Geriatric interprofessional education for enhancing students’ interest in treating older people

Interprofessional education is one of the interventions used to increase health care students’ motivation for working with older patients. Previous research about such interventions has been conducted without the use of control groups and has given inconclusive results. The objective of the present curricular resource was: Does geriatric paper-based interprofessional education influence students’ interest in treating older people? During a one-year period, undergraduate fourth-year medical and third-year nursing students wrote four health care plans for four different paper-based older patient cases. In the intervention group students were paired up in interprofessional couples. In the control group students made the assignment alone. Interest for working with older patients was measured on a 5-point Likert scale before and one year after the intervention. In both groups, no significant change was found. Before-interest score of the interprofessional group was relatively high (3.8) so the non-significant results may be due to a ceiling effect. Nursing students’ interest in treating older people at the start of the research was higher than medical students’ interest.


Introduction
Healthcare workers specialized in treating older patients are urgently needed, but there is a lack of interest among students for doing this 1,2 .WHO suggests interprofessional education (IPE) and collaborative practice as the most promising solutions to overcome this shortage 3 .Since a variety of disciplines are involved in geriatric care, IPE is well-matched with geriatric care education.The combination of IPE and geriatric care education has been studied together in different settings, with different aims [4][5][6][7][8] .Only a few studies have investigated if IPE in geriatric care improves students' motivation for working with older patients.These studies have been conducted without a control group and have given inconclusive results [9][10][11][12][13] .Whether IPE improves students' motivation to work with older patients remains unanswered.Therefore, the research question for this study was: Does geriatric problem-based interprofessional education influence medical and nursing students' interest in treating older patients?

Participants
Two groups of students were included in this study: (1) Undergraduate third-year nursing students, in a four-year educational program (classroom education alternates with clinical practice).They had finished a theoretical geriatrics course.All groups in that stage of their education program at our facility between March 2018 and March 2019 were included in the study, which meant three groups of nursing students (maximum 24 students per group).Assignment to the IPE-or UPE-group took place at the first session.The nursing students were individually randomly (alphabetically) assigned to the intervention or control group; (2) Undergraduate fourth-year medical students who were starting their master's program, consisting of different clerkships alternated with a few weeks of classroom based teaching, including a clerkship care for older people in a nursing home.Every six weeks a group of maximum nine students started their clerkships at our educational facility.All groups that started between March 2018 and March 2019 were asked to participate in the study.Assignment to the intervention or control group took place at the first session.Before assigning them to one of the two groups, their schedule was evaluated for a match with the nursing students' program at all sessions.If there were sessions, for example during holiday breaks of the nursing education program during which the medical students could not collaborate with nursing students, the whole group of medical students was assigned to the control group.
Students had no prior interprofessional education experience.

Setting and assignment
At the Northwest Clinics in Alkmaar, the Netherlands, the students were asked to draw up health care plans for four paper-based geriatric patient cases, over a one-year period.The four cases, with an increasing level of difficulty and typical geriatric care problems, were constructed in collaboration with several geriatric experts 14 .A patient case included information about the patient's background, medication, description of the current health problem, social and functional status and some results from a physical examination.The first patient case is visible in the supplementary files, as an example (Supplementary file 1 -Case one).
Students were asked to draw up a health care plan 'like they would in clinical practice'.They were allowed the use of books or guidelines, but were not allowed to discuss with others (except their assigned partner if they were in the intervention group).In the instructions the students were suggested to think of diagnostics, medication, consultation of different specialists, nursing interventions and 'to-do' tasks before discharge.
In the control group, students wrote the health care plans on their own (uniprofessional education group, i.e., UPE-group).In the intervention group, the health care plans were written by randomly paired medical and nursing students (interprofessional education group, i.e., IPE-group) (Figure 1).In each session different pairs were assembled to create diversity among the collaboration partners.The intervention group was placed in a different (class)room, separate from the control group.The scheduled time for the assignment was 45 minutes.A researcher or research assistant supervised the students for identifying (non-)collaboration and was available to answer procedural questions.Before (T1) and one year after the intervention (T2) all students reported their interest in working with children, adults and older patients on a 5-point Likert scale (Figure 2).At T1 the questionnaire was handed out in person.At T2 the students received the questionnaire by email.
The questionnaire consisted of one question, that needed to be answered by the students for 3 patient groups: 'elderly', 'adults' and 'children'.This question was: 'How interesting do you find these patient groups?Mark the option that best describes you at this time for each patient group".Below the question there was a table in which the students could tick boxes for the 3 patient groups, there were five possibilities,

Amendments from Version 1
We are grateful for the opportunity to revise and improve our manuscript and we would like to thank the reviewers for their constructive comments.We have revised the manuscript to improve the issues that needed to be clarified.We added more information in the Method section and added 2 supplementary files to improve the reproducibility.We addressed all issues of the reviewers, and our response is visible in the 'Response to the reviewers'-form.
Any further responses from the reviewers can be found at the end of the article  from "Not interesting at all (1)" to "Very interesting ( 5)".This short questionnaire was self-developed.
Data analysis SPSS version 28.0.0.0 was used for analysis.If the assumptions for parametric testing were met, before and after interest scores were compared using Paired t-tests.

Ethical approval
The study was submitted to the local scientific board of Northwest Clinics, the Netherlands, which considers all study proposals within the institution.Since the study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (section 1.b WMO, 26th February 1998), the local scientific board of Northwest Clinics approved the study and waived the need for approval by an Ethics Committee/Institutional Review Board.All participants received a research information letter and signed an informed consent form.Participation was voluntary.Written informed consent was obtained from all participants for using their anonymous data in our study.All methods were performed according to the relevant guidelines and regulations.

Results
One hundred and twenty-nine students filled out the T1 questionnaire, and sixty-two (48%) filled out the T2 questionnaire.Two completed questionnaires lacked a research identification number, so sixty students were included in the final analysis.
In the total group (n=129) there were no differences between the UPE-and IPE-groups.Within the group included in the analysis (n=60), we found differences between the UPE-and IPE-groups (Table 1).
The assumptions for parametric testing were met.In both groups the interest in treating older patients did not change significantly after the intervention.The only significant result was a decrease in interest in treating children in the UPE-group (Table 2).

Discussion
In this study we found no significant change in interest in treating older patients before and after the intervention, in both the UPE-and IPE-groups.There are a few possible reasons for this lack of change.
First, at T2 the proportion of nursing students differed between the UPE-and IPE-group (39% in the UPE-group versus 66% in the IPE-group, p=0.044).We conducted further analyses to investigate the group characteristics.The nursing students were significantly younger than the medical students (19.4 versus 23.1 years, p<0.001), which caused the significant age difference between the groups.Also, the interest score at T1 differed between the nursing and medical students (3.8 versus 3.0, p=0.012).Consequently, the bigger proportion of nursing students was probably the reason of the higher interest score at T1 in the IPE-group.The differences between nursing and medical students must be taken into account in future research about interest in geriatrics.
Second, the lack of change in interest in especially the IPE-group could have been caused by a ceiling effect.Hughes et al. 15 also scored fourth year students' attitudes towards older patients after a geriatric educational intervention and found similar scores (3.86).Perhaps even with the most successful interventions, higher mean interest scores are unachievable.
Third, it is possible that the lack of significant change is caused by the nature or the intervention.It was in a classroom setting with paper-based cases.Perhaps, working with standardized or real patients, would have led to different results.
In our study, the only significant result was the decline in interest in treating children in the uniprofessional group.Earlier research has also found such trends in interest: downwards for children, upwards for older people, among both medical and nursing students [16][17][18][19] .These trends are without interventions and happen just as a result of progression in students' education.This emphasizes the importance of the usage of a control group, because students' interests and preferences change over time.
Besides interprofessional education, several other types of interventions have been studied aiming to increase students' interest in older patients, such as 'older adult mentor programs', geriatric courses and home visits [20][21][22] .Tullo et al. 21 This study is subject to some limitations.First, due to a low response rate at T2, the study has a small sample size.Second, although the intervention was spread out over a longer period, it was relatively small (4 sessions).Third, we measured interest after one year, so it is possible that the intervention did influence students' interest directly after, but this effect was not sustained.Maybe an intervention with more or longer sessions is necessary to make a change sustainable.

Ethics and consent
The study was submitted to the local scientific board of Northwest Clinics, the Netherlands, which considers all study proposals within the institution.Since the study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (section 1.b WMO, 26th February 1998), the local scientific board of Northwest Clinics approved the study and waived the need for approval by an Ethics Committee/Institutional Review Board.All participants received a research information letter and signed an informed consent form.Participation was voluntary.Written informed consent was obtained from all participants for using their anonymous data in our study.All methods were performed according to the relevant guidelines and regulations.

Data availability
The privacy officers of Amsterdam UMC advised not to share the student data due to ethical considerations: we didn't asked students their permission at the start of the study, and we are not able to do it retroactively.
At the start of our study, all students signed an informed consent form, but we didn't ask the students their permission to share the data with others.At that time open data sharing wasn't common.All students are now out of reach, so asking their permission afterwards is not an option.We anonymized the file, but because it is a small sample size, and we included two different groups of students (medical and nursing), students (or others) might be able to identify themselves.No intermediary data can be de-identified without compromising anonymity.Thus, there are no conditions under which access will be granted.First, I would like to complement the authors with this work which is highly relevant.It is well written and interesting.The figures are very beautiful and clear.However, this was the first time that I read the paper, and some point could be clarified.Some abbreviations are introduced without spelling them out first (UPE).Probably, this is the result of previous revisions.Please check the full paper "like you've never read it before" on readability. 1.
The result section could be improved.I do think the results are accurate, but the readability could be improved.The tables aren't clear enough without further explanation in text while it should be clear on its own.
To specify: a) why are so many characteristics given of those not included in the analyses.Isn't that confusing?b) please specify that one is the before and the other is the after measure.c) Please verify what is compared to what.Additional question: was a repeated measure ANOVA considered since you have two groups before and two groups after.

2.
The discussion section is good, no additional advises.
To take above together, it is a good paper, but the readability needs small point of improvement.
Perhaps one additional citation could be used.

Is the study design appropriate and does the work have academic merit? Yes
Are sufficient details of methods and analysis provided to allow replication by others?Yes If applicable, is the statistical analysis and its interpretation appropriate?Partly

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Geriatric medicine I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
patient, older people -need to be consistent and I would suggest they are people not patients.
There needs to be a definition of IPE and the acronym IPE is not consistently used throughout.

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For an international audience you need to explain terms such as clerkship.That is not a term that I am familiar with.

Conclusion:
The discussion brings up new information which should not occur in a discussion i.e. bigger proportion of nursing students -where is this mentioned in results?Why would this be a reason for higher interest scores?

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You mention a score of 3.86 in another study but no indication of whether you are comparing the same scale.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and does the work have academic merit?Partly

Are sufficient details of methods and analysis provided to allow replication by others? Partly
If applicable, is the statistical analysis and its interpretation appropriate?Yes

Have any limitations of the research been acknowledged? Partly
Are all the source data underlying the results available to ensure full reproducibility?
variables being examined for their correlations?What testing was used?Need to report in the data analysis section.The sentence was then followed by a report on the age comparison between nursing and medical students, but the report was on the p-value instead of the r-statistic (correlation).To investigate correlation, the authors need to have at least two different variables being examined.Testing the age variable (only one variable) and comparing the difference between two groups of participants is not a correlation.Reviewer Expertise: interprofessional education I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Is
The abstract gives a clear summary of the article.Over one year, fourth-year medical and thirdyear nursing students were compared in intervention (MD plus RN) and control (solo) groups to write four health care plans for four different geriatric paper cases.Interest for working with older patients was measured by self-report and no significant change was found between groups.Authors theorize that this may be due to a ceiling effect, particularly with RN students whose baseline interest in geriatrics was higher than medical student interest.Current, known research was cited and appropriately applied to the research question: "Does geriatric problem-based interprofessional education influence medical and nursing students' interest in treating older patients?"The design was a controlled experimental study, which was appropriate to the question.Methods are easily reproducible, and statistical analysis and interpretation was appropriate and correct.Limitations were identified and conclusions were valid.
The writing was appropriate except for minor issues with casual language use in the Discussion section, e.g."a couple of factors" and "Maybe higher means scores are harder to find."It is interesting that the only significant finding was a decline in interest for treating pediatric patients.Is this proportional to any increase, even if statistically insignificant, in treating geriatric patients (in other words, not a true decrease, simply a proportional issue?).Worth commenting on in the discussion section.Lastly, I recommend clarity regarding whether IPE itself makes no statistically significant difference, vs. IPE with paper cases instead of real patients makes no statistically significant difference.In other words, is it the IPE or the paper?My hypothesis is that if students were working with 4 standardized or real patients over the same time period with the same exercise, there may be more of a difference.This could be mentioned as an opportunity for further research if there are no current studies of this nature.
As an IPE/patient outcomes researcher, I thank you for the opportunity to review this submission.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and does the work have academic merit?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes

Have any limitations of the research been acknowledged? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.

Figure 1 .
Figure 1.Visualisation of the intervention and control group.
the work clearly and accurately presented and does it cite the current literature?YesIs the study design appropriate and does the work have academic merit?PartlyAre sufficient details of methods and analysis provided to allow replication by others?NoIf applicable, is the statistical analysis and its interpretation appropriate?PartlyHave any limitations of the research been acknowledged?PartlyAre all the source data underlying the results available to ensure full reproducibility?PartlyAre the conclusions drawn adequately supported by the results?PartlyCompeting Interests: No competing interests were disclosed.

Table 1 . Total group characteristics and characteristics of the group included in the analysis.
23scribe that longer rather than shorter interventions, and interventions that involve healthy older adults instead of older patients in a clinical environment, are more likely to improve students' attitudes towards older adults.Meiboom et al.23emphasize a more rigorous and bigger curricular change instead of low impact discrete interventions to motivate students for the medical care for older patients.

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I note the title has been changed but paper based is still intermittently used throughout the paper.I'd suggest this is a method and should be explained there and is not needed elsewhere.Overview of student numbers is still unclear; table needs to be explained.I'm still not clear on how many students were invited to participate.Why only one question -wouldn't asking other questions potentially about participant characteristics have added to the analysis?
○ Study Design: ○ Were they still students at that point?○If not, what impact could this have had?○