Multiprofessional education for allied health professionals in rheumatology: Breaking down traditional barriers

MUSCULOSKELETAL CAREMusculoskelet. Care 4(1): 48–58 (2006)Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/msc.18

Professional issue

Multiprofessional education for allied health professionals in rheumatology: Breaking down traditional barriersElaine Dawson RGN BS(Hons)

Nurse Practitioner, Rheumatology Department, Christchurch Hospital, Christchurch, Dorset

Introduction

This report documents the research and development of an innovative vocational course for allied health professionals (AHPs) working in rheumatology. It examines the professional, economic and political influences on extended role practice for these professionals. The course is run by the University Of Brighton School Of Health Professions, in collaboration with rheumatology teaching centres (approved centres) across the UK, and the Arthritis Research Campaign (arc).

Current development of extended roles in nursing and allied health professions

Specialism in nursing and allied health professions has occurred in response to many factors including economic constraints and the drive to reduce the workload of junior doctors (Humphries and Masterson, 1998), changing patterns in health care needs (Read, 1998) and political and professional influences.

The NHS is committed to ‘expanding the roles which the allied health profes-sions play in health and social care, ensuring they can use their skills flexibly and creatively to the benefit of patients’ (Department of Health, 2000a) and the Nursing and Midwifery Council code of professional conduct encourages nurses to partici-pate in learning activities that develop their competence and performance while emphasizing personal responsibility for safe practice through individual professional accountability (Nursing and Midwifery Council, 2004).

The Agenda for Change proposes to reward NHS staff for what they do and for their skills and ability, rather than for their job title. This will enable staff to give their best for patients by working in new ways and breaking down traditional barriers (Department of Health, 2000b).

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Musculoskelet. Care 4: 48–58 (2006)Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/msc

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Breaking down traditional barriers 49


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Background research

The predominant disease pattern in the United Kingdom is that of chronic or long-term rather than acute disease (Department of Health, 2000c). Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that primarily affects the peripheral joints causing joint destruction and often leads to considerable disability. The treatment of RA is rapidly advancing with specialist nurses and AHPs being major contributors in the multidisciplinary care of such patients.

The contribution of nurses and AHPs in the management of rheumatology patients is well documented (Hill, 1992; Thompson et al., 1992). Their roles are recognized as adopting a holistic approach, incorporating the patients’ biopsychosocial and physical needs into their overall management (Ryan, 1997).

The Education Sub-Committee (ESC) of the Arthritis Research Campaign (arc) recognized this contribution and set up a working party in 1997 to establish a foundation for a career structure for AHPs working in extended roles in rheuma-tology. The term AHP would apply to nurses, occupational therapists, physiothera-pists and podiatrists.

A survey of consultant rheumatologists and AHPs was conducted to identify current AHP roles (Carr, 2001). The survey revealed a wide variation in the roles performed by AHPs. Workshops for nurses, physiotherapists, occupational thera-pists and consultant rheumatologists helped to define core clinical competencies and training requirements for extended clinical practice, from entry level to advanced practice. The workshops highlighted some of the barriers encountered by AHPs in accessing further training in rheumatology, including access to funding, negotiating with employers for study time and the fact that suitable courses were often too far away to attend (Carr, 2001).

The education project

With the evident need for a standardized training for AHPs in rheumatology, the arc Education Sub-Committee approved a further three year project grant for the development of an entry level education course for AHPs. A project co-ordinator was appointed who would work with the AHP working party members to write the course material under the supervision of an experienced educationist. The course material is based on the core clinical competencies identified in the initial research (Carr, 2001). A Masters programme for advanced practitioners will be developed at a later date.

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Selection of a collaborative partner

In 2003 universities in the UK were invited to tender applications to partner arc in accrediting and delivering the course. A series of panels and visits resulted in the University of Brighton being selected as the accrediting partner.

Recruitment of rheumatology teaching centres

In addition to an accrediting partner, the AHP working party proposed to deliver the face-to-face teaching via approved rheumatology teaching centres throughout the UK. These approved centres would provide students with role models and dis-seminate teaching expertise at accessible geographical locations.

A survey of rheumatology departments in the UK was carried out in July 2003 to determine the level of interest in delivering the taught component of the entry level course.

A total of 489 departments were contacted by post; interested departments were asked to supply: a contact name and address, details of any departmental interest in participating in teaching the entry level modules, and numbers of AHPs interested in enrolling in the entry level and MSc courses.

Response

A total of 52 departments replied of which 35 expressed an interest in becoming a teaching centre. In all, 164 AHPs requested to enrol in part or all of the entry level course and 48 AHPs in the MSc Course (Figure 1).

Second survey of rheumatology departments

The rheumatology departments who had expressed an interest in teaching were contacted again in June 2004. Each department was asked to complete a question-naire providing details of: (1) their teaching facilities and resources for up to 20 students, (2) teaching experience/qualifications of staff members willing to partici-pate in the teaching, (3) catering and car parking facilities, and (4) local travel links and a list of suitable accommodation for students.

From the 22 departments who replied, the AHP working party selected five northern and five southern centres. The approved departments were able to provide the facilities and teaching expertise to host the teaching and were situated in suit-able geographical locations. The University of Brighton has organized a one day ‘training and learning’ workshop for the rheumatology teaching centres. Each teaching centre will host one or two modules per year.



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Course development

The modular entry level course is flexible, part-time and principally self-directed. To enable students to fit their study around work and family commitments, the course is mainly distance learning with short taught components. The core clinical competencies identified in the arc Conference Proceedings no. 12 (Carr, 2001) inform the module content (Table 1). Students will have between 18 months and 3 years to complete six modules. Each Level 3 module carries 10 credits equivalent to 100 hours learning. On successful completion of the course, students will be awarded a Graduate Certificate in Rheumatology Practice (Figure 2).

AHPs interested in the Education Programme

0

10

20

30

40

50

60

70

80

90

100Part of Entry Level Course

Entire Entry Level Course

MSc Course

FIGURE 1. Survey response from AHPs.

TABLE 1. Course content

Knowledge Skills

Disease pathogenesis IT and study skillsRheumatological conditions Critical appraisalBlood investigations History takingPsychosocial implications of chronic disease Musculoskeletal examinationMultidisciplinary approach to patient care Patient educationDrug Therapy Drug monitoring Communication skills Measuring health status Clinical evaluation

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The AHP working party has defined the course aims based on the knowledge and skills outlined above, the intended learning outcomes of the modules, the teaching and learning methods that would enable students to achieve these out-comes, and the assessment methods used to demonstrate their achievement.

Learning outcomes

The module aims are linked to the intended learning outcomes, teaching and learning strategies and the module assessment. The intended learning outcomes have been written using appropriate Level 3 descriptors. Level 3 or Honours (H)

Core Sk i l l s in Rheumato logy Prac t i ceUni t A-Introductory se l f -d irec ted s tudyUni t B-Face to face taught component Uni t C-Se l fd irec ted s tudy and module

asses sment

Profes s iona lSk i l l s in

Rheumato logyPract i ce

Uni t s 1 , 2 and 3

Needs Analys i sAudit of applicant's current role and responsibilities and personal development plan

Graduate Cer t i f i ca te in Rheumato logy Prac t i ce

Profes s iona l Sk i l l s in Rheumato logy Prac t i ce module may be under taken in tandem wi th the o ther modulesUni t 1 : IT and Study Sk i l l sUni t 2 : Ref l ec t ive Prac t i ce , Profes s iona l and Eth ica l I s sues Uni t 3 : Cr i t i ca l Appra i sa l and Ev idence -Based Prac t i ce

Core Sk i l l s in Rheumato logy Prac t i ce module must becommenced be fore any o f the four spec ia l i s t modulesThe four spec ia l i s t modules are :Cl in ica l Eva luat ion in Rheumato logyDisease Management in Rheumato logy Pat i ent Educat ion in Rheumato logy Psychosoc ia l Aspec t s in Rheumato logyThe four spec ia l i s t modules may a l so be s tud ied as s tand a lone modules and can be taken in any order

Spec ia l i s t moduleUni t s A , B and C




FIGURE 2. Overview of the structure of the graduate certificate in rheumatology practice.



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level is a higher education qualification defined by the Quality Assurance Agency for Higher Education (2005) as: ‘Bachelor’s degrees with Honours, graduate certifi-cates, and graduate diploma Honours degrees’.

Level descriptors are generic statements describing the characteristics and context of one level against which learning outcomes and assessment criteria can be reviewed in order to design modules and assign credit at the appropriate level (Gosling and Moon, 2001). Table 2 highlights the learning outcomes from the Clinical Evaluation in Rheumatology Module. In multidisciplinary or non- traditional education programmes, level descriptors act as indicators of quality standards (Moon, 2002).

Learning and teaching strategies

Students will be mainly self-directed learners and the module ‘Professional Skills in Rheumatology Practice’ is entirely independent study. The remaining five modules have three separate units: Unit A – self-directed preparatory pre- residential study block unit, Unit B – residential 2 or 3 day study block at one of the rheumatology teaching centres, and Unit C – self-directed learning and sum-mative assessment.

Module workbooks

Each module includes comprehensive workbooks to guide the students through the self-directed distance learning and contains both formative and summative assessment tasks. Students will be required to undertake specific tasks prior to attending the study block for the modules. Some of this work may also be used during teaching sessions in the module study blocks, e.g. reflection on case history taking.

TABLE 2. Outcomes from the clinical evaluation in rheumatology module

At the end of the module the rheumatology practitioner will be expected to:

• Take a clinical history• Carry out a joint examination on a patient with inflammatory arthritis• Know how to utilize appropriate assessment tools including questionnaires• Devise a management plan for the patient and justify the rationale for the decisions

reached

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Online support

The University of Brighton will provide support for students’ distance learning with a virtual learning environment (Student Central) and online library facilities. A course-specific site is available on Student Central together with sites for each of the modules. The module workbooks can be accessed online and students will be able to download and print the material to use in paper format.

Personal tutor

Students will be allocated a personal tutor, which, in the first instance, will be the course leader. The role of the personal tutor encompasses the provision of support for study skills and pastoral care.

Course leader

The course leader is funded by arc and appointed by the university. The course leader will organize the delivery of the course, provide academic support for the students and oversee the assessment process.

Workplace mentors

Students will have selected a mentor as part of the application process for the course. Since much of the student’s learning will take place in the workplace, the mentor will be able to provide ongoing professional and academic support for the student.

Rheumatology teaching centres

Attendance at the teaching centres enables students to access rheumatology doctors and AHPs who are experts in their field. The work that students undertake in Unit A is essential groundwork for the module study blocks. The rheumatology tutors will be able to facilitate the students’ practical and theoretical learning.

Students may be required to discuss their Unit A work as part of a seminar or workshop. Tutors will provide guidance for further independent learning in Unit C and help students prepare for work on the module assessment. During the study blocks, keynote presentations will provide the basis for workshops and seminar presentations. Clinical sessions will be included in the modules as appropriate, where students are expected to acquire a practical skill, e.g. joint examination.



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Module assessment

Formative assessment

Formative assessment tasks, including self and peer assessments have been incor-porated into each of the module workbooks (see Table 3).

Self and peer assessment can be a learning experience for students, often changing their role from passive to active and providing them with valuable feed-back (Moon, 2002). Many of the formative tasks will be carried out in the students’ clinical workplace and the students’ learning will be consolidated through guided reflections on their experiences (Beaty, 2001).

Summative assessments

The range of summative assessments used across the course is designed to reflect the professional activities and skills of the students (see Table 4).

The course leader has overall responsibility for the first marking of assessments with a representative sample of work second marked by a member of the University

TABLE 3. Example of a formative assessment from the disease management in rheumatology module

Observe three different people (if possible from different professional groups) performing joint or soft tissue injections.

Make short notes on your reflection on the professional issues involved in terms of:

• Procedure• Consent• Indications• Patient information• Accountability• Risks and ethical issues (particularly in relation to a non-doctor performing the

injection)

TABLE 4. Examples of summative assessments used in the modules

1. Critically appraise, review and discuss a research article relevant to an aspect of your practice

2. Observed Structured Clinical Examination (OSCE)3. Write a magazine article on rheumatoid arthritis from a patient’s perspective

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of Brighton course team. Two external examiners will view a sample of assessed work and ensure the assessment process is sound and fairly conducted. Written feedback to students will be in the form of detailed qualitative comments against predetermined assessment criteria and this will allow students to reflect on their learning experience for each module.

Needs analysis

Due to the multiprofessional nature of the students’ backgrounds and experience, the needs analysis has been developed as part of the application process for the course. The needs analysis will enable the prospective student and the course leader to assess training requirements and suitability for the course. Each applicant will complete an audit and assessment of their current roles, training, experience and confidence. The needs analysis also requires the applicant to complete a learning styles questionnaire, a personal development plan and a short written statement justifying the potential benefit of the course to their personal and professional development. It will also be part of the process for accrediting learning that has resulted from prior experience. Applicants will also have identified an appropriate mentor for the course.

Professional skills in rheumatology practice module

This module introduces the student to essential skills in self-directed study, reflec-tive practice, critical appraisal, information technology and communication. It also explores the legal, professional and ethical frameworks which underpin autono-mous practice. It can be studied in tandem with the other modules and the assess-ment will be a professional portfolio. Students will select relevant pieces of work from all six modules and submit the portfolio as the final assessment at the end of the course.

Core skills in rheumatology practice module

This module introduces basic knowledge and skills to students new to rheumatology practice regardless of their professional background. It will provide students with an opportunity to review, upgrade and consolidate their knowledge base. The sub-sequent four specialist modules are build on the content of the core skills module so that students will have the opportunity to develop further their understanding of key concepts at a deeper level and in a broader context.



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Specialist modules

Psychosocial aspects in rheumatologyThis module examines the principles of the psychosocial effects of rheumatoid arthritis. It aims to enable the student to develop skills in history taking and assess-ment of the psychosocial effects of the disease. Coping strategies will be studied and students will enhance their communication and counselling skills in order to help patients with coping and compliance difficulties. The extent of social support and social provision for patients with chronic disease will be explored.

Clinical evaluation in rheumatology practiceThis module is designed to advance the students’ clinical assessment and evaluation skills through guided study, lectures, practical workshops, reflection on practice and clinical supervision. This module consolidates the history taking and examination skills and knowledge of the clinical signs of rheumatoid arthritis introduced in the core skills in rheumatology practice module. Clinical measure-ment tools are explored and students will explore and advance their decision making skills.

Disease management in rheumatologyThis module develops knowledge and skills in relation to the principles of the management of inflammatory arthritis, the role of the multidisciplinary team and the principles of drug therapy and safety issues.

Patient education in rheumatologyThis module has been designed to explore the many facets of patient education through the student’s own reading, observation of and reflection on current edu-cational provision. Discussion with patients and colleagues will further inform the taught elements of the module.

Course evaluation

Detailed student feedback will be important in the evaluation of the course and will be used to inform course reviews and future course developments. Verbal feedback from students will be obtained when the course leader meets students at the different rheumatology centres. Formal written evaluation of each of the modules will be requested from students at the time of submitting the module assessment. A student representative will be elected for each cohort and invited to

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attend the course board, where they will have the opportunity to present general student feedback.

This unique multiprofessional course has the potential to become the standard for clinical governance and career development for AHPs in rheumatology. Further research is planned on the impact of the course on students and the effectiveness of multiprofessional education.

References

Beaty L (2001). Supporting learning from experience. In H Fry, S Ketteridge, S Marshall (Eds). A Handbook for Teaching and Learning in Higher Education (pp. 134–46). London: Kogan Page.

Carr A (2001). Defining the extended clinical role for allied health professionals in rheumatology. ARC Conference Proceedings No. 12.

Department of Health (2000a). Meeting the Challenge: A Strategy for Allied Health Professionals. London: Department of Health.

Department of Health (2000b). A Health Service for All Talents: Developing the NHS Workforce. London: Department of Health.

Department of Health (2000c). The NHS Plan: A Plan for Investment, a Plan for Reform. London: Department of Health.

Gosling D, Moon J (2001). How to Use Learning Outcomes and Assessment Criteria. London: SEEC (Southern England Consortium for Credit Accumulation and Transfer, University of East London).

Hill J (1992). A nurse practitioner rheumatology clinic. Nursing Standard 9: 25–8.Humphries D, Masterson A (1998). Practising at a higher level. Professional Nurse. 14(1): 10–13.Moon J (2002). The Module and Programme Development Handbook. London: Kogan Page.Nursing and Midwifery Council (2004). The NMC Code of Professional Conduct: Standards for

Conduct Performance and Ethics. London: Nursing and Midwifery Council.Quality Assurance Agency (2005). Understanding qualifications: The frameworks for higher

education qualifications. From: http://qaa.ac.uk/students/guidesRead S (1998). Exploring new roles for nurses in the acute sector. Professional Nurse 14(2): 90–4.Ryan S (1997). Rheumatology: Professional issues. Nursing Times 93(16): 55–8.Thompson P, Moran C, Aubrey-Fletcher S (1992). Rheumatology Monitoring Clinics. Bailliere’s

Clinical Rheumatology, Vol. 6 (No. 1). London: Bailliere Tindall.

Correspondence should be sent to Elaine Dawson, Nurse Practitioner, Rheumatology Department, Christchurch Hospital, Fairmile Road, Christchurch, Dorset BH23 2JX. E-mail: [email protected]

Received September 2005Accepted October 2005

http://qaa.ac.uk/students/guides

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Multiprofessional education for allied health professionals in rheumatology: Breaking down traditional barriers