164 students were asked to complete reflections in order for program developers to ascertain what students learned from the home care experience. Students were asked 3 questions:
- Name at least one insight that you had about the role of the health professional you accompanied in the community. What did you learn about his/her scope of practice that you were unaware of?
- What determinants of health did you observe during your visit? Provide examples of how you think a determinant of health may have influenced the health status of a patient.
- Reflect on your visit. If you were to see this patient in the hospital setting or in your office, how would your experience of visiting his/her home change your approach or understanding of their health status?
The 161 student reflections were analyzed using Thematic Content analysis. The following themes came out of the analysis:
A) SCOPE OF PRACTICE
Surprises - students were surprised to find that the scope of practice of clinicians was either, broader, different, or more important than they had anticipated. Students realized how blurred the scopes of practice are. Students were also surprised to find that the role of health professionals in the community was more complex than imagined. Health professionals in the community were observed to act as advocates for patients and provided support and patient-centred, holistic care. Placements also provided students with the opportunity to view, first hand, some of the challenges faced by health professionals working in the community.
The following quotes illustrate student’s surprise:
“However, following this experience, I was enlightened on the scope of practice of social worker[s]. In addition to arranging the aforementioned services, social workers are also involved in counseling, health education and patient risk management. Moreover, they may also act as a liaison between the patient and other health professionals including physicians.”
“While shadowing the speech pathologist, I found it very interesting in how the professional observed the patient through a holistic lens, not necessarily focusing on the specific task. Not only did the health professional assess the physical, but also the social and psychological well being of the patient. I learned how often the social and psychological self could manifest into issues that the speech pathologist may be referred for. By assessing the whole being, the health professional was able to identify a variety of issues that were at play for the patient, making the professional a very power advocate in the care of the patient.”
B) DETERMINANTS OF HEALTH
Placements in the community enabled students to see how the health of patients is affected by access to health services; biology/genetics; education; employment; gender; language or culture; socio-economic status; personal health practices; physical environments; and social support.
The following quotes illustrate student’s exposure/understanding of the effects of determinants of health of patient health:
“the first patient that we saw was not well educated as a child; thus, he worked in a factory where he was exposed to harmful chemicals that have clearly impacted his health in a negative way. He had little control over the work he did because of his lower position within the factory and a poor education closed the opportunity for safer and more promising jobs.”
"It was made apparent that socioeconomic status was a significant determinant of health during my visit. The patients seen resided in Burlington and were all financially secure. They could afford all the necessary equipment (walkers, wheelchairs, stability poles) as well as live in upscale apartments. One patient lived in an assisted-care facility where she enjoyed the ability of living independently in her own apartment, but had 24-hour access to help within the building. Although I learned that the CCAC will cover most of the cost for necessary equipment, this may still be too expensive for people of limited income, a common situation."
C) INSIGHTS INTO THEIR OWN APPROACH
Students expressed insight into the limitations of office visits, and expressed increased understanding of the patient as a whole person. Students acknowledged the need for team work and continuity of care.
The following quotes illustrate students' insights into their own approach:
“A brief glimpse around the piles of garbage and old trinkets around her home pointed to a lady who was not as 'together' as she had insisted. One would presume, then, that in an office setting, the severity of her psychiatric illness may not be as blatant as that during a home visit where the patient's habitat/niche is in full view and where no amount of preening would be able to hide the reality of his/her disorder."
“Seeing patients in their homes is a little humbling, you have to adapt what you are thinking to what you are actually seeing, you can see a patient in the office and be frustrated about their weight due to bad dietary habits, but when your in their home you can understand that it is very difficult to get around with crutches in the small kitchen and so the only option is ready prepared meals that are not high in nutritional value. So i think that being in the home gives you a better view of what it is like for people in different places in their life.”
Students acknowledged that the experience will change their clinical reasoning, intervention and how they work with team members.
The following quotes illustrate how students will change they way they practice:
“As a physician, this experience has taught me the importance of knowing about resources where people can find help; so being aware of local charities, social programs and community-run help centres may be the difference of preventing the 'fall through the cracks' and facing the consequences of being oblivious to the fall.”
“I think I would make a concerted effort to connect more deeply with the patient and to try to find out from him what I or another health professional would be able to do to help make his treatment and recovery easier for him physically, emotionally and financially.”
Most students stated that they found the experience to be highly valuable whereas 6 stated that changes needed to be made before the program is implemented, and 2 students thought the experience was not worth the time investment. The following quotes illustrate some of the student’s perceptions,
“Very useful session. Certainly an eye opener to see a patient outside the clinic or hospital. Provided a lot of insight to the patient's day to day living and how that influences their health.”
“Didn’t find it tremendously useful for the amount of time it took, readings were sufficient”