Immersing undergraduates into an interprofessional longitudinal rural placement

Introduction: An Integrated Multidisciplinary Model of Education in Rural Settings (IMMERSe) program was piloted in 2010 in a rural region of South Australia. The aim of the program was to place students from different health programs together, in a rural environment, for one or two semesters of the academic year to promote interprofessional learning. Students were given the opportunity to participate in joint fortnightly education sessions with an emphasis on interprofessional relations and teamwork, undertaking activities such as case studies, role plays, journal club, work shadowing and invited speakers. Methods: A qualitative approach was used to explore student perspectives of a rural interprofessional clinical placement. Students were invited to participate in focus groups and reflective writing exercises. This data was analysed in relation to the students’ thoughts and reflections around professionalism, teamwork and collegial relationships. Results: The analysis resulted in three major themes: (1) interprofessional interactions with other students; (2) interprofessional interactions with other health professionals; and (3) interprofessional interactions with the community. Students in our study demonstrated a new level of respect for health professionals outside of their discipline, and gained a sense of how their own independent roles can blend or partner with others’ roles, to draw on each other’s expertise. Conclusions: Student learning experiences can be enhanced through engagement and integration in a rural community context. Interprofessional learning in a rural community placement can increase students’ understanding of professionalism, teamwork and


Introduction
Flinders University and Country Health South Australia (CHSA) recently developed a program in Mt Gambier, South Australia, named IMMERSe (Integrated Multidisciplinary Model of Education in Rural Settings).The IMMERSe program is based on the premise that interprofessional learning (IPL) while embedded in rural practice will increase a student's understanding of professionalism, teamwork and collegiality, as well as the health system and regulatory frameworks which support their own practice 1 .Interprofessional learning is the acquisition of interprofessional knowledge, skills and attitudes which students would not usually acquire effectively through other processes 2 .A study took place during the pilot phase of the program to determine how a rural interprofessional clinical placement impacted on student perspectives about interprofessional collaboration (IPC), an important concept for rural practice.

Background
Significant national reform is currently underway in Australia to improve health workforce capacity and skills.Health Workforce Australia (HWA) has determined the need to improve service delivery models such as team-based and collaborative models of care 3 .National recognition includes the 'need to move towards interprofessional training and work practices, where two or more professionals learn with, from and about one another to improve collaboration and quality of care' (p18) 3 .Interprofessional education (IPE) is regarded as a key strategy to improve the delivery and outcomes of increasingly complex health care by promoting IPC 4,5 .Interprofessional collaboration has resulted in better health services by optimising the skills of healthcare teams and shared case management 6 .
Interprofessional education is one way to prepare our future graduates as effective and functioning team members.The need to increase IPE and interprofessional practice has become a topic of international debate.Historically, there has been some doubt as to the effect of IPE programs, mainly due to the difficulty in reliably measuring their effectiveness 7,8 .One recent study reported the complexity of IPL facilitation, citing that all parties found the change-making process both 'arduous and time-consuming'(p.29) 9 .The complexities of delivering IPE 10 may be the reason that there is minimal IPE in the core curriculum of Australian universities.Interprofessional education requires systemic changes, for example, in the UK IPE has driven healthcare-related policy goals, and in Canada and the USA, IPE has been embraced by government, with funding provided to develop competencies for collaborative practice 11 .The argument for undergraduate IPE is that ideally many graduates should enter the workforce with awareness of the roles and responsibilities of other health disciplines.A silo approach can cause difficulties in healthcare delivery and may lead to workplace conflict, inefficient use of resources and ineffective patient care 12 .A collaborative approach is, therefore, critical to transforming a cultural shift to provide better patient safety 13 .Rural communities provide an ideal context for student exposure to interprofessional clinical practice and an experience of its importance [14][15][16] .The advantages of educating health professionals in a rural environment include widening the scope of their knowledge and skills as well as providing the experience of working and living in a rural environment 17 .Nationally, there have been a relatively small number of pilot IPE initiatives.Such pilot projects have involved only small numbers of students on isolated, ruralbased short-term placements with limited scope and inability to produce sustainable change 18,19 .Debate continues regarding the best way to achieve and sustain IPL.

Integrated Multidisciplinary Model of Education in Rural Settings (IMMERSe) Program
In the IMMERSe program, students from different health professional courses at Flinders University are placed together for one or two semesters, not only to meet their own course curriculum requirements, but to also gain knowledge and skills in and the values of IPC.One program semester is equal to 12 teaching weeks plus 2 exam weeks (14 weeks) and this is the same for each of the courses.The two points of difference in this program are the longitudinal and IPL components.The longitudinal focus of the program sought to replicate outcomes following the success of the Flinders University full-year, community-based medical student program known as the Parallel Rural Community Curriculum (PRCC).The PRCC program has demonstrated that longitudinal placements increase the recruitment of graduates to rural medical practice, and are more sustainable and rewarding for clinical supervisors working in areas of workforce shortage 20,21 .Setting up a program like IMMERSe has meant overcoming the challenges of successfully networking across a wide range of stakeholder groups by continuing to build meaningful partnerships, and monitoring that all roles and visions are clear and understood.The IMMERSe program is primarily a learning experience which meets the relevant course objectives with an additional IPE component.The students also have exposure to rural practice and life in a rural community.
A key component of the program is participation in a joint fortnightly practicum, with an emphasis on interprofessional relations and teamwork, and application of IPL outcomes to IPC in the clinical setting.Types of activities in the IPL program included case studies, role plays, journal club, work shadowing and invited speakers.The complexities of planning and implementing a program like IMMERSe are the impacts upon course curriculum requirements, registration and accreditation requirements, staffing and relocation of students.The IMMERSe program operates from the Flinders University Rural Clinical School in Mount Gambier, which is the largest regional city in South Australia with a population of approximately 25 000 people, based 450 km from the nearest city.The Rural Remote and Metropolitan Areas (RRMA) classification assigns Mt Gambier as Rural Zone 1 22 .The students also had clinical experience in other parts of the south-east region which included the smaller rural and remote towns of Millicent, Penola and Naracoorte.The Mt Gambier region is well served by established health services but, like many rural and regional areas, there is a fluctuating and short supply of health professionals.
In 2010, two final-year students from Nutrition and Dietetics (N&D), one final year student from Speech Pathology (SP) and two students from the Paramedic Program (PP) (1 st year level) took part in the pilot of IMMERSe program.In partnership with CHSA and the South Australian Ambulance Service, Flinders University students were placed in Mt Gambier's regional services under clinical supervision.The time spent on placement varied, with N&D and SP students commencing in April and finishing in November 2010, and PP students commencing in July and finishing in June 2011.The university provided a dedicated interprofessional clinical educator [CN] to mentor the student cohort.Through structured IPL activities and rural exposure, students were encouraged to learn about both the rural context as well as IPC in rural settings.This article explores the experiences of health professional students involved in an IPL program during a longitudinal rural placement.

Methods
This qualitative study was undertaken using complexity theory as a conceptual framework 23 : Complexity theory acknowledges the inability to totally understand the whole through an understanding of the parts but rather aims to understand the whole by understanding the interaction of its parts (p3).
In the social sciences, complex adaptive systems are defined as systems of interconnected elements which have the capacity to self organise and adapt to in response to each other 24 .Complexity views student thinking and learning as an emergent process and therefore becomes a tool with which to view how the students adapt to their environment 23 .This study aimed to explore the role of the IMMERSe student, and how each of their paths and interactions with other health professionals and patients assisted their learning journey.
All five 2010 IMMERSe students were invited to participate in three different research activites during their placement.First, they were invited to a focus group at mid-placement (August 2010) and again near the end of the academic year (November 2010).Second, students were encouraged to fill in clinical logs each week.The clinical logs were a course assessment requirement for the N&D students, so the logs were adapted to include all of the IMMERSe students.A reflective exercise was added to the logs whereby students could comment on what they had learnt.Reflective journaling is a way of mapping the learning journey and helps to 'sort out what's gone on, and confirm the important things before they get lost' (p337) 25 .To assist in their reflections students were asked to describe how a specific experience affected their thinking and their current practice, and to provide insights on interprofessional practice and team interaction.The clinical logs also assisted the topic coordinators from each course to understand the types of rural cases the students were exposed to (not reported).Finally, students also completed a short reflective writing exercise where they were asked to consider how they were progressing towards meeting the graduate qualities defined by the Faculty, and their impressions of the fortnightly interprofessional teaching sessions.
All five students consented to participate in the focus groups and to their de-identified reflective writing exercises and clinical logs being used as data for the project.A four stage process was used to analyse the data sets including the transcriptions and students' reflective journals.Open coding and axial coding were performed by two members of the research team [LG and JR] using NVivo v9 (www.qsrinternational.com).Open coding was reviewed by all members of the research team.Following this, two members of the research team [CN and ML] returned to the data to independently review axial coding.Selective coding was then performed through an iterative process involving the whole research team to develop a conceptual model of the study findings.Despite the small sample size, the amount of data collected from three different sources was rich in description and therefore theoretical saturation was achieved.

Ethics approval
Ethics approval was granted from Flinders University Social and Behavioural Ethics Committee (No 4855), and the Department of Health Human Research Ethics Committee (368/05/2013).

Results
The analysis resulted in three major themes: (i) interprofessional interactions with other students; (ii) interprofessional interactions with other health professionals; and (iii) interprofessional interactions with the community.The key element of IPE is that students from different disciplines must be given the opportunity to interact with those who they are learning with, from and about, so this analogy is used to present our themes.From each major theme, sub-themes were developed to explain each premise.Direct quotes are presented under each sub-theme to demonstrate the findings.Student disciplines have not been included to protect the anonymity of each student.

Theme 1 Interprofessional Interactions with other students
This theme describes the benefits associated with the students' interactions with each other.Some students shared accommodation and all students interacted in the clinical field and attended fortnightly sessions together as part of the IPL curriculum.There were two main elements found in the data, Interprofessional knowledge (IPK) and the Transformed relationships.
Interprofessional knowledge: Students referred to gaining new knowledge, and how this related to IPK, and resulted from being given the opportunity to interact with others.Interprofessional knowledge can be explained as a new body of professional knowledge which underpins interprofessional practice 26 .Interprofessional knowledge is not meant to take the value away from each discipline's own separate body of knowledge.The philosophy behind IPK is that IPE can result in the development of a wider knowledge base which is associated with an area of professional competence 26 .The knowledge acquired as a result of IPL is what is required for collaborative practice, such as what other professionals contribute and how to communicate and work with all professions and/or healthcare team members 27 .As with any competency, it is the level of mastery obtained which may differ among students, depending on the depth of IPC experiences.The impact of IPL meant that students were able to ask questions of each other to increase their IPK.One example of their understanding of patient referral is given in the following quote:

Students in the
Talking to the med students has been really good… just catching up with the med students and talking to them about things and they say, 'Oh can we refer for that?' 'Yes, you can definitely refer to us for that'.Otherwise you can't get to do that unless by chance you know some medical students.(Focus group 1, 2010) The student implies that this knowledge would not normally be gained in his/her own curriculum.Interprofessional knowledge was therefore gained through positive dialogue with students from other professions.
Transforming relationships: The interactions with other students began to transform relationships with each other and towards health professionals.Students began to view themselves as being on an equal level with others.Students often spoke or wrote about their relationships with other health professionals.
This student explains her thoughts about being on the same level with other student disciplines: In terms of my university study, I would never have the opportunity to sit down with these people on an equal level and discuss the types of things we are discussing.(Student 3, Clinical Log, September 2010) The students in their first focus group discussed the personal implications of equality in professional relationships: It makes working on the wards much nicer when we feel like we are on the same level.It's horrible going there feeling like, 'Oh I need to know something but I can't ask the nurses or can't ask the doctors or feel like I am being annoying?' (Focus group 1, 2010) In the above quotes, the student participants relate to the nature of collaborative relationships, where it is important to feel that everyone is equal in that relationship.

Students also built on personal development skills through their relationships with other students:
Working closely with someone in a closer relationship with me is really good for me I think.I have been quite a stressed person in group situations in the past, but our living situation means I need to practice more understanding, care, trust and compassion, which has proven to be very beneficial to me so far.I feel calmer.(Student 3, Clinical Log, July 2010) This student refers to the fact that accommodation was shared with the other students in the program, and alludes to how this opportunity expands her own life perspectives.

Theme 2: Interprofessional Interactions with health professionals
This theme describes the learning which occurred through varied student experiences with health professionals during the IMMERSe program.Students explained how these experiences enhanced their understanding of professional roles and interprofessional practice.These included appreciation and respect for professional roles, evidence of IPL, and being able to observe or experience transdisciplinary and interprofessional practice.
Appreciation and respect for professional roles: Students explained how, through their exposure to various health professionals in different contexts, they came to understand and appreciate many health professional roles.
The following student reflects on the role of the nurse: I could never be a nurse!They have to remember so much, there is so much going on -and it's really important things, like medications, things that have a big impact on a patient's health.They have to deal with family and end-of-life decisions.It is a big load, physically, emotionally and professionally.(Student 3, Clinical Log, August 2010)

Students had the opportunity to be involved in community health training sessions:
Working with the health professionals [sic] was really insightful.Showed how closely [sic] our suggestions for intervention were, and how a multidisciplinary approach can work for various clients of various ages.(Student 1, Clinical Log, June 2010) The presenters were so great, and I gained a new level of respect and appreciation for social workers, particularly in terms of child safety.They are so socially aware and compassionate.(Student 3, Clinical Log, August 2010) One student described a situation where health professionals can react differently to a work 'shadowing' experience (where student/s accompany another health professional or student for a day/shift to observe how the other operates).
It was interesting to see the reactions from all the different clinicians as they realize I am not a medical student, …that's come to have a look and understand what goes on in the surgical ward.It was a mixed bag of reactions actually, where some surgeons were more than happy to explain the processes and others were clearly not at all impressed about having a student who didn't need to be there.And others were just not impressed about having any student in their operating room, medical or otherwise.I think that's quite sad, because they were students once too.(Student 5, Clinical Log no.

2, 2011)
This student demonstrates exposure to both positive and negative reactions from health professionals who were challenged by teaching students from other professions.
Interprofessional learning: Students provided evidence of IPL (with, from and about other professions) which occurred through their interactions with other health professionals outside of their own discipline.One student explains a session where she attended a hospital in-service session, which was mostly aimed at nursing staff, and how this made her think about the role of the nurse: Although I have had a lot of experience with the topic [sic], this session was very valuable … it showed me there is so much more to think about that nurses usually take care of.(Student 2, Clinical Log, August 2010) The following students describe their experience of being able to work-shadow or observe different professions: I learnt the processes of doing a paramedic shift… I enjoyed it so much.They are amazing people and do an amazing job.
They are very calm and controlled, and knowledgeable.I was so impressed by the work they do and their knowledge base.(Student 3, Clinical Log, June 2010) I also had the opportunity that day to be dropped at the hospital to watch the retrieval team retrieve the patient.This proved to be the best learning curve for the day.This is an opportunity I wouldn't have been able to see in Adelaide.I worked with the paramedics, doctors, nurses, retrieval doctors and the RFDS [Royal Flying Doctor Service] nurse.This was a great insight into how things work from the professional side and the procedures.(Student 4, Clinical Log, August 2010) Students were able to learn about IPC through different types of IPL activities such as small group sessions, work shadowing and opportunities to be involved in a range of multidisciplinary events.

Transdisciplinary and interprofessional practice:
Students provided examples and insights from their own experiences, either from working collaboratively with other professionals (interprofessional practice) or discovering where boundaries overlapped (transdisciplinary practice).
The students in a focus group discussed the benefits of being able to interact with other professions: When you only stick to people from your own discipline there's kind of these rules 'Oh we don't do that' or 'This is how it is done' and if you don't talk to people of other disciplines then you just would probably still do that.But talking to other people…, we would never probably learn about that and we wouldn't expect it to be part of our role because I think a lot of [our profession] that work already think 'I don't do that -this isn't our role…' I was quite surprised, saying is that appropriate for me to help a patient with this?And it is.(Focus group 1, 2010) One student attempted to explain how each profession's scope should contribute to team-based care: Certain conditions require a multidisciplinary approach for the best treatment.No one member can treat the client alone.This again highlights the importance of a team approach, with individualized roles that need to work together.This student highlights that when health professionals work collaboratively, they place the patient at the centre of their care.A key concept behind IPE is to include the patient in the healthcare team 11 .

Theme 3: Interactions with the community
Through interactions with community members, students were able to view health care from a community perspective.For the purpose of this research, we have defined community as those who participate in health care either as a patient or service provider.Two subthemes, 'Understanding health care in a community' and 'Increased communication skills' are the elements described in this theme.
Understanding health care in a community: Students revealed an increase in understanding of their position in the healthcare system, and how in their role as future health professional, they contribute to the primary healthcare team approach.
The following student gained a different perspective about how the system works in relation to being able to benefit the patient: It made me think about the way that the public health system works.I really want to gain more understanding of this because sometimes, 60 minutes or 30 minutes just does not work and patients could receive care that is so much more beneficial, in a clinical way but also in a personal way.(Student 3, Clinical Log, September 2010) This student reflected on how IMMERSe improved his/her understanding of the healthcare system: It [being part of IMMERSe] allows me to learn things with relation to the health system I wouldn't otherwise learn nor have the opportunity to learn.I get to see and do things other students won't see or potentially even see during the duration of their career which is beneficial for me and my ability to deliver a better level of health care.(Student 5, Reflective Journal 1, 2010) The following student wrote a meaningful passage about how they now value and respect the patient or client as a result of IMMERSe: I have learnt that we need to be seeing the patient as a person who has his own life, and that his life is of equal value to my own -he needs all the things I need, I just happen to have more of them at this time.He needs understanding and respect, and needs to be valued for his own feelings and opinions.(Student 3, Clinical Log, August 2010) Increased communication skills: Students were able to portray how they developed their communication skills as a result of their interactions with clients and health professionals.The following student described how his/her communication skills have developed through exposure to the community: I feel my communication skills with clients/other health professionals have dramatically improved from constantly having to 'put myself out there' in the community.I am finding it easier to articulate sentences and portray my view and advice more effectively.(Student 2, Reflective Journal 1, 2010) During a focus group one student explained how the program enabled her to gain the confidence to seek the opinion of another professional: Having the opportunity to go to a surgeon and say this is my opinion on this patient -that's really important.There's going to come a time when you have to do that and you won't have a supervisor to support you there, you're just going to be on your own.That's an opportunity I have had here.(Focus group 2, 2010) In the final focus group the students discussed their increased confidence as a result of their interactions with the community: Its aided our confidence as well… Our educators and other people in community health say 'We don't really think of you as a student' -it gives you confidence to then go -OK, then I am ok to make these informed decisions without having to always go back to a supervisor.And obviously you check still but you feel you are making an informed decision there and then.(Focus group 2, 2010) Student understanding of the healthcare system and healthcare teams, in relation to individual roles and expectations, improved through professional and peer interactions.Their understanding was also increased through the students' ability to engage and integrate into a rural community.

Discussion
Looking through the lens of the students in this study, the IPL opportunities challenged students' thinking and understanding of interprofessional collaborative care.While some students were in their final year and others were near the beginning of their course, our findings demonstrate that there was an increase in the appreciation of other rural health professionals.All students also exhibited improved understanding of the wider impact of practising with other professionals.Guitard, Dubouloz and Savard et al assessed IPL on a clinical placement, and found that students attained new knowledge about interprofessional work and roles, but felt they were unable to capture whether students could apply interprofessional knowledge to their practice 28 .The IMMERSe students evidently gained 'new knowledge', and this study captured the thinking behind the students' interactions.It may depend on the types of activities provided, and how they are assessed, as to whether students are able to demonstrate application of IPK in the practice setting.Milburn and Colyer suggested 'that interprofessional practice is a discrete and contextualised entity whose discourse is interprofessional knowledge-in-action' (p322) 26 .The authors agree with this statement and suggest that IPK cannot always be taught, but rather is learnt as a result of student interaction with health professionals in different clinical contexts and community settings.
The IMMERSe program provided IPL episodes, which enhanced students thinking and talking about collaborative practice, in relation to their future as a graduate working in a team-based environment.The students were able to place the patient as central to their care, which indicates the successful development of a collaborative approach when working with other health professionals 29 , and was further enhanced through their multidisciplinary experiences in the rural setting.Authors suggest that there would be less exposure to multidisciplinary teams in the urban setting, where there is more of a speciality focus 30 .The IMMERSe students revealed that providing patient-centred care is an acquired skill that requires understanding and development.Importantly, the students demonstrated that the interactions and dialogue they experienced began to transform their thinking about relationships and collegiality, and raised their awareness about new ways of working, as a result of IPL.
Being involved in IPL allows opportunity for personal and professional growth which contributes to being able to learn and work together 31 .Intra-personal learning is a relatively unexplored component of IPE, where students can discover more about their own independent learning needs and behaviours 29 .Our findings support a relationship between IPL and intra-personal learning.
Students in this study demonstrated a new level of respect for health professionals outside of their discipline.They were able to experience, and therefore understand, where each discipline's scope of practice was a contributor to IPC, and also where their own roles may overlap.This demonstrates the value of students being given the opportunity to work across boundaries.Student experiences in the study reflected a 'degree of integration' among the professions; such as the difference between 'interdisciplinary', where there is shared decision-making in a clinical episode and 'transdisciplinary', where the professional boundaries become blurry 32 .This helped students to gain a sense of how their own independent roles can blend or partner with others' roles and draw on each other's expertise.
Using complexity theory to understand collaborative practice means thinking about how each of its determinants are the interconnected elements.Exposure to all four interactional determinants of collaboration; collaboration, respect, communication, and trust 28 might be expected for a student who is placed in a team-based environment.In this clinical context, health professionals are required to work across 'an intricate web of professional relationships' which potentially impact on the health outcomes and safety of patients(p4) 33 .Experiencing collaborative practice meant that students gained insight to thinking beyond their own profession, and reaching out to the suggestions of patients and health professionals, across other occupational and discipline groups.
Milburn and Colyer stated that for interprofessional collaborative practice to be effective, health professionals need to draw on each other's shared knowledge which is 'common to both and unique to neither' (p321) 26 .To do this, the authors argue that new graduates must have experiences where they can examine the roles of other health professionals in the clinical context.Hollenberg and Bourgeault sum up the urgency of this 32 : The ability to understand and appreciate the 'cognitive maps' of other professions is, therefore, of utmost importance for the entire field of IPE/IPC, as it forms the basis for successful collaboration (p186).
Reflective writing and practice became an important component of being able to evaluate student learning.Just as experiential learning fosters reflection; reflection helps to understand different perspectives and helps students develop professional judgement 34 .The findings in this study suggest self-insight, through reflective journaling, assisted the IMMERSe students to begin to understand the complex nature of IPC, which was assisted by their rural experience.
To help sustain the program, future planning has included increasing student numbers and involving extra course disciplines for the following year.Further to this, Flinders University has engaged with another rural site to expand the program in the future.Student suggestions for the future direction of the IMMERSe program were that their own curricula be aligned better with the IPL experiences.Therefore, the present authors recommend that sustaining a program like this requires IPE to be embedded into each of the course's curricula as opposed to being just an 'opportunity'.

Limitations of the study
Student numbers were limited as there were only five students in the commencing cohort for the pilot program.Therefore, for improved research rigor, the findings should be compared with data from the future groups of IMMERSe students.As there was representation from only three professions, findings may have differed depending on the type of profession represented.The article is also restricted only to the views of the students in the study and not the clinicians and educators.

Conclusion
This study's findings support the theory that IPL in a rural community placement can increase students' understanding of professionalism, teamwork and collegiality.Students, through reflective journaling, demonstrated an increase in interprofessional knowledge and were able to reflect on their own scope of practice in relation to the patient, the team and the healthcare system.Although planning and delivering a program like IMMERSe may not come without its challenges, the benefits for the student and the future of our healthcare system are optimistic.Finally, IPE is a useful tool to prepare our future graduates to work professionally across boundaries, and this can be enhanced in a rural community context.
IMMERSe program felt that their integration with other students helped them to gain new knowledge: I feel like the knowledge I pick up from being with other students from other professions is incredible, I have an understanding of the way each profession works and what kinds of problems and benefits each person has taken from the program.(Student 5, Reflective Journal 1, 2010)

(Student 2 ,
Clinical Log, August-November 2010) Students reflected on the importance of teamwork as a result of experiencing collaborative practice: I think the more patients can see us (health professionals) work as a team together, the more confidence and trust they will have in the health industry as a whole.It is really nice to work with people as part of a team and put all of our energy in to the person sitting in front of us.(Student 3, Clinical Log, August 2010)