Experimental tutoring project: from guidelines to clinical practice

Introduction

Cardiac Rehabilitation (CR) Guidelines aim is to render rehabilitative intervention available to all patients involved in the programs and to efficiently manage cardiac rehabilitation in post-acute and chronic phases (Giannuzzi et al., 2006). After the first publication of the Italian Survey on Cardiac Rehabilitation in 2001, a growing number of enrolled patients (15.8% more) and hospitals and extrahospital structures joined CR programs, because of the cost-effectiveness of rehabilitative intervention in CR. Stabilization of patients is the first step for a Guideline-based CR program starting from patient’s global assessment, risk factor identification and treatment, and clinical assistance in order to better tailor rehabilitation programs on patients’ needs. This simple “CR starter-pack” already guarantees the best assistance to patients, maintaining achieved outcomes, adherence (collaborative participation of the patient) and compliance (adherence to therapy over time) to treatments. However, size of eligible patients for CR program and the lack of mid- and long-term adherence/compliance are some critical issues highlighted by the CR Guidelines. Other issues are:

• Inadequate training of healthcare workers;
• Difficulties in organizing interdisciplinary work teams.

In order to overcome these problems and apply CR Guidelines to clinical practice, we developed an experimental internship tutoring project for trans-skill acquisition (Dovigo, 2015) (Dovigo, Clara, Rocco, & Zappella, 2015): trans-skills identify grey areas in which more than a single professional profile work together (Binetti & Valente, 2003). Indeed, during degree courses, a high-quality standard training cannot be guaranteed only by coordinating didactic activities. Therefore, an effective integration of all teaching activities and regular surveys through quality assessment of the results and students’ evaluations are necessary for trans-skill acquisition. Few studies are present in literature on training experience evaluation at both local and national levels; in these reports, the evaluation was addressed to students, to assess their acquired skills, and to patients, to evaluate level of satisfaction, perceived quality and adherence and compliance indices.

Objectives

Promote interdisciplinary tutoring activities in order to teach students how to work in team developing trans-skill competences. Actively involve patients in the construction and management of the assistential and rehabilitative activities to improve adherence and compliance.

Materials and Methods

At Salerno University an experimental pedagogy project involved third-year students attending the Degree Course in Physiotherapy, Nursing, and the fifth year of Medicine, who performed a professionalized clinical internship at the Complex Operative Unit (UOC) of Cardiac Rehabilitation (CR), University Hospital “San Giovanni di Dio Ruggi d’Aragona” in Salerno. Every patient who undergoes a cardiac surgery operation is operated from the same Cardio Surgery team belonging to UOC of “Cardiochirurgia 1” of the University Hospital. Some of the patients are admitted to the Cardiac Surgery Department, representing the control group, some others are admitted to the Cardiac Rehabilitation Department, representing the experimental group. Professionals involved were physiotherapists, nurses, medical doctors. Both students and tutors were involved. We divided students (60) and patients (100) in two groups, experimental and control groups, each of them composed by 30 students, 50 patients from the Cardiac Surgery Unit (control group) and 50 subjects from the UOC of CR (experimental group). The latter Unit has three beds for patients who underwent heart surgery. The taking charge of the patient was performed by an interdisciplinary team of nurse, physiotherapy and medical students and compared with the one elaborated by their tutors in the same day. Blood samples were collected at each physiotherapy assessment by nurses to evaluate modifications in molecular markers of cardiovascular wellness such as nitric oxide. A 6-minute walking test was performed for exercise tolerance measurement. The interdisciplinary team is guided by a team-leader chosen in rotation between students who has the responsibility to make sure that the patient’s rehabilitation folder is constantly filled in every part and constantly updated. The team-leader has the task of guiding the team ensuring that each member performs his task, that everyone communicates and has all the information concerning the patient as well as the complete and global classification of the patient. He must be constantly updated on the clinical conditions of the patient, including every small variation, and of each procedure and examination. In our experimental study, the team leader also performed functions of case manager, being responsible for communicating to the patient all the team’s decisions and responding to any questions, in order to reduce the plurality of behaviour of the different team members, even if perfectly tuned. An essential function of the team-leader is to set up the team and ensure that the operators communicate with each other. He must create a circular communication between all the operators and between these and the patient in such a way that external communication directed at the patient is the expression of a serene organizational climate and a fluid and effective internal communication. After defining the patient’s need for assistance and rehabilitation, customized medical programs were designed within individual rehabilitation projects. Aims and time of execution and realization were fully explained to patients and shared with them. In order to encourage an active patient participation to the study and to effectively evaluate fatigue scales recorded during treatment, students elaborated, in collaboration with patients, cartoons representing fatigue intensity and/or dyspnea severity. In particular, patients have participated with great enthusiasm to the graphic activity suggesting additional graphical activities or prescriptions, such as sternal wound management, suggested diet, pharmacological therapy scheme (Figure 1). To objectively evaluate goal achievement, we gave a “self-assessment questionnaire” to students for learned skill assessment and we provided a rating scale for adherence and compliance evaluation to patients (Table 1).

Self-assessment questionnaire on the skills acquired during the Internship Training carried out at the University Hospital

 Assessment skills

How much do you consider yourself able to perform a physiotherapy assessment in a patient of the Cardiac Rehabilitation U.O.C.?

 □ 0 □ 1 □ 2 □ 3 □ 4 □ 5

 Abilities to plan the rehabilitative program

How much do you consider yourself able to build a customized rehabilitation program based on relevant data collected during the assessment of a patient afferent to the Cardiac Rehabilitation U.O.C. and define short-term, mid-term and long-term objectives?

 □ 0 □ 1 □ 2 □ 3 □ 4 □ 5

 Teamwork skills

How much do you consider yourself able to interact with an interdisciplinary team?

 □ 0 □ 1 □ 2 □ 3 □ 4 □ 5

 Comunication skills

How much do you consider yourself able to understand the rehabilitative needs of the patient and build an effective therapeutic relationship?

 □ 0 □ 1 □ 2 □ 3 □ 4 □ 5

Results

Analysis of goals achieved by students

Students aimed to develop transdisciplinary skills (Trotta, Marzano, Cofano, & Tortorano, 2005): improve teamwork abilities, communication and empathy to patients; and design rehabilitation programs according to current Guidelines. As shown in Figure 2, students in the experimental group improved those skills more than control group: assessment skills by 0.7 points more than the control group; planning abilities for rehabilitative intervention by 0.8 points; teamwork skill by 1.3 points; communication and empathy skills by 1 point (Figure 2).

Analysis of goals achieved by patients

Patients were willing to actively participate in the design and management of healthcare and rehabilitative activities, and to improve long-term adherence and compliance to the CR program (Murante, 2009). For this assessment (Figure 3), we evaluated parameters during the first 3 weeks of treatment and a 3-month follow-up. Adherence and compliance increased by a mean of 1.5 point in the experimental group during observed period, with maximum increase at the third week and follow-up. Both groups had a decrease of adherence and compliance at follow-up, although the experimental group had a lower decrease. 3 months follow-up aim was to assess the maintenance of outcome achieved at the hospital discharge (Figure 4). All patients had a regression, 25 in the control group and 8 in the experimental one; while 25 patients of the experimental group and 20 of the control one had a maintenance of outcome achieved at the hospital discharge. As for improvements, 5 patients of the control group and 17 of the experimental group enhanced their health status after the hospital discharge.

Discussion

The proposed internship training modality aims to support comparison and “reflection in action”, a process that allow reflecting on own knowledge during the execution of the action finalized to treatment of the patient in order to activate prior knowledge and to integrate tacit skills. This leads to a shift from ability to competence through action: reflection-in-action ßà reflection-on-action. Essential is the comparison between different protagonists who are part of the care and rehabilitation path and the active use of this kind of approach in order to promote transversal, trans disciplinary competences and overcome the fragmentation of knowledge and competence. Learning to compare onto a scientific case, already during the training years, means wearing the tailored dress of interdisciplinarity. Otherwise, it could remain only a used and abused term in current language, even confused with multidisciplinarity, but it doesn’t face up needs and problems of the patient in an integrated way. The current training models of different professions needed to be implemented in order to encourage the application of the evidence-based medicine, in association with the study of scientific literature, to clinical practices, basing the traineeship on the integration of knowledge and competences (Tomietto et al., 2009). Within the realization of our project, every stakeholder immediately learns how to talk together in team during the training years, focusing their attention towards the achievement of shared aims. This made the students able to acquire trans-competence skills, integrating specific organizational assistance needs finalized to the rehabilitation of the patient. The latter implemented adherence and compliance and is stimulated by the fully collaborative context in which he is at the center. The core of this work is a poster, of the same title, published at the National Conference of the Degree Courses in Bologna in 2018. It then underwent a series of changes and additions thanks to the collaboration also of students of the Master’s Degree in Science Rehabilitation of Health Professions, cited among the authors. Future developments: internship activities organized in this way allow and favor an active comparison between Physician and Healthcare Professionals in every step of the taking charge of the patient and of the training of the students.

Conclusion

Our preliminary results, generated by team-coordinated efforts, show a simple method to apply CR Guidelines to clinical practice, by improving healthcare worker knowledge and patient adherence and compliance to treatment. Noteworthy, our simple approach might also be applied to other UOC programs, thus involving an ever-growing number of students, tutors and patients.

Conflict of interest

The authors declare no conflict of interest regarding the publication of this paper.

Informed Consent

The patients signed the informed consent which is available if required.

Acknowledgments

We would like to thank the University of Salerno, the University Hospital “San Giovanni di Dio Ruggi d’Aragona” in Salerno, all the patients enrolled in the study, and all the students who took part in the study.

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