotation, called Interprofessional  and  Mixed  Rotation  (IMR), was proposed in 2018-2 to tackle the needs to favor the development of basic practical skills in mental health attention (interview, psychological first    aid,    agitated    patient    approach),    to promote the development of competencies for interprofessional work (acknowledgement, respect,    collaboration,    communication)    and to optimize the integration of theoretical and practical aspects. The objective of the present article is to describe the planning, structure and implementation of the Interprofessional Rotation in Mental Health in the Medicine and Psychology Faculties at Universidad de La Sabana, active to this date.

MATERIALS AND METHOD

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Two steps were carried out to set up the IMR. The  first  step  was  a  viability  study  followed by the design of the curricular structure and logistics.

Viability study: Once the needs in formation and the  importance  of  interprofessional  education were established, the availability of infrastructure and human resources was verified jointly between the Department of Mental Health and Psychiatry, the Faculty of Medicine (FM), the Faculty of Psychology  (FP),  and  the  Simulated  Hospital –  Centre  for  Clinical  Simulation,  Universidad de La Sabana (CSCUS). Several meetings were carried out with people key to the process: Deans from both Faculties, practice directors, teachers, directors of the possible practical and simulated practice stages (CSCUS director, Psychology Service Centre (PSC) director). The budget, physical spaces, and personnel were assigned after these work encounters and internal processes in each Faculty.

Curricular    structure    and    logistics    design: during this second phase we counted with the participation of the practice area locations and teachers assigned by each Faculty. Each of the spaces and educational moments were outlined with  a  specific  objective,  in  accordance  with the objectives and common and differential competencies. Once the rotation was approved by  the  respective  Faculties,  the  total  number of students participating in the program was estimated,   and   the   topics   and   bibliography were agreed upon. Following this, work guides were developed for clinical and simulated environments  as  well  as  scripts  for  the  actors who would intervene during simulation sessions, logistic specifications for each session, expected learning outcomes (ELO), and evaluation forms. Likewise, a Moodle platform was set up with all the information to facilitate and complete these tasks. Actors were chosen and trained around the objectives and peculiarities of the rotation. All actors are Universidad de La Sabana students who receive training specific to the area and whose work is recognized thought the PAT Program (Learn to Work Program).(14)

RESULTS

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An Interprofessional Rotation was designed and implemented in two attention spaces (and was therefore also called Mixed Rotation): first, a clinical space at the PSC; and second, a simulated space at the CSCUS, located within campus. This first rotation counted with 72 seventh semester medicine students and 10 psychology students from ninth and tenth semester. This corresponds to the medical health practice semester for medicine students, and clinical practice semesters for psychology students.

Clinical scenario

The PSC at Universidad de La Sabana is a first level psychological attention center located in downtown Chia. It counts with several consulting rooms and a Gesell Chamber. Students rotated at this facility three times per week with an intensity of four hours each time. Teachers of the FP were in charge of one of these clinical sessions, while psychiatrist from the Department of Mental Health from the FM were in charge of the remaining two. During these sessions, a professional performed the clinical attention while the students performed a guided observation in the Gesell Chamber. All patients  were  informed  prior  to  attention  that they  were  being  observed  through  the  crystal by medicine and psychology students. Patients verbally gave their consent for this consultation modality. An instructive was developed for this guided  observation.  Each  student  was  assigned a point of observation (e.g. non-verbal language, interview techniques, diagnosis, etc.). Likewise, a briefing and debriefing was carried out before and after each patient. At the end of the week, students handed in a clinical history for one of the observed and discussed patients.

Simulated scenario

The CSCUS is 1000 m2 space found within the university where everyday clinical scenarios that healthcare students can go through are simulated. It counts with areas for external consult, emergency service, hospitalization, and surgery, which can adapt according to different needs. Simulated mental health practices have been performed in this space since its opening.(15)

During the first MIR, four sessions were carried out with a duration between three to five hours (Table 1). Session 1 consisted in clinical interview   in   mental   health.   The   ELO   for this session consisted in developing basic communication  skills,  and  clinical  interview

with  patients  with  mental  symptoms.  During this first session, students performed interviews with simulated patients with observation and feedback by the actors, peers, and the instructor. By the end of the session, students must have completed a role play interview were they each were physicians or psychologists for which each of them received feedback one by one. On the other hand, the ELO for Session 2 consisted in learning psychological first aid. For this session, simulated patients were also set up in different scenarios, both in hospital and community settings. The agitated patient approach was addressed in Session 3 with cases on increasing complexity up to requiring immobilization. The ELO for this stage were evaluating the risk of agitation of a patient, and carry out the general approach in the management of psychomotor agitation. Finally, all learning outcomes were integrated during Session 4. The ELO for the las  session  were  therefore  kept  in  the  same line and can be summarized in performing the initial addressing of a patient, which included diagnosis, management plan, and follow up.

Supporting  bibliographic  material  was  prepared for each session. Taking into account the objective for non-specialized attention, this bibliographic material included guides from the Pan-American Health Organization, such as the “Guide for mhGAP Intervention for Mental, Neurological, and Substance Use Disorders at a Non-Specialized Level”(15),  and  the  “First  Psychological  Help:

Guide for Field Workers” (17). The distribution and sessions can be found in Table 1.

Logistic aspects

The structure of each of the simulated sessions was organized jointly with the CSCUS. The actors rehearsed the cases and scripts prior to sessions.

Students were divided in groups of seven (two from the psychology program and five medicine students) which rotated in every scenario during the designated week to guarantee the rotation of all students. The same rotation was carried out
16 times. The evaluation methods implemented included videos of clinical interviews, written products (complete medical history of a real patient), and written exams as evaluation for reading control. Additionally, continuous feedback was provided during each session by the instructor, peers, and actors, using “in vivo” modelling, observation guides, case discussion, and the use of the Gesell Chamber in all scenarios. Likewise, a one-on-one feedback was delivered for all exams and evaluated products by means of the Moodle platform according to predesigned rubrics.

At the end of each rotation, students took a written evaluation. Additionally, an evaluation of each one of the 16 groups was carried out by the team of instructors one month after the star of the rotation, and at the end of the rotation. Pertinent adjustments that were deemed necessary based on this evidence (e.g. change from one to two actors in three of the four simulated sessions) were performed and implemented in the following rotations.

The final evaluation taken by the students highlighted the achievement of competencies, organization, methodology and the importance of continuous feedback for their education (Table 2)

DISCUSSION

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Given that mental well-being is one of the pillars of health(18,19), and that mental disorders cause high morbidity, mortality and disability, the formation of mental health professionals is still a great necessity. From this perspective, interprofessionalism promotes better results in the quality of attention in this field of knowledge.(9)

This RIM in mental health, with healthcare and simulated scenarios, in which students of medicine and psychology participated under the supervision of instructors from both areas, is a first approach to the landing of interprofessional formation. Additionally, in the national context, this initiative specifically responds to the developments and curricular updates suggested to medicine programs that work groups such as the National Council for  Medical  Education,  and  the Association  of Medicine Faculties, have proposed in order to optimize the quality of medical education in the country.(21)

The implementation of interprofessional work involves healing a series of obstacles such as failures un communication, conflicts of power, professional culture clashes, diverging approximations to care and treatment, and conflicts related to leadership, which require training such as the one proposed in the described IMR.(1,6,22)

Analyzing   the   IMR   under   the   lens   of   the Leicester model uncovers converging points(1,8). For example, the concrete experience is obtained by means of observation and performance of interviews, which leads to theory being set in practice. The introduction to guided observations and debriefing, in a similar manner as the reflection exercises and co-evaluation lead to abstract conceptualization, and lastly, the input of the students to the approaches or treatments allow  them  to  be  active  in  their  experience. On  another  point,  the  advantages  offered  in the  realization  of  interprofessional  education in mental health include the acquisition of the knowledge of each other’s labor, including their skills and competencies(23,24); the optimization of attention quality(24,25); optimization in the use of resources and care of professionals(25). From this we find that one of the challenges is proposing strategies that can be longitudinally implemented to ensure interprofessionalism as a mode of action cultivated from the first years of professional education and training.

The impact of our rotation has been partially valued, given its recent implementation. However, testimonies from participants and their performance in theoretical-practical exams in mental health are evidence of a positive result. Towards the future, we propose evaluating the impact in performance in the long term with students who are in their last stages of formation, or ideally graduated alumni.

In conclusion, the IMR with clinical and simulated components is a useful strategy in the process of learning competencies specific to mental health. Additionally, it facilitates de acquisition of skills in teamwork, allowing collaborative learning from different optics of mental health.

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