problem solving scenarios geriatric

10 Best Problem-Solving Therapy Worksheets & Activities

Cognitive science tells us that we regularly face not only well-defined problems but, importantly, many that are ill defined (Eysenck & Keane, 2015).

Sometimes, we find ourselves unable to overcome our daily problems or the inevitable (though hopefully infrequent) life traumas we face.

Problem-Solving Therapy aims to reduce the incidence and impact of mental health disorders and improve wellbeing by helping clients face life’s difficulties (Dobson, 2011).

This article introduces Problem-Solving Therapy and offers techniques, activities, and worksheets that mental health professionals can use with clients.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is problem-solving therapy, 14 steps for problem-solving therapy, 3 best interventions and techniques, 7 activities and worksheets for your session, fascinating books on the topic, resources from positivepsychology.com, a take-home message.

Problem-Solving Therapy assumes that mental disorders arise in response to ineffective or maladaptive coping. By adopting a more realistic and optimistic view of coping, individuals can understand the role of emotions and develop actions to reduce distress and maintain mental wellbeing (Nezu & Nezu, 2009).

“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu, Nezu, & D’Zurilla, 2013, p. ix). It aims to encourage the client to cope better with day-to-day problems and traumatic events and reduce their impact on mental and physical wellbeing.

Clinical research, counseling, and health psychology have shown PST to be highly effective in clients of all ages, ranging from children to the elderly, across multiple clinical settings, including schizophrenia, stress, and anxiety disorders (Dobson, 2011).

Can it help with depression?

PST appears particularly helpful in treating clients with depression. A recent analysis of 30 studies found that PST was an effective treatment with a similar degree of success as other successful therapies targeting depression (Cuijpers, Wit, Kleiboer, Karyotaki, & Ebert, 2020).

Other studies confirm the value of PST and its effectiveness at treating depression in multiple age groups and its capacity to combine with other therapies, including drug treatments (Dobson, 2011).

The major concepts

Effective coping varies depending on the situation, and treatment typically focuses on improving the environment and reducing emotional distress (Dobson, 2011).

PST is based on two overlapping models:

Social problem-solving model

This model focuses on solving the problem “as it occurs in the natural social environment,” combined with a general coping strategy and a method of self-control (Dobson, 2011, p. 198).

The model includes three central concepts:

Social problem-solving
The problem
The solution

The model is a “self-directed cognitive-behavioral process by which an individual, couple, or group attempts to identify or discover effective solutions for specific problems encountered in everyday living” (Dobson, 2011, p. 199).

Relational problem-solving model

The theory of PST is underpinned by a relational problem-solving model, whereby stress is viewed in terms of the relationships between three factors:

Stressful life events
Emotional distress and wellbeing
Problem-solving coping

Therefore, when a significant adverse life event occurs, it may require “sweeping readjustments in a person’s life” (Dobson, 2011, p. 202).

Enhance positive problem orientation
Decrease negative orientation
Foster ability to apply rational problem-solving skills
Reduce the tendency to avoid problem-solving
Minimize the tendency to be careless and impulsive

D’Zurilla’s and Nezu’s model includes (modified from Dobson, 2011):

Initial structuring Establish a positive therapeutic relationship that encourages optimism and explains the PST approach.
Assessment Formally and informally assess areas of stress in the client’s life and their problem-solving strengths and weaknesses.
Obstacles to effective problem-solving Explore typically human challenges to problem-solving, such as multitasking and the negative impact of stress. Introduce tools that can help, such as making lists, visualization, and breaking complex problems down.
Problem orientation – fostering self-efficacy Introduce the importance of a positive problem orientation, adopting tools, such as visualization, to promote self-efficacy.
Problem orientation – recognizing problems Help clients recognize issues as they occur and use problem checklists to ‘normalize’ the experience.
Problem orientation – seeing problems as challenges Encourage clients to break free of harmful and restricted ways of thinking while learning how to argue from another point of view.
Problem orientation – use and control emotions Help clients understand the role of emotions in problem-solving, including using feelings to inform the process and managing disruptive emotions (such as cognitive reframing and relaxation exercises).
Problem orientation – stop and think Teach clients how to reduce impulsive and avoidance tendencies (visualizing a stop sign or traffic light).
Problem definition and formulation Encourage an understanding of the nature of problems and set realistic goals and objectives.
Generation of alternatives Work with clients to help them recognize the wide range of potential solutions to each problem (for example, brainstorming).
Decision-making Encourage better decision-making through an improved understanding of the consequences of decisions and the value and likelihood of different outcomes.
Solution implementation and verification Foster the client’s ability to carry out a solution plan, monitor its outcome, evaluate its effectiveness, and use self-reinforcement to increase the chance of success.
Guided practice Encourage the application of problem-solving skills across multiple domains and future stressful problems.
Rapid problem-solving Teach clients how to apply problem-solving questions and guidelines quickly in any given situation.

Success in PST depends on the effectiveness of its implementation; using the right approach is crucial (Dobson, 2011).

Problem-solving therapy – Baycrest

The following interventions and techniques are helpful when implementing more effective problem-solving approaches in client’s lives.

First, it is essential to consider if PST is the best approach for the client, based on the problems they present.

Is PPT appropriate?

It is vital to consider whether PST is appropriate for the client’s situation. Therapists new to the approach may require additional guidance (Nezu et al., 2013).

Therapists should consider the following questions before beginning PST with a client (modified from Nezu et al., 2013):

Has PST proven effective in the past for the problem? For example, research has shown success with depression, generalized anxiety, back pain, Alzheimer’s disease, cancer, and supporting caregivers (Nezu et al., 2013).
Is PST acceptable to the client?
Is the individual experiencing a significant mental or physical health problem?

All affirmative answers suggest that PST would be a helpful technique to apply in this instance.

Five problem-solving steps

The following five steps are valuable when working with clients to help them cope with and manage their environment (modified from Dobson, 2011).

Ask the client to consider the following points (forming the acronym ADAPT) when confronted by a problem:

Attitude Aim to adopt a positive, optimistic attitude to the problem and problem-solving process.
Define Obtain all required facts and details of potential obstacles to define the problem.
Alternatives Identify various alternative solutions and actions to overcome the obstacle and achieve the problem-solving goal.
Predict Predict each alternative’s positive and negative outcomes and choose the one most likely to achieve the goal and maximize the benefits.
Try out Once selected, try out the solution and monitor its effectiveness while engaging in self-reinforcement.

If the client is not satisfied with their solution, they can return to step ‘A’ and find a more appropriate solution.

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Positive self-statements

When dealing with clients facing negative self-beliefs, it can be helpful for them to use positive self-statements.

Use the following (or add new) self-statements to replace harmful, negative thinking (modified from Dobson, 2011):

I can solve this problem; I’ve tackled similar ones before.
I can cope with this.
I just need to take a breath and relax.
Once I start, it will be easier.
It’s okay to look out for myself.
I can get help if needed.
Other people feel the same way I do.
I’ll take one piece of the problem at a time.
I can keep my fears in check.
I don’t need to please everyone.

5 Worksheets and workbooks

Problem-solving self-monitoring form.

Answering the questions in the Problem-Solving Self-Monitoring Form provides the therapist with necessary information regarding the client’s overall and specific problem-solving approaches and reactions (Dobson, 2011).

Ask the client to complete the following:

Describe the problem you are facing.
What is your goal?
What have you tried so far to solve the problem?
What was the outcome?

Reactions to Stress

It can be helpful for the client to recognize their own experiences of stress. Do they react angrily, withdraw, or give up (Dobson, 2011)?

The Reactions to Stress worksheet can be given to the client as homework to capture stressful events and their reactions. By recording how they felt, behaved, and thought, they can recognize repeating patterns.

What Are Your Unique Triggers?

Helping clients capture triggers for their stressful reactions can encourage emotional regulation.

When clients can identify triggers that may lead to a negative response, they can stop the experience or slow down their emotional reaction (Dobson, 2011).

The What Are Your Unique Triggers ? worksheet helps the client identify their triggers (e.g., conflict, relationships, physical environment, etc.).

Problem-Solving worksheet

Imagining an existing or potential problem and working through how to resolve it can be a powerful exercise for the client.

Use the Problem-Solving worksheet to state a problem and goal and consider the obstacles in the way. Then explore options for achieving the goal, along with their pros and cons, to assess the best action plan.

Getting the Facts

Clients can become better equipped to tackle problems and choose the right course of action by recognizing facts versus assumptions and gathering all the necessary information (Dobson, 2011).

Use the Getting the Facts worksheet to answer the following questions clearly and unambiguously:

Who is involved?
What did or did not happen, and how did it bother you?
Where did it happen?
When did it happen?
Why did it happen?
How did you respond?

2 Helpful Group Activities

While therapists can use the worksheets above in group situations, the following two interventions work particularly well with more than one person.

Generating Alternative Solutions and Better Decision-Making

A group setting can provide an ideal opportunity to share a problem and identify potential solutions arising from multiple perspectives.

Use the Generating Alternative Solutions and Better Decision-Making worksheet and ask the client to explain the situation or problem to the group and the obstacles in the way.

Once the approaches are captured and reviewed, the individual can share their decision-making process with the group if they want further feedback.

Visualization

Visualization can be performed with individuals or in a group setting to help clients solve problems in multiple ways, including (Dobson, 2011):

Clarifying the problem by looking at it from multiple perspectives
Rehearsing a solution in the mind to improve and get more practice
Visualizing a ‘safe place’ for relaxation, slowing down, and stress management

Guided imagery is particularly valuable for encouraging the group to take a ‘mental vacation’ and let go of stress.

Ask the group to begin with slow, deep breathing that fills the entire diaphragm. Then ask them to visualize a favorite scene (real or imagined) that makes them feel relaxed, perhaps beside a gently flowing river, a summer meadow, or at the beach.

The more the senses are engaged, the more real the experience. Ask the group to think about what they can hear, see, touch, smell, and even taste.

Encourage them to experience the situation as fully as possible, immersing themselves and enjoying their place of safety.

Such feelings of relaxation may be able to help clients fall asleep, relieve stress, and become more ready to solve problems.

We have included three of our favorite books on the subject of Problem-Solving Therapy below.

1. Problem-Solving Therapy: A Treatment Manual – Arthur Nezu, Christine Maguth Nezu, and Thomas D’Zurilla

This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.

Written by the co-developers of PST, the manual provides powerful toolkits to overcome cognitive overload, emotional dysregulation, and the barriers to practical problem-solving.

Find the book on Amazon .

2. Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Arthur Nezu and Christine Maguth Nezu

Another, more recent, book from the creators of PST, this text includes important advances in neuroscience underpinning the role of emotion in behavioral treatment.

Along with clinical examples, the book also includes crucial toolkits that form part of a stepped model for the application of PST.

3. Handbook of Cognitive-Behavioral Therapies – Keith Dobson and David Dozois

This is the fourth edition of a hugely popular guide to Cognitive-Behavioral Therapies and includes a valuable and insightful section on Problem-Solving Therapy.

This is an important book for students and more experienced therapists wishing to form a high-level and in-depth understanding of the tools and techniques available to Cognitive-Behavioral Therapists.

For even more tools to help strengthen your clients’ problem-solving skills, check out the following free worksheets from our blog.

Case Formulation Worksheet This worksheet presents a four-step framework to help therapists and their clients come to a shared understanding of the client’s presenting problem.
Understanding Your Default Problem-Solving Approach This worksheet poses a series of questions helping clients reflect on their typical cognitive, emotional, and behavioral responses to problems.
Social Problem Solving: Step by Step This worksheet presents a streamlined template to help clients define a problem, generate possible courses of action, and evaluate the effectiveness of an implemented solution.

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While we are born problem-solvers, facing an incredibly diverse set of challenges daily, we sometimes need support.

Problem-Solving Therapy aims to reduce stress and associated mental health disorders and improve wellbeing by improving our ability to cope. PST is valuable in diverse clinical settings, ranging from depression to schizophrenia, with research suggesting it as a highly effective treatment for teaching coping strategies and reducing emotional distress.

Many PST techniques are available to help improve clients’ positive outlook on obstacles while reducing avoidance of problem situations and the tendency to be careless and impulsive.

The PST model typically assesses the client’s strengths, weaknesses, and coping strategies when facing problems before encouraging a healthy experience of and relationship with problem-solving.

Why not use this article to explore the theory behind PST and try out some of our powerful tools and interventions with your clients to help them with their decision-making, coping, and problem-solving?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

Cuijpers, P., Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. (2020). Problem-solving therapy for adult depression: An updated meta-analysis. European P sychiatry , 48 (1), 27–37.
Dobson, K. S. (2011). Handbook of cognitive-behavioral therapies (3rd ed.). Guilford Press.
Dobson, K. S., & Dozois, D. J. A. (2021). Handbook of cognitive-behavioral therapies (4th ed.). Guilford Press.
Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook . Psychology Press.
Nezu, A. M., & Nezu, C. M. (2009). Problem-solving therapy DVD . Retrieved September 13, 2021, from https://www.apa.org/pubs/videos/4310852
Nezu, A. M., & Nezu, C. M. (2018). Emotion-centered problem-solving therapy: Treatment guidelines. Springer.
Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual . Springer.

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Occupational Therapy Interventions for Older Adults With Chronic Conditions and Their Care Partners

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Beth Fields; Occupational Therapy Interventions for Older Adults With Chronic Conditions and Their Care Partners. Am J Occup Ther November/December 2021, Vol. 75(6), 7506390010. doi: https://doi.org/10.5014/ajot.2021.049294

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Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project. In this Evidence Connection article, I describe a clinical case report of an older adult with a chronic condition and his daughter who received home health occupational therapy services. I discuss the occupational therapy evaluation and intervention processes with these clients to support chronic condition self-management, coping skills, and problem solving, drawing on findings from the systematic review on the effectiveness of interventions for care partners of people with chronic conditions published in the July/August 2021 issue of the American Journal of Occupational Therapy . It is my hope that this Evidence Connection article can be used to inform and guide clinical decision making when working with older adults with chronic conditions and their care partners.

As the population continues to age and experience chronic conditions, care partners (i.e., family members and friends who provide care, usually without payment) have become increasingly critical to the long-term care system. In response, many prominent organizations, including the Institute of Medicine and the Institute for Healthcare Improvement, are endorsing a person- and family-centered model of geriatric care ( Clay & Parsh, 2016 ). Key features of this model include collaboration and information sharing, education and training, and active participation and decision making by health care practitioners, older adults, and their care partners. To support this model, payment and coverage innovations in Medicare and Medicaid are beginning to emerge. For example, home health agencies can provide care partner supportive services such as education and training to Medicare beneficiaries ( Centers for Medicare & Medicaid Services, 2017 ; National Academies of Sciences, Engineering, and Medicine, 2016 ).

In this article, I provide a clinical case report that demonstrates how occupational therapy practitioners can support and participate in this model of care. This case report exemplifies findings of a systematic review on the effectiveness of interventions for care partners of people with chronic conditions, published in the July/August 2021 issue of the American Journal of Occupational Therapy ( Rouch et al., 2021 ). I describe the occupational therapy evaluation and intervention processes for supporting chronic condition self-management, coping skills, and problem solving for an older adult with a chronic condition and his daughter receiving home health occupational therapy services.

Clinical Case Report

John, age 70 yr, was referred to home health occupational therapy because of a recent diagnosis of peripheral neuropathy made during his annual check-up with his primary care practitioner. He self-reported that since his wife died, he has not been managing his Type 2 diabetes well. His peripheral neuropathy has been limiting his ability to do normal activities because of mild numbness and pain in his feet. John’s daughter, Dawn, attended his annual check-up with him for the first time. Dawn was surprised to learn that her father has not been managing his diabetes. Together, John and Dawn decide that she will take a more active role in helping her father improve his health, the role that John’s wife had previously assumed.

Occupational Therapy Evaluation and Findings

John is independent in activities of daily living, including dressing, feeding, functional mobility, and personal hygiene.

He is a retired computer programmer and enjoys surfing the web and playing online games.

John feels lonely since his wife passed and has not been sleeping well.

He enjoys visiting with his daughter and would like her to play a more active role in helping him get back on track with his health. Dawn confirmed that she is willing and able to better support her father.

John describes his home as being accessible after changes made to accommodate his wife’s progressive condition.

Previous performance patterns included going on short morning walks with his wife, going out to eat with friends, and taking care of all the yard work. Before her death, John’s wife managed the house, including grocery shopping, cleaning, and cooking.

Table 1 presents findings from the other assessments Madeline administered during the evaluation: the Canadian Occupational Performance Measure (COPM; Law et al., 2014 ), the Brief Health Literacy Screening Tool ( Haun et al., 2012 ), and the Patient-Reported Outcome Measurement Information System (PROMIS) Global Health scale (Version 1.2; Hays et al., 2009 ).

Occupational Therapy Intervention

Moderate evidence for group-based interventions in which older adults and their care partners focus on learning and applying chronic condition–specific education, coping skills, and problem solving to improve well-being and quality of life.

Moderate evidence for educational interventions in which older adults and their care partners focus on learning how to adapt daily living skills.

Given that most of the studies in the systematic review had moderate to low strength of evidence, Madeline also reviewed other pertinent sources, including the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; AOTA, 2020 ), the Centers for Disease and Control and Prevention (CDC), and the Self-Management Resource Center (SMRC). In the OTPF–4, she found descriptions of occupations related to health management. From the CDC and SMRC, she identified recommendations for physical activity and online workshops. Drawing from available evidence, her clinical expertise, and John’s and Dawn’s preferences, Madeline developed a plan of care for home health occupational therapy. Over the course of 2 mo, John and Dawn participated in four in-person home health occupational therapy sessions. Targeted outcomes included improved well-being, quality of life, and knowledge of John’s chronic condition.

Group Self-Management Intervention

After learning from the occupational profile and COPM that John and Dawn wanted to work on building a healthier lifestyle together, Madeline suggested they attend a virtual diabetes self-management group workshop. The workshop lasts 6 wk, requires about 2 hr of work each week, and covers establishing healthy nutrition and exercise habits, communicating effectively with loved ones and health care practitioners, managing medications, and using relaxation and breathing techniques ( Cai & Hu, 2016 ; SMRC, 2021 ; Toseland et al., 2004 ). John and Dawn reported that they would sign up to take the online workshop together. Dawn shared that she was particularly interested in talking with other care partners online to find out how they empower their loved ones to improve their health. John and Dawn both expressed that they want to learn strategies to prevent problems caused by peripheral neuropathy (i.e., swollen feet, pain, loss of muscle tone and balance).

Coping Skills Intervention

Findings from the PROMIS Global Health scale indicated to Madeline that John and Dawn are experiencing decreased quality of life and poor mental health. During the first and second occupational therapy sessions, Madeline provided strategies to John and Dawn to help them cope with the recent passing of their loved one. In particular, she helped them establish a journaling routine in which John and Dawn would each record their thoughts and feelings on a daily or weekly basis. She also shared information on the impact of sleep on health and provided some suggestions for building a better nighttime routine, including listening to music, taking a warm bath, and reading a favorite book. Last, Madeline encouraged both John and Dawn to either resume participating in a meaningful hobby or explore a new one ( Hood et al., 2015 ; Hoppes & Segal, 2010 ; Wolff et al., 2009 ).

Problem-Solving Intervention

During the third and fourth occupational therapy sessions, Madeline worked with John and Dawn to adapt their daily living skills by using problem-solving strategies. Because John has limited health literacy, Madeline used plain language, visual aids, and the teach-back method when introducing strategies. For example, John identified that he has had a hard time preparing healthy meals and finding time to exercise. Madeline had John brainstorm potential solutions while encouraging Dawn to think about how she could help her father improve his meal preparation and exercise routines. They both decided that they needed to learn how to read nutrition labels and how much exercise is recommended on a weekly basis.

Madeline described the basics of nutrition using good and bad “nutrition facts” labels as examples. She then had John and Dawn teach these facts back to her. Dawn reported that she was willing and able to help her father create a grocery list that included healthier food choices as part of their weekly routine. Madeline also shared that the general recommendation for exercise is about 150 min spread out throughout the week. John and Dawn discussed what it would take for them to establish a walking routine together. They reviewed their schedules and determined that they could meet up at a nearby park to walk the various trails 3 times a week for at least 30 min. Madeline suggested that if they found themselves having a difficult time sticking to this routine, they should evaluate the activity to determine what alterations could be made ( CDC, 2020 ).

Discharge Summary

Through the use of these evidence-based interventions, John and Dawn met their established goals after completing four occupational therapy home health sessions and a 6-wk online workshop. At follow-up, John’s COPM scores had improved from 5 to 9 (of 10) on both the Performance and Satisfaction scales. John and Dawn also started a weekly walking routine, which was improving their well-being and relationship. They have met up to walk the trails at three different parks near their neighborhoods. John and Dawn found the journaling helpful for coping with their recent loss and managing their health. John’s scores on the PROMIS scale improved to 16 ( T score = 50.8) for the physical health items and 16 ( T score = 53.3) for the mental health items, indicating good global health.

John and Dawn reported that they have not followed through with developing a weekly grocery list and meal preparation plan. They determined that Dawn has been juggling too many work demands to help with this health management–related task. However, they discussed and set up a meal delivery option for John that includes healthier food items that he prepares on his own.

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PROBLEM-SOLVING THERAPY FOR OLDER ADULTS

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S. Cummings, PROBLEM-SOLVING THERAPY FOR OLDER ADULTS, Innovation in Aging , Volume 1, Issue suppl_1, July 2017, Page 18, https://doi.org/10.1093/geroni/igx004.066

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Problem solving therapy (PST) is an effective intervention for treating older adults who struggle with stress related health and mental health issues (D’Zurilla & Nezu, 1999; Nezu, Nezu & D’Zurilla 2013). Clients are trained to overcome major obstacles that inhibit effective coping and heighten stress by means of problem identification, generation of solutions, solution implementation, and post-implementation evaluation. Effective problem solving involves the ability to adaptively develop and match helpful solutions to life problems while taking into account internal and external factors that impact the problem (Nezu, 2013). Research documents the effectiveness of PST for use with older adults experiencing a variety of issues ranging depression, anxiety and mild cognitive impairment to cancer, arthritis and post-stoke functioning (Kirkham, Seitz, & Choi, 2015). PST treatment principles and strategies will be presented and the research base reviewed. A case study will highlight the PST treatment approach with older adults.

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Encyclopedia of Geropsychology pp 1–6 Cite as

Problem Solving in Old Age

Christiane A. Hoppmann 2 &
Pavel Kozik 2
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First Online: 01 January 2016

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Coping ; Decision-making ; Everyday problem solving ; Problem solving ; Collaborative cognition

Problem solving involves the recognition that there is a discrepancy between one’s current state and a desired end state as well as the strategies aimed at reducing this discrepancy (Marsiske and Margrett 2006 ).

At a very general level, problem solving represents the process by which an individual appraises and approaches problem (Marsiske and Margrett 2006 ). Problem solving thus involves various subcomponents including identifying specific characteristics of the problem at hand, making concrete plans, deciding on appropriate strategies, and engaging in behaviors that are aimed at reducing the discrepancy between current status and desired outcome (Marsiske and Margrett 2006 ). Hence, problem solving is a complex process that unfolds over time and that may have meaningful real-world implications.

There is a very large spectrum of problems that have been addressed in the adult...

Collaborative Problem-solving Strategies
Fluid Cognitive Abilities

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Hoppmann, C.A., Kozik, P. (2016). Problem Solving in Old Age. In: Pachana, N. (eds) Encyclopedia of Geropsychology. Springer, Singapore. https://doi.org/10.1007/978-981-287-080-3_206-2

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G. DAVID SPOELHOF, MD, GARY L. DAVIS, PhD, AND ADDIE LICARI, MD

Am Fam Physician. 2011;84(10):1149-1154

Patient information: See related handout on caring for older family members with depression , written by the authors of this article.

Author disclosure: No relevant financial affiliations to disclose.

The diagnosis of depression in older patients is often complicated by comorbid conditions, such as cerebrovascular disease or dementia. Tools specific for this age group, such as the Geriatric Depression Scale or the Cornell Scale for Depression in Dementia, may assist in making the diagnosis. Treatment decisions should consider risks associated with medications, such as serotonin syndrome, hyponatremia, falls, fractures, and gastrointestinal bleeding. Older white men with depression are at high risk of suicide. Depression is common after stroke or myocardial infarction, and response to antidepressant treatment has been linked to vascular outcomes. Depression care management is an important adjunct to the use of antidepressant medications. Structured psychotherapy and exercise programs are useful treatments for select patients.

The epidemiology of geriatric major depression is similar to that of younger adults, affecting 5 to 10 percent of older patients in primary care outpatient settings and occurring more often in women. 1 Depression in older persons may represent a relapse of depression from earlier in life rather than a new depressive disorder presenting late in life. Persons with late-onset depressive symptoms are more likely to have underlying cerebrovascular disease or incipient dementia. This may explain why response to psychological and pharmacologic treatment approaches is lower in older populations. Psychotic depression, which causes delusions or hallucinations, is more common in late-life depression. 1 The following illustrative cases highlight challenges presented by older patients with depression.

Case 1 . An 85-year-old nursing home patient with dementia has been withdrawn and eating poorly. The staff thinks that she may be depressed and asks you about prescribing an antidepressant .

Major depression in older patients is diagnosed using the same criteria as in younger adults. It is based on the persistence of the core symptoms of anhedonia or depressed mood for two weeks, with four or more of the following: feelings of worthlessness or guilt, decreased ability to concentrate or make decisions, fatigue, psychomotor agitation or retardation, insomnia or hypersomnia, significant changes in weight or appetite, and recurrent thoughts of suicide or death. 2

The diagnosis can be more difficult in older persons, because they may have somatic symptoms related to comorbid illnesses and are less likely to report certain symptoms, such as guilt. Depressive symptoms such as fatigue and hypersomnia may be a consequence of illness. 3 The diagnosis may be further obscured by dementia, limiting the patient's ability to provide a thorough history. Table 1 shows a comparison of the symptoms and signs of depression and dementia. 4 Depression is more common in patients in nursing homes and is often manifested by weight loss. 5

The Geriatric Depression Scale is a useful screening tool that has been validated for use in patients with dementia who have Mini-Mental State Examination scores as low as 15 ( Table 2 6 ) . 7 The Cornell Scale for Depression in Dementia is a caregiver-based evaluation tool that can be used to diagnose depression that accompanies more severe dementia. 8 It can be accessed at http://www.amda.com/resources/2005_updates_ltc_teaching_kits/dementia.pdf . Other causes of depressive symptoms should be considered, such as delirium, adverse effects from medication, or metabolic disorders ( Table 3 9 , 10 ) .

Treating depression in patients living in a nursing home may be problematic because polypharmacy makes medication interactions and adverse effects more likely. Compromised renal or hepatic function also may contribute to adverse reactions. Tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, and other second-generation antidepressants have similar effectiveness. Based on their adverse effect profiles, SSRIs are the preferred medications for treating depression in older adults. Based on expert opinion, citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft) may be preferred because of fewer drug interactions or cognitive risks. 11

Frail older patients are more likely to be taking other medications with serotonergic properties ( Table 4 12 ) . Therefore, care should be taken to avoid serotonin syndrome, which is manifested as autonomic (e.g., hyperthermia, hypertension, tachycardia), neuromotor (e.g., hyperreflexia, myoclonus, tremors) or cognitive/behavioral (e.g., confusion, anxiety, hallucinations) symptoms. 12

Because hyponatremia has been linked to the use of SSRIs, serum sodium levels should be checked if a patient exhibits lethargy or delirium after starting therapy. 13 SSRI use also increases the risk of falls, fractures, gastrointestinal bleeding, and sleep disturbances. 14 – 17 The duration of therapy required to maintain remission is uncertain. 18 , 19 Based on principles of geriatric pharmacotherapy, patients should have periodic assessments for continuing medication or tapering to a minimal effective dose.

Case 2 . Three weeks ago, a 75-year-old man presented with a viral-sounding illness. The patient seemed apathetic, but commented that he needed to recover in time for hunting season. He later died of a self-inflicted gunshot wound .

White men older than 65 years account for a disproportionate number of completed suicides. 1 Depression is a major risk factor for suicidal ideation ( Table 5 ) . 20 Suicidal patients may present to their physician with seemingly unrelated symptoms shortly before making an attempt. A mood change, especially when means for self-harm (e.g., firearms) are readily available, should prompt a careful evaluation for suicidal ideation. Suicidal intent, the presence of a plan, and the means available to carry out the plan should be addressed directly in the interview.

Management of suicidal ideation in older patients requires hospitalization, unless there is a reliable source of psychosocial support, and good follow-up is assured. Although SSRI therapy has been shown to reduce suicidal ideation, it has been difficult to demonstrate that it reduces the rate of suicide attempts. 21 , 22 Medications more likely to be lethal in overdose (e.g., tricyclic antidepressants) should be avoided. Persisting suicidal ideation is one of the indications for electroconvulsive therapy, which may be safely administered to older patients. Other indications for electroconvulsive therapy are lack of response to medication, psychosis, and previous good response to this modality. 23

Case 3 . A 72-year-old woman had a myocardial infarction and underwent coronary artery bypass grafting four weeks ago. She has been participating in an outpatient cardiac rehabilitation program. Her therapist is concerned about her lack of progress and apparent apathy. The patient's son comments that she seems uninterested in participating in family activities and looks depressed .

About 20 percent of patients who have a stroke or myocardial infarction develop major depression. 24 , 25 Depression persisting after an acute coronary event increases the risk of future cardiovascular events and death. 26 In one study, response to treatment for depression was associated with a 7.4 percent risk of recurrent cardiac events, compared with a 25.6 percent risk in those whose depression did not respond to treatment. 27

The American College of Cardiology and the American Heart Association recommend screening for and treating depression for secondary prevention in patients with ST-segment elevation myocardial infarction. Assessment is recommended during hospitalization, one month after discharge, and annually thereafter. 28 Cognitive behavior therapy (CBT) or antidepressant medication is recommended for treatment. SSRIs are generally well tolerated by patients with cardiac conditions. Whether treatment of depression prevents future cardiovascular events is uncertain. A study of patients with acute coronary syndrome showed treatment of depression to be associated with greater patient satisfaction and a reduction of depressive symptoms, with a trend toward improved cardiac prognosis. 29

Case 4 . An 82-year-old woman comes to the office for a checkup three months after the death of her husband. The patient says her daughter asked her to make the appointment because she had not seemed like herself lately. The patient expresses anhedonia, and her 10-item Geriatric Depression Scale score is 7 out of 10. Her physical examination and laboratory tests are otherwise unremarkable. You prescribe a 30-day supply of an SSRI with three refills. Six weeks later, she says she discontinued the medication after the 30-day supply ran out and did not understand that she needed to get a refill. She is uncertain whether the medication was helpful .

Depressive symptoms may be a normal part of bereavement. Symptoms causing functional impairment and persisting without improvement for more than two months after the loss of a loved one should result in consideration for treatment. 30 After a diagnosis of depression is established, pharmacotherapy is one of several treatment options ( Table 6 ) . 11

If medication is chosen, there is increasing evidence that a prescription with office-based follow-up is inferior to an organized program of depression care management or collaborative care. 31 , 32 Depression care management involves the designation of an allied health professional to assist treatment by providing education and close follow-up, and monitoring response to treatment. 33 A randomized study compared usual care with pharmacotherapy augmented by depression care management. It found improved remission rates and medication adherence over the 12-month intervention (number needed to treat = 4), and the results were sustained for another 12 months after intervention had ended (number needed to treat = 9). 34 The evidence in favor of depression care management is strong enough that the U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adults (including older adults) only when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. The USPSTF notes that the evidence demonstrating a benefit of screening in the absence of depression care support is small. 35

Structured psychotherapy yields depression remission rates similar to medication, and may be preferred in patients at higher risk of adverse drug reactions. 36 CBT is the most widely studied form of psychotherapy and has been shown to be effective in geriatric depression, particularly in mild to moderately severe cases. CBT involves replacing negative distortions of events and situations with more positive and rational cognitive responses. 37 , 38 There is some evidence that the effects of CBT may be longer lasting than drug therapy following discontinuation of treatment. Older persons do well with CBT, but need special attention because of memory impairment and sensory deficits, primarily hearing loss. 39

There is some evidence that aerobic and anaerobic exercise programs are helpful for treating depression. A meta-analysis specific to older patients found evidence of benefit for major depression but the effects were not sustained unless the exercise program continued. 40 A Cochrane review on exercise for adult depression found evidence of benefit comparable to cognitive therapy. 41 Both reviews noted inconsistencies in the quality of the studies and the need for further research.

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Ables AZ, Nagubilli R. Prevention, recognition, and management of serotonin syndrome. Am Fam Physician. 2010;81(9):1139-1142.

Corrington KA, et al. A case of SSRI-induced hyponatremia. J Am Board Fam Pract. 2002;15(1):63-65.

Ensrud KE, Blackwell TL, Ancoli-Israel S, et al.; Study of Osteoporotic Fractures Research Group. Use of selective serotonin reuptake inhibitors and sleep disturbances in community-dwelling older women. J Am Geriatr Soc. 2006;54(10):1508-1515.

Dalton SO, Johansen C, Mellemkjaer L, et al. Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study. Arch Intern Med. 2003;163(1):59-64.

Ensrud KE, Blackwell TL, Mangione CM, et al.; Study of Osteoporotic Fractures Research Group. Central nervous system-active medications and risk for falls in older women. J Am Geriatr Soc. 2002;50(10):1629-1637.

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Reynolds CF, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age. N Engl J Med. 2006;354(11):1130-1138.

Dombrovski AY, Lenze EJ, Dew MA, et al. Maintenance treatment for old-age depression preserves health-related quality of life: a randomized, controlled trial of paroxetine and interpersonal psychotherapy. J Am Geriatr Soc. 2007;55(9):1325-1332.

Turvey CL, Conwell Y, Jones MP, et al. Risk factors for late-life suicide: a prospective, community-based study. Am J Geriatr Psychiatry. 2002;10(4):398-406.

Unützer J, Tang L, Oishi S, et al.; IMPACT Investigators. Reducing suicidal ideation in depressed older primary care patients. J Am Geriatr Soc. 2006;54(10):1550-1556.

Bruce ML, Ten Have TR, Reynolds CF, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004;291(9):1081-1091.

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Engaging Group Activities for Geriatric Patients: A Guide to Improving Quality of Life

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It’s time to get creative! As an experienced group activities coordinator, I’m always looking for fun ways to engage our elderly patients in meaningful activities that promote physical and mental well-being.

There are so many fantastic group activities out there – and the best part is they don’t have to be expensive or complicated.

Benefits Of Group Activities For Geriatric Patients

In this article, I’ll share some of my favorite ideas for group activities that are perfect for those aged 65+. Let’s get started with these exciting opportunities!

Check Out My Post: 11 Group Activities Ideas For Boosting Self Esteem .

Benefits Of Group Activities For Geriatric Patients

Group activities for geriatric patients have many benefits. It is important to understand these benefits when creating programming that can best serve elderly individuals. Physical activity, cognitive stimulation, and social interaction are just a few of the advantages that come with engaging in group activities.

Physical activity has been proven to be beneficial for older adults as it contributes to improved balance, flexibility, strength, and endurance. Not only does physical exercise help keep muscles toned, but it also helps maintain healthy blood pressure levels and heart function.

Additionally, exercising regularly can reduce joint pain, improve posture and increase energy levels which leads to a better quality of life overall.

Cognitive benefits gained through participating in group activities include mental stimulation through problem-solving tasks or memory games. Having access to an environment where seniors can engage in meaningful conversations encourages them to stay socially connected while learning new information about topics like nutrition education or current events.

The social aspect of being around others is key for reducing feelings of loneliness or isolation that some elders may experience due to their age or limited mobility.

In addition to physical and cognitive benefits, group activities offer emotional support from both peers and staff members who understand the challenges faced by aging populations on a daily basis. This sense of community togetherness provides participants with a safe place where they feel accepted and appreciated regardless of any limitations they may have encountered during their life thus far.

Engaging in various forms of recreational activities offers numerous opportunities for elderly people to live full lives despite whatever obstacles they face along the way.

Through regular participation in such programs, geriatric patients benefit greatly from the physical health improvements as well as increased confidence provided by positive reinforcement in a supportive atmosphere created by fellow participants who share similar experiences with one another.

Group activities also offer a great opportunity for caregivers and family members to join in on the fun too! From outdoor picnics and walks around the neighborhood, to indoor game nights – these activities can create lasting memories while encouraging connection between generations.

With careful planning and consideration, the possibilities are endless when it comes to creating enjoyable experiences that will leave your patients feeling energized and fulfilled!

Fun Group Activities Ideas For Geriatric Patients

1. Physical Activity Options

Now that we have discussed the benefits of group activities for the elderly, let’s explore physical activity options. It is important to ensure that geriatric patients get enough physical exercise in a safe and secure environment.

Chair exercises are one way to provide gentle movements with minimal effort. This includes simple stretches that can be done while sitting on a chair or other supportive surfaces.

Yoga exercises are also beneficial as they focus on breathing techniques, postures, relaxation, and balance which improve overall well-being. Low-impact aerobics helps older adults increase their cardio health without putting too much strain on joints or muscles.

Stretching exercises are also great for maintaining flexibility and range of motion while strength training focuses on muscular endurance and increases muscle mass over time. These physical activities can help elderly people stay fit, healthy, and active!

Next up: Cognitive Activity Ideas

2. Cognitive Activity Ideas

One in three seniors experiences some form of cognitive decline, making it important for caregivers to provide geriatric patients with engaging activities that challenge the mind. Here are some great ideas for mental stimulation and fun brain games!

Memory exercises are an excellent way to keep the brain active. Try having your patient recall past events or people from their lives – this could involve a game where they have to name as many family members as possible in two minutes or it can be something more creative like drawing pictures of former homes or workplaces.

Crossword puzzles, word searches, and jigsaw puzzles also make excellent activities; these require attention to detail while doing them and will help stimulate the brain.

Encouraging physical activity is just as important as mindfulness-based activities. Going on walks outside (when weather permits) helps get oxygen pumping throughout the body while providing a change of scenery and calming environment. Playing catch or throwing around a beach ball is another great way to stay active together while keeping minds engaged by counting points scored when playing certain games.

These activities are sure to bring out smiles and laughter among elderly individuals who need mental exercise but may not realize how much fun it can actually be!

3. Social Interaction Ideas

Apart from cognitive activities, social interaction ideas are also important for geriatric patients. Socializing with others can help to improve the mental and physical health of seniors. It is essential to offer companionship programs that include intergenerational activities such as game nights or support groups.

These types of activities will provide the elderly patient with a sense of purpose and joy while helping them combat loneliness and depression. Additionally, these experiences can increase their self-esteem and create lasting relationships among all involved.

Involving younger generations in these activities opens up a whole new world of possibilities for seniors. They learn about different cultures and beliefs, which helps them stay connected to the ever-changing modern world around them.

Through these interactions, they gain confidence in themselves allowing them to remain active members of society despite their age. With this newfound confidence comes improved overall well-being both mentally and physically.

The next step is providing arts and crafts ideas that engage geriatric patients in creative projects that stimulate their minds while bringing out their imaginative side.

4. Arts And Crafts Ideas

Engaging in arts and crafts is a great way to keep elderly people entertained. It’s also an excellent way for geriatric patients to exercise their creative muscles while having fun! Here are some ideas to consider when planning activities:

Painting : Whether it’s painting on canvas or creating postcards, seniors can have fun using paintbrushes and expressing themselves by creating art.
Scrapbooking : Scrapbooks allow seniors to reminisce about the past through photos, stories, and other memorabilia. Creating scrapbooks together can be a wonderful bonding experience for all involved.
Paper Folding Projects : Origami provides seniors with an opportunity to create something beautiful from basic materials such as paper, scissors, and glue sticks. These projects are easy enough for anyone of any age level to complete successfully. No matter what type of project you choose, engaging in arts and crafts is sure to bring out everyone’s inner artist! With just a few supplies, senior activities like these can offer hours of entertainment that will help brighten up your day. Now let’s move on to music and dance ideas!

5. Music And Dance Ideas

Let’s investigate the benefits of music and dance for our senior companions as we move on to the next exercise. A vital aspect of living, music has the power to unite people of all ages. It has a special ability to create moments of the connection while also providing physical and mental stimulation among seniors.

Music therapy activities provide numerous benefits to geriatric patients such as improved memory, increased focus, better relaxation skills, enhanced communication abilities, reduced anxiety levels, and greater emotional stability. Dance classes are another great way to combine socialization with exercise and improve coordination in elderly adults.

Programs like senior ballroom dancing or line dancing have proven particularly successful in engaging participants from varying age groups in lively bouts of fun!

Beyond these structured programs for music and dance, there are many other opportunities for seniors to express themselves through rhythmical movement – even if it’s just tapping their feet along to some upbeat tunes at home. As long as our elders feel comfortable doing so, they should be encouraged every step (or twirl!) of the way! Now on to exploring gardening activities …

6. Gardening Activities

Gardening activities offer geriatric patients a wonderful opportunity to engage in physical activity while out in the fresh air. Many elderly gardening programs are available, and they can be tailored specifically to meet the needs of the geriatric population.

Senior gardening is an excellent way for older adults to get their hands dirty and enjoy nature’s beauty.

A few ideas include creating container gardens that can easily be transported from one area to another, planting flowers or vegetables, or caring for established plants.

Furthermore, many seniors may find joy in teaching younger generations about horticulture techniques and plant care.

Activities also give seniors a wonderful feeling of accomplishment when they see their hard effort pay off. These kinds of outdoor activities also have a number of health advantages, including enhanced muscle, coordination, and balance, all of which support general wellness.

Participants who switch to outdoor sports have more chances to experience the environment while exercising at any level.

7. Outdoor Activities

Ah, the nostalgia of being outdoors. What better way to enjoy a sunny day than going out for a picnic or engaging in some leisurely outdoor games? Geriatric patients can benefit from spending time outside and staying active through various activities – here are some creative ways to help your elderly loved ones get their daily dose of fresh air and physical activity.

Whether it’s taking a walk along the beach or playing a game at the park, there is no shortage of outdoor activities available for geriatric patients who want to stay physically active and mentally sharp. With proper safety precautions taken, seniors should feel comfortable participating in any number of these enjoyable pastimes – all without leaving home!

As we transition into discussing nutrition education programs next section, remember that providing geriatric patients with access to physical activities is just one part of maintaining overall wellness – both inside and out!

8. Nutrition Education Programs

For this Program, you can hire the services of a nutrition expert.

The purpose of these sessions is to help participants understand how the nutrient content of foods affects their health as seniors. In the sessions, you’ll discuss topics such as calorie intake, diabetes management, heart health, and more.

The program also provides practical tips for incorporating healthy eating habits into daily life.

These classes are not only informative but also enjoyable – and will start lively discussions between participants!

Frequently Asked Questions [FAQs]

Are there any age restrictions on participating in group activities.

It is important to understand the relevant participation guidelines and requirements for each activity to ensure eligible patients can take part safely and enjoyably. Age requirements play an integral role in creating engaging activities that accommodate all ages while ensuring safety regulations are met.

When it comes to setting up group activities such as outdoor sports, painting classes or dancing sessions, we must also consider any necessary age restrictions.

As well as looking at local laws and safety regulations around the type of activity being organized, careful thought needs to be given to individual patient capabilities so that they don’t feel excluded from participating due to their age or health condition.

For instance, if organizing an aerobic class we may set an upper limit for participants under 70 years old depending on how strenuous the activity is expected to be.

Overall, taking suitable precautions when establishing age restrictions on group activities helps create safe environments where everyone can have fun without feeling restricted by their own personal circumstances.

Keeping these criteria in mind allows us as coordinators – and our elderly population – to participate in enjoyable experiences together regardless of varying abilities and ages.

How Often Should Group Activities Be Scheduled?

When it comes to scheduling frequency for group activities, geriatric activity coordinators must consider a range of factors. This includes planning resources and assistance programs that are available as well as the needs of elderly patients.

Here are three tips I’ve learned over years of experience:

Schedule activities at least once per week – this allows adequate time between sessions for participants to rest and absorb information from the previous session.
Plan varied types of activities with different levels of physical intensity – this way, everyone can participate regardless of their abilities.
Establish regular check-ins with participants, either in person or via phone/video call – this helps ensure that they have access to support if needed.

It is essential for activity coordinators to keep these points in mind when creating a plan for scheduling frequency for group activities. It takes careful thought and consideration to make sure that all stakeholders are being taken into account.

Additionally, it’s important to be open to feedback and adjust plans accordingly based on participant needs or other circumstances that may arise throughout the course of planning and executing group activities.

Are There Any Special Safety Precautions That Need To Be Taken With Geriatric Patients?

I’m often asked about the special safety precautions necessary when planning activities. This is a great question because it’s important to ensure that elderly participants remain safe and secure while engaging in group activities.

There are several factors to consider when implementing safety protocols for geriatric programs:

Medical conditions:
Mobility issues
Chronic health problems
Cognitive impairment
Environment:
Well-lit areas
Appropriate seating arrangements
Adequate supervision

These factors must be taken into account when designing activities for elderly people in order to adequately safeguard each member. For instance, it might be helpful to have seats available at various event locations if a participant has trouble traveling.

It might also be a good idea to designate one or two people to keep an eye on the area so that any medical crises can be handled right away. In addition, providing adequate lighting will make older people feel more at ease for the length of their exercise.

It’s important to remember that group activities for geriatric patients should be age appropriate and tailored to each individual. We must also consider any special safety precautions or assistance programs needed in order to ensure the activity is enjoyable, comfortable, and safe for all participants.

For example, I recently coordinated a group activity at an assisted living facility consisting of an outdoor picnic with music and dancing.

The event was well attended by both residents and staff members alike! Everyone had a great time enjoying the sunshine while listening to classic songs as they danced around together. It was especially rewarding seeing the smiles on their faces throughout the day.

Group activities can provide many benefits such as increased mobility, improved cognitive skills, enhanced socialization opportunities, and much more. With enough planning and preparation, geriatric patients can have access to engaging experiences that help make life more meaningful.

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v.10(1); 2020

Original research

Interprofessional education in geriatric medicine: towards best practice. a controlled before–after study of medical and nursing students, sanja thompson.

1 Geratology department, John Radcliffe Hospital, Oxford, UK

2 Medical Sciences Division, University of Oxford, Oxford, UK

Kiloran Metcalfe

Katy boncey, clair merriman.

3 Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK

Lorna Catherine Flynn

4 Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

Gaggandeep Singh Alg

Harriet bothwell, carol forde-johnston, elizabeth puffett, caroline hardy, james beale, associated data.

bmjopen-2017-018041supp002.pdf

bmjopen-2017-018041supp001.pdf

bmjopen-2017-018041supp003.pdf

To investigate nursing and medical students’ readiness for interprofessional learning before and after implementing geriatric interprofessional education (IPE), based on problem-based learning (PBL) case scenarios. To define the optimal number of geriatric IPE sessions, the size and the ratio of participants from each profession in the learner groups, the outcomes related to the Kirkpatrick four-level typology of learning evaluation, students’ concerns about joint learning and impact of geriatric IPE on these concerns. The study looked at the perception of roles and expertise of the ‘other’ profession in interprofessional teams, and students’ choice of topics for future sessions. Students’ expectations, experience, learning points and the influence on the understanding of IP collaboration, as well as their readiness to participate in such education again were investigated.

A controlled before–after study (2014/2015, 2015/2016) with data collected immediately before and after the intervention period. Study includes additional comparison of the results from the intervention with a control group of students. Outcomes were determined with a validated ‘Readiness for Interprofessional Learning’ questionnaire, to which we added questions with free comments, combining quantitative and qualitative research methods. The teaching sessions were facilitated by experienced practitioners/educators, so each group had both, a clinician (either geratology consultant or registrar) and a senior nurse.

Participants

300 medical, 150 nursing students.

Tertiary care university teaching hospital.

Analysis of the returned forms in the intervention group had shown that nursing students scored higher on teamwork and collaboration post-IPE (M=40.78, SD=4.05) than pre-IPE (M=34.59, SD=10.36)—statistically significant. On negative professional identity, they scored lower post-IPE (M=7.21, SD=4.2) than pre-IPE (M=8.46, SD=4.1)—statistically significant. The higher score on positive professional identity post-IPE (M=16.43, SD=2.76) than pre-IPE (M=14.32, SD=4.59) was also statistically significant. Likewise, the lower score on roles and responsibilities post-IPE (M=5.41, SD=1.63) than pre-IPE (M=6.84, SD=2.75).

Medical students scored higher on teamwork and collaboration post-IPE (M=36.66, SD=5.1) than pre-IPE (M=32.68, SD=7.4)—statistically significant. Higher positive professional identity post-IPE (M=14.3, SD=3.2) than pre-IPE (M=13.1, SD=4.31)—statistically significant. The lower negative professional identity post-IPE (M=7.6, SD=3.17) than pre-IPE (M=8.36, SD=2.91) was not statistically significant. Nor was the post-IPE difference over roles and responsibilities (M=7.4, SD=1.85), pre-IPE (M=7.85, SD=2.1).

In the control group, medical students scored higher for teamwork and collaboration post-IPE (M=36.07, SD=3.8) than pre-IPE (M=33.95, SD=3.37)—statistically significant, same for positive professional identity post-IPE (M=13.74, SD=2.64), pre-IPE (M=12.8, SD=2.29), while negative professional identity post-IPE (M=8.48, SD=2.52), pre-IPE (M=9, SD=2.07), and roles and responsibilities post-IPE (M=7.89, SD=1.69), pre-IPE (M=7.91, SD=1.51) shown no statistically significant differences. Student concerns, enhanced understanding of collaboration and readiness for future joint work were addressed, but not understanding of roles.

Conclusions

Educators with nursing and medical backgrounds delivered geriatric IPE through case-based PBL. The optimal learner group size was determined. The equal numbers of participants from each profession for successful IPE are not necessary. The IPE delivered by clinicians and senior nurses had an overall positive impact on all participants, but more markedly on nursing students. Surprisingly, it had the same impact on medical students regardless if it was delivered to the mixed groups with nursing students, or to medical students alone. Teaching successfully addressed students’ concerns about joint learning and communication and ethics were most commonly suggested topics for the future.

Strengths and limitations of this study

This is a novel evidence regarding good practice for geriatric undergraduate interprofessional education (IPE) derived from a large unselected (inclusive) cohort of medical and nursing students.
A controlled before–after study, with students randomly assigned to the intervention and control groups, combining quantitative and qualitative research evaluation.
The number of nursing students was smaller, so the control group consisted of only medical students.
The nursing students had more clinical experience than the medical students at the time of the geriatric IPE.
Medical students were not divided by their entry level, they were mixed from graduate-entry and standard-entry medicine course.

Introduction

The recommendations for interprofessional education (IPE) from professional accreditation bodies for healthcare students 1 2 relates closely to the specialty of Geriatrics, as being delivered by interprofessional (IP) teams. WHO considers IPE to be ‘key to improving global health outcomes and to the global health workforce crisis’, 3 the Institute of Medicine recommends education in IP team care for health professionals, while IP team-based practice is recognised as an essential model in particularly for complex medical issues. 4 5

IPE is believed to prepare practitioners for effective teamwork, which is particularly important for the person-centred, collaborative geriatric care, 6 with patients often presenting with complex issues, necessitating whole-team involvement in finding comprehensive solutions, as individual team members’ knowledge from the training of only one discipline is often not sufficient. 7 This confirms the consensus among geriatricians (and other healthcare professionals) that the provision of good care for all older patients through only autonomous practice is not achievable. 8 The theoretical basis for IPE is known. 9 Nevertheless, IPE in geriatric medicine still lacks established standards and best practice, for example, regarding the optimal timing and delivery, or which IPE models are most effective for addressing specific problems. 10–14 It is well known that one of the difficult things to learn in the healthcare provision process is the timing and the way of communication among healthcare providers, both for teams and or individuals. 8 Taking into consideration that professional identity starts early in the training, the development and implementation of geriatric IPE modules are not surprising; 15 16 however, the literature on geriatrics IPE at the undergraduate and postgraduate level is still sparse. The geriatric IPE models address various problems regarding complex geriatric patients, including problems in palliative geriatrics, comprehensive geriatric assessment, a clinic-based consultation or a clarification of role confusion among members of the teams. 16–19 Such education is based on the presumption that skills for interprofessional care are not acquired ‘naturally’ before graduation, nor are they necessarily acquired with ongoing clinical experience. 8 20–23 There are various IPE models, even including some based on e-learning courses. 21–23

Previous work on IPE has shown that it can have advantages in improving staff morale and patient outcomes and that the various IP teams develop in different ways (eg, differences in surgical or geriatrics teams), the assumption is that certain teams in healthcare settings attract certain personality types, but who share unique goals and values regarding care or specific issues in the patients. 8 12 14 Some of the common core competencies outlined by the health professionals (regardless of their specialty) being most important for the effective collaborative practice, are the role understanding and communication. 24

As a step to meet the need for geriatric IPE at the undergraduate level, without compromising the integrity of uniprofessional medical and nursing education, 25 a geriatric IPE was developed for medical and nursing students and run as a controlled before–after study in Oxford (Medical School, NHS, Oxford University Hospitals Foundation Trust and Brookes University). Set in a tertiary care university-based teaching hospital (John Radcliffe Hospital), during the 2014/2015 and 2015/2016 academic years, a study aimed to identify an effective way of delivering undergraduate geriatric IPE.

Data were obtained using mixed-methods (quantitative or qualitative), due to the complexity of assessing IPE and possible confounding factors that could affect the validity of the results when evaluating the impact of IPE. The study was conducted as a controlled before–after study, with data collected immediately before and after the intervention period. It was decided at the planning stage that a validated scale should be used for the evaluation. Use was made of the Readiness for Interprofessional Learning Scale (RIPLS) 26 in a modified form, in order to assess the readiness of healthcare students to engage in shared learning activities which consisted of four subscales: teamwork and collaboration, positive professional identity, negative professional identity and roles and responsibilities. 27 Students participating completed the modified RIPLS preintervention and postintervention in both intervention and control groups, including a number of open-ended questions that we added to the questionnaire to allow students to expand on their experiences in the teaching session and to add to our understanding of the geriatric IPE ( online supplementary files 1; 2 ).

Supplementary data

Student cohort.

The workshops were delivered to medical students from Oxford University Medical School and nursing students from Oxford Brookes University. Medical students were at the beginning of their 6-week clinical attachment, mixed from Year 4 of the 6-year course and Year 2 of the 4-year graduate entry course, preceding their clinical exposure to geriatrics-related problems. The researchers did not know the medical students’ affiliation. All medical students also attended the introduction course to geriatrics and a communication skills workshop (addressing dementia/delirium and challenging behaviours in older patients) during that teaching week. 28 Nursing students were recruited from Years 2 and 3 (due to the significantly smaller number of nursing students in clinical placements at the JR Hospital in Oxford, compared with medical students) of their 3-year course. The nursing students had already cared for older patients during previous clinical placements throughout their course, their curriculum covering a life-span approach to theory and practice. None of the students had any specific teaching in interprofessional collaboration prior to this session.

Eighty medical students (two groups of 40 from each academic year) could not be matched with nursing students, so acted as the control group. The decision about the grouping of students to the intervention and the control groups was determined exclusively by the number of students from both institutions and their availability for clinical rotations (students allocations to the rotations was the routine administration decision by both University organisations). So, all students were randomly assigned to the intervention and control groups, this being determined by the separate timetables from their respective institutions issued before this teaching. The formation of control groups was determined by the available medical students who could not be matched with the nursing students on the JR Hospital site due to their numbers.

The sessions were based on problem-based learning (PBL) with standardised case-scenarios relevant to geriatric practice mapped to the learning objectives on the Joint Royal Colleges of Physicians Training Board geriatric medicine curriculum 29 mirroring situations encountered by clinicians/nurses, requiring an IP collaborative approach ( online supplementary file 3 ). 14 30

Each workshop comprised approximately 30–45 min of introduction by a senior clinician and a nurse, followed by 2 hours of self-directed learning and a session facilitated jointly by nurses and geriatricians, aiming to facilitate professional socialisation 30 31 and collaboration through constructive discussion about the skills required from each profession when caring for older patients. It aimed to build higher level skills (such as reflection by students/facilitators) and cooperative learning 4 while problem-solving these cases. A short power point presentation contained several slides explaining the venues, the structure of the sessions and the names of the facilitators designated for each group. The presentation also included basic information about one case (as an example) that students will work on, with few images related to the themes of the cases (eg, patient’s hands with severe psoriasis after treatment refusal to illustrate self-neglect/abuse). Students were encouraged to discuss all cases in a way they felt was important from their professional point, including the initial nursing and medical management steps (eg, patient hygiene, ABCD), main nursing and medical concerns in the continuation of care for each case, how to approach the shared role needed in the management of these patients—the complementary roles or how to plan early interdisciplinary involvement.

The group was then split to accommodate similar numbers of attendees according to their roles as medic or nurse, to ensure an even spread of disciplines. Each IPE subgroup never had more than 10 members to aid discussion. Each student received a typed worksheet with all case scenarios and several suggested questions to help discussion of each case, related to the problems relevant to both professional groups. Students were allocated an hour to work through the case scenarios on their own, without facilitators and were expected to complete most of the work themselves first. The groups had another hour allocated afterwards with two lead facilitators from each profession (a geriatrician and a senior nurse), in order to discuss these cases. The input from them was to encourage further discussion about potential problems when managing these cases, about the roles of each professional and to hear their experience with these or similar cases. Both facilitators reflected on their own experience of such cases/situations. The mixed groups could discuss the scenarios with the ‘other’ profession during both sessions—something that was possible for the control group in its final session with the facilitators, with the emphasis on each profession’s contribution/collaboration/role in the management of given cases.

The potential problems if using only a single quantitative or qualitative method for assessing the learning outcomes of IPE are well known, 12 32–34 so the assessment was carried out with mixed (quantitative and qualitative) methods, anonymously, on a voluntary basis. The quantitative analysis was conducted with a validated modified questionnaire, ‘RIPLS’ which assesses participants across four subscales ( online supplementary files 1, 2 ). 26 27 32 Additionally, we created extra questions with free comments addressing students’ perception of the roles of nurses/doctors, their concerns about IP working; curricular topic suggestions for future IPE sessions; students’ expectations, the type of experiences encountered and the impact of the workshop on their understanding of collaboration and their ability to work together in future. The questionnaire was administered before and after the workshop.

Data were transcribed by KM, KB, ST and HB, on a Microsoft Excel spreadsheet and the results from RIPLS were analysed with a Wilcoxson signed-rank test by LCF. For the open-ended questions, all responses were transcribed by ST, HB to a spreadsheet and coded and analysed by LCF. LCF who is a non-specialist from the wider team and experienced qualitative researcher analysed all free-text responses. 35 Qualitative data from the free-text questionnaire were analysed using NVivo V.10. Of note, 300 medical and 150 nursing students participated.

In quantitative assessment, we compared mean RIPLS subscale scores with a Wilcoxson signed-rank test to determine if the IPE intervention had changed students’ attitudes.

When all the results from all students are analysed for the intervention groups for the students who returned their forms (185 preintervention and 200 postintervention), the statistically significant improvements post-IPE was found in all four RIPLS subscales, due mainly to nursing students responses: teamwork and collaboration, positive professional identity, roles and responsibilities and negative professional identity ( figure 1 ).

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Object name is bmjopen-2017-018041f01.jpg

Results for all nursing and medical students showed post-IPE statistically significant improvements in all four RIPLS subscales. IPE, interprofessional education; RIPLS, readiness for interprofessional learning.

But, when a t-test is applied to the forms from the nursing students only (preintervention 91, postintervention 95 returned forms, figure 2 ) it showed, on average, that participants scored higher on teamwork and collaboration post-IPE (M=40.78, SD=4.05) than pre-IPE (M=34.59, SD=10.36). This difference was statistically significant ( t (−5.32)=115.86, p=0.000). Participants scored lower on negative professional identity after IPE (M=7.21, SD=4.2) than before it (M=8.46, SD=4.1). This difference was statistically significant ( t (2.06)=183.94, p=0.041). Participants on average scored higher on positive professional identity (M=16.43, SD=2.76) post-IPE than prior to the IPE session (M=14.32, SD=4.59). This difference was statistically significant ( t (−3.78)=146.2, p=0.000). On average, participants scored lower on roles and responsibilities after IPE (M=5.41, SD=1.63) than before it (M=6.84, SD=2.75). This difference was statistically significant ( t (4.27)=145.14, p=0.000).

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The nursing students in the intervention group showed post-IPE statistically significant improvements in all four RIPLS subscales. IPE, interprofessional education; RIPLS, readiness for interprofessional learning.

As shown in figure 3 , the analysis of the returned forms from the medical students from the intervention group analysis (preintervention 94, postintervention 105 returned forms) had revealed that they had scored higher on teamwork and collaboration post-IPE (M=36.66, SD=5.1), than pre-IPE (M=32.68, SD=7.4). This difference was statistically significant ( t (−4.36)=162.43, p=0.000). Also, these students on average scored higher on positive professional identity (M=14.3, SD=3.2) post-IPE than prior to the IPE session (M=13.1, SD=4.31). This difference was statistically significant ( t (−2.24)=197, p=0.026). However, these medical students scored lower on negative professional identity after IPE (M=7.6, SD=3.17) than before it (M=8.36, SD=2.91). This difference was not statistically significant ( t (1.69)=197, p=0.092), and there was little difference in post-IPE for roles and responsibilities after IPE (M=7.4, SD=1.85) than before it (M=7.85, SD=2.1). This difference was not statistically significant ( t (1.58)=197, p=0.116).

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Object name is bmjopen-2017-018041f03.jpg

Post-IPE, the medical students in the intervention group showed statistically significant improvements in two RIPLS subscales: teamwork and collaboration and positive professional identity. IPE, interprofessional education; RIPLS, readiness for interprofessional learning.

The results for the control group of students who returned the forms (preintervention 74, postintervention 54) are shown in figure 4 . Post-IPE results had shown the significant improvements in the teamwork and collaboration (M=36.07, SD=3.8), than pre-IPE (M=33.95, SD=3.37). This difference was statistically significant (t(−3.35)=126, p=0.001). The control group had scored higher on positive professional identity subscales (M=13.74, SD=2.64) post-IPE than prior to the IPE session (M=12.8, SD=2.29). This difference was statistically significant (t(−2.16)=126, p=0.033).

An external file that holds a picture, illustration, etc.
Object name is bmjopen-2017-018041f04.jpg

Post-IPE, the medical students in the control group showed statistically significant improvements in two RIPLS subscales: teamwork and collaboration and positive professional identity. IPE, interprofessional education; RIPLS, readiness for interprofessional learning.

The control group scored slightly lower on negative professional identity post-IPE (M=8.48, SD=2.52) than pre-IPE (M=9, SD=2.07). This difference was not statistically significant (t(1.23)=100.42, p=0.219). They also on average differed little on roles and responsibilities (M=7.89, SD=1.69) pre-IPE (M=7.91, SD=1.51) than post-IPE. This difference was not statistically significant (t(.11)=126, p=0.916).

Unexpectedly, the results collected from all medical students show that both the intervention and control groups have the same outcome and this is illustrated in figure 5 .

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Object name is bmjopen-2017-018041f05.jpg

Post-IPE results show that medical students from the intervention and control groups had identical change in the RIPLS subscales. IPE, interprofessional education; RIPL, readiness for interprofessional learning.

All feedback forms were assessed for free-text comments.

Open-ended questions and results

Awareness of roles, expertise and responsibilities ( tables 1 and 2 ): in terms of the actual session, both groups enjoyed getting to know more about the other role’s perspective and what they would do in different situations. They also enjoyed learning about how they could collaborate with one another. Medical students found IPE improved their understanding of nursing priorities and thinking, and also illustrated the differences in expertise/skills and roles between the two groups. Both groups enjoyed sharing their different experiences.

Qualitative data pre-IPE for the intervention and control groups: awareness of roles, expertise and responsibilities; nursing and medical students’ concerns about IPE; curriculum topics

IPE, interprofessional education.

Qualitative data post-IPE for the intervention and control groups; awareness of roles, expertise and responsibilities; nursing and medical students concerns about IPE; curriculum topics

Nursing students concerns about IPE ( tables 1 and 2 ): prior to the session concerns about learning alongside medical students; they felt intimidated and feared there would be a hierarchy, but IPE appeared to be successful in removing these concerns, with nursing students finding the sessions very open and comfortable who also indicated that they found easy to contribute to the session, and they found the group to be very welcoming and respectful, and the session to be very relaxed. The results of this study also suggest that the nursing students became more confident as a result of the teaching; with some indicating that they would be happier to approach a doctor in the future or share information with them. It would appear that IPE resulted in boosting nursing confidence around their medical peers, and decreased concerns about feelings of inferiority/intimidation. Nursing students suggested that the teaching session highlighted the fact that medical students were not so different to nursing. It is also interesting that post-IPE nursing students appeared to be more specific in defining their own areas of expertise and in some way shifted nursing perspectives of their own expertise, describing more expertise than prior to IPE.

Medical students concerns about IPE ( tables 1 and 2 ) were about working with nursing students being perceived as arrogant, pretentious and condescending prior to the session. During the session, they found it very easy to contribute, regardless of group (intervention or control) and both felt IPE had emphasised the importance of communication. Both professions also felt that teaching had improved their knowledge of the roles in the multidisciplinary team (MDT).

In terms of perceptions of each other’s role, pre-IPE and post-IPE ( tables 1 and 2 ) views of the doctors’ role remained the same across both professional groups and teaching conditions (active vs control). Everyone viewed this role as one focused on diagnosis and treatment, with some clinical decision makings. In terms of the nursing role, nursing students’ perceptions also did not change much post-IPE, but more nursing students discussed the fact about the roles and responsibilities for working collaboratively for the best of the patient interests. This was not a common theme among the medical student responses in either the intervention or the control groups. Similar to role, both nursing and medical student perceptions of doctors’ expertise did not change much post-IPE. Perceptions of the role very much focused on doctors’ medical knowledge and knowledge of treating the patient. Medical student descriptions of nursing expertise also did not appear to change much across either groups or condition. However, as stated earlier, nursing student perceptions of nursing expertise were somewhat more extensive post-IPE.

Curriculum topics : the list created initially pre-IPE by students for the future topics varied a bit, but post-IPE, the most common topics suggested by both groups included working on case scenarios, communication, ethics, the deteriorating patient and emergency situations. What is even more interesting is the fact after teaching some of the control group suggested doctor/nursing roles as a topic for future teaching ( tables 1 and 2 ).

Receptiveness to geriatric IPE : it was received generally in a positive light by both healthcare groups, but slightly more so by nursing students. It appears to have reinforced the importance of collaborative working, with a majority of students believing it had improved their ability to work collaboratively and most stating that they would be happy to participate again ( table 3 ).

Qualitative data post-IPE for the intervention and control groups; ease of contribution/voicing opinion during IPE, meeting the expectations from IPE, participating in IPE again, enjoyment in IPE, learning points from IPE, understanding collaboration, the impact of IPE on the ability to work collaboratively

Please note real comments from students are in written in Italics.

Expectations of IPE ( table 3 ) varied among the students before the session, but post-IPE, most students expressed positive views and felt that it was more useful than they had expected it to be. Out of both nursing and medical students, nursing students appeared more open to the overall concept of IPE, unlike medical students. Some medical students had higher expectations from the feedback sessions and their learning about the nurses’ role. Majority of students in both groups enjoyed this experience, found contribution/voicing opinion during IPE easy and would like to take part in IPE again ( table 3 ).

Understanding of interprofessional collaboration ( table 3 ): both groups felt that the teaching enhanced their understanding of interprofessional collaboration and increased their ability to work collaboratively. Nursing students felt their ability had been enhanced through a better understanding of the roles in MDT and the doctor’s perspective. Medical students believed their ability was improved through a better understanding of the nursing perspective and indicated they would greatly value the views of other healthcare professionals. Only a minority of students felt it had not increased their understanding or ability.

Future IPE sessions-included comments about better organisation that smaller groups were more effective and some preferred a shorter session ( table 3 ).

This workshop was developed to promote IPE, through better understanding of participants’ own and others’ professional roles (nursing/clinicians), through observation and exploration of participants’ reciprocal perceptions, participating in cooperative learning 36 and collaborating practice between ‘old-timers and newcomers’, where more skilled practitioners assist the learner’s development beyond their competence. 10 37 38 The promotion of participants’ responsibilities, joint working/decision-making, interchanging IP knowledge, problem-solving, 39 40 mutual respect, trust-development based on the knowledge of the role performance, behaviours, attitudes, communication, coordination and negotiation, while working on common geriatric problems that are relevant to both professions, 4 10 14 41–45 were encouraged.

This group-based and case-based IPE replaced the model where students learn exclusively from the instructor, emphasising instead learning closer to real-world settings, based on cooperation, requiring students to work collaboratively. 8 14 However, it was assumed that IPE facilitators possess some key knowledge and skillsin the care of the elderly patients, have the ability to manage diverse expectations. Theywere focused in their preparation for these sessions on the PBL case scenarios, more on encouraging students to ask the right questions in a group context. 46

The literature describes many methods for delivering IPE to health professionals, regardless of specialty, including attending common courses, IP healthcare team activities, patient simulations and elective live-in placements, 4 44 45 47 based on the assumption that IPE-related general principles are applicable to education in geriatric medicine. 12 Difficulties encountered while setting up IPE in undergraduate geriatrics included the lack of data for selecting the following: optimal students level of clinical experience and education, best teaching methods, most suitable curriculum topics for such teaching, optimal number of students per teaching group, length and number of sessions. Also, other encountered difficulties included the timetabling of large number of students/staff from three different organisations, securing adequate teaching space and qualified teachers and how best to evaluate the teaching.

About our IPE sessions were based on geriatric case scenarios and allowed close contact between IP tutors from both disciplines and students in groups, who reflected on cases/practice-reflection: a ‘prerequisite of professional caring’ including situated learning. 10 42 48 49 The emphasis was on promoting ethical practice, relationship-centred care, collegiality, learning together and also learning about each other, communication including narrative methods, 47 50 51 all possibly influencing hidden curriculum. This teaching relied on theories that IPE is based on social, cooperative and collaborative learning, the so-called group model, where learning is created in the interaction/inter-relationship with others, related to the formation of clinical judgement, that the knowledge from IPE could be acquired from the faculty and peers, allowing students to gain a view of ‘others’ professions’ by feeling, watching and thinking. 52 The sessions complied with levels 1 and 2a of the Classification of Interprofessional Outcomes. 42 These results are in accordance with the results of the IPE studies, showing positive reaction of learners to IPE, and improvements in attitudes/perceptions and collaborative knowledge/skills. What is still needed is further evidence about geriatric IPE effect on behaviour, benefit to patients and longer term outcomes. 53

Different disciplines and teamworking bring different philosophies, problem-solving styles and system issues, while working together on a given clinical problem/scenario as a context for decision-making. Students’ work was combined with the input from senior teachers/practitioners (the intervention groups had the advantage of participating twice with ‘other’ professionals). This teaching could not ensure that participants would continue to function as ‘members of the teams’; it aimed to improve their ability to communicate while emphasising that each profession work is based on the mastery and utilisation of distinct types of expert information, the acquisition of the ability of one profession to understand the judgement, meanings and recommendations of ‘others’, the ‘mastery of differing cognitive and normative maps of different professions’. 8 Teaching pointed towards recognition of the limits of one’s own type of knowledge and skill set, and the recognition when to rely on the ‘others’ as confirmed by student feedback. 36 54 55

Our medical and nursing students showed gains in RIPLs domains, thereby supporting that there was a true benefit from the experience, correlating to the results from other IPE studies. 17 The success of this teaching may be also attributed to the nature of geriatrics as a collaborative specialty, and to the educators’ collaborative approach (characteristic for geriatrics problem-solving) in all given cases, contributing both to the students’ positive attitude and to the positive results of the study. For it is well-known example that nursing-practitioner interactive communication with the team members was commonly reported as enhancing team collaboration and its efficiency. 51 56

Interestingly, the intervention and control groups with medical students only, had similar results with the improvements of the RIPLS scores in the same domains, raising the possibility that the group of geriatric educators when mixed from two different health professions, are capable together to successfully deliver geriatric IPE to the uniprofessional groups of learners via PBL method. This can have important implications for the future practice making IPE delivery simpler. This teaching allowed participants to reflect, correct each other’s biases and to see the viewpoint different from their own and for the control group this was also possible, as facilitators represented the ‘other discipline’. 14 39 40 57 Further research is necessary to untangle the impact of geriatric specialty itself from the impact of geriatric IPE, and to look what would happen if the same geriatric IPE is delivered to the different profession (eg, nursing students only), including what impact would such IPE have, if geriatrics is replaced with a different specialty.

IPE had a more positive impact on nursing students, with statistically significant improvements across all aspects of the questionnaire. We speculate that this was probably due to their more extensive clinical experience where they may had already encountered clinical situation needing collaboration between members of the MDT, influencing their perception of their and other professions’ roles, being less ‘observers’, but more ‘workers’ incorporated in their teams. 33 58

The immediate outcomes included students’ perception of improved ability to work collaboratively, the knowledge, that the ‘others’ hold and the importance of communication. The majority enjoyed this learning experience.

The free text about nursing students’ expectations of IPE before the sessions included concerns about their inadequate knowledge, fear of being undermined, intimidated, judged inferior and not being taken seriously by medical students. Medical students’ concerns were about the effectiveness of this learning, as well as that they might appear proud or arrogant to the nursing students, confirming that participants arrived with various assumptions about the other members of the team. 14 After IPE, nursing students highlighted that medical students were not so different and the majority of all students stated that they now had no concerns about IPE. Few medical students stated that the groups were starting from different knowledge levels/backgrounds or that IPE was happening too early in their training.

During the sessions, almost all found it easy to contribute regardless of group (intervention or control) or profession; IPE matched students’ expectations, they enjoyed getting to know more about the other role’s perspective, and what they would do in different situations. IPE helped their understanding of IP collaboration, ability to work together, of differences in training and expertise/skills/roles.

Some students (mainly from the control group) complained about ‘long sessions’ and organisation; a certain number of these students would not participate further unless the activities were better organised and nursing students did not participate. This was understandable: they needed less time to complete their tasks in the first place, as they were not paired with nursing students.

The majority stated that the workshop met their expectations; a few said that it was more useful than expected. A minority asked for more specific teaching on IP collaboration. The most commonly suggested curricular topics for future IPE sessions were teaching about communication and ethics in geriatrics.

Despite recommendations in the literature for equal numbers from each profession in the participating groups, we could not achieve it. Yet this did not affect the positive outcomes of IPE. The optimal size of the IPE groups of learners is not known: 12 our results indicate that 10 should be the maximum number in each group, though a few students thought this number was too high. From our experience, we learnt that the groups should have 10 or less than 10 students, as better quality discussion is achieved in smaller groups where every member had a voice that was not lost. A big challenge with organising IPE was the logistics of finding appropriate space.

The unplanned benefit of this teaching included strengthened links through joint work between practice-based clinicians and university educators (NHS/Universities). Overall positive feedback from the students had impact for the future teaching: the new plans for the further development of undergraduate geriatric IPE will also include other students (paramedics and pharmacy) who will join medical and nursing students in the future teaching sessions. The significant changes are to be implemented, as the direct consequences of the results of this study are the inclusion of more clinically experienced Year 6 medical students, instead of Year 4 in future geriatric IPE sessions.

This open and flexible approach by two academic institutions in collaboration with NHS trust staff enabled ‘cutting through disciplinary boundaries’, 14 emphasising that it is possible and indeed practicable to combine uniprofessional and IP discourses, so we would recommend this form of IPE for geriatrics, with the expanding of the inclusion of other professions. The results from this teaching may be seen as confirming that the outcomes of IPE delivery in geriatrics are positive, regardless of the form it takes, 12 possible also due to conveying to the students the skills, knowledge and energy of the geriatric teams and their ability to solve problems. 59

The limitations of this study include the use of RIPLS scale, and known concerns about it 27 33 60–62 prompted the use of the modified scale. In the meantime further development and validation of instruments to measure the variety of IP competencies related to IPE continued, giving more options to the researchers compared with the time of planning and conducting our study, and in 2017 a global consensus was reached on IP learning outcomes, as well as guidance on the purpose of the assessments in IPE. 34 63

Statistical analysis was limited by the fact that not all students returned the feedback forms (possibly missing more negative views, but this is less likely as completion was anonymous). However, some students commented that completing both questionnaires was time-consuming, possible contributing to the reduced rate of feedback. The overall number of nursing students was smaller owing to the nursing availability at the JR hospital site; the control group consisted of only medical students for the same reasons. Other limitations are also not distinguishing between graduate and undergraduate entry medical students, possible influencing the study results, as the age and maturity of students is well recognised that can influence learning outcomes. 64 65 Also, students had unequal levels of clinical experience at the time of their IPE workshops, with the nursing students having more than the medical students at the time of the workshop, as well as the lack of the involvement of patients and carers in the development of this study 66 . The study was conducted on the PBL case-scenarios, and future work should expand to the clinical practice. The strength of the study is the inclusion of a larger number of participants from both disciplines, the inclusion of the control group and that this was a controlled before–after study.

Our findings have several implications for the undergraduate education in geriatrics. They indicate that some aspects of geriatric medicine can be delivered effectively to nursing and medical students through PBL IPE, if facilitated by educators from both professions. Developing IP skills is difficult with traditional, lecture-based teaching; this project describes one alternative way of delivering such teaching, showing that IPE can significantly improve students’ attitudes to working and learning with other professions. This easily replicable teaching method provides a simple means of reinforcing the importance of collaborative working when looking after older patients.

While IPE had a more positive impact on nursing students, medical students had still shown statistically significant improvements in two domains (teamwork and collaboration and positive professional identity), revealing identical results in the intervention and control groups, suggesting that the delivery of geriatric IPE could be simplified and still successfully delivered to the undergraduate students by a mixed group of educators, if they act as members of the IP team, to the uniprofessional groups of learners, via PBL method, ‘enabling the professions to learn with, from and about each other’. 67

Overall, IPE appeared to be successful in addressing some cultural issues that may have acted as barriers to working together, and in allowing groups to understand each other’s perspectives, emphasising the importance of each role in MDT. A majority of students (both professions, intervention and control groups) believed the experience had enhanced their understanding of collaboration and their ability to work together, particularly boosting nursing students’ confidence in their expertise around their medical peers. This programme demonstrated a simple, easily implementable yet effective means of providing appropriate education in geriatric medicine through IPE to medical and nursing students, applicable in the UK and abroad.

Future research into IPE in geriatrics should investigate the impact if only nursing students act as control group; if it occurs later in medical students’ education; if sessions are longer and repeated; if they incorporate exclusively the topics suggested by the majority of students and if delivered in clinical setting. Future research should also investigate what would happen if such teaching were delivered to other professions.

In conclusion

Effective undergraduate geriatric interprofessional education (IPE) could be delivered in one session to the group not bigger than 10 students, not requiring equal number of learners from each profession.
Mixed group of educators successfully delivered IPE to uniprofessional groups of learners via problem-based learning method, as intervention and control groups had improved readiness for interprofessional learning scores in the same domains.
IPE had more positive impact on nursing students, probably attributable to their more extensive clinical experience before geriatric IPE.
Geriatric IPE helped resolve some students’ concerns; nursing about inadequate knowledge, medical about being perceived as arrogant.
The most commonly suggested topics for future geriatric IPE sessions were about communication and ethics.

Supplementary Material

Acknowledgments.

A. Gardner (medical student) and L Twhittle (nurse) initiated the first pilot IPE project in clinical medicine at the OUH in 2013 and the concept of this IPE. Ms Z Scullard gave continuous support to the project and Ms K Quinlan gave the advise about the evaluation of the project. Funding acknowledgement: The project had a financial support from Health Education England Thames Valley (HEETV). The case studies mentioned were created for teaching purposes and do not represent real patients.

Twitter: @DrGSAlg

Contributors: ST designed the study, acquired data, designed analyses, led the workshops and wrote the paper. KM designed the study, acquired data, designed analyses and wrote the paper. KB, HB and CH acquired data, performed statistical analyses, led the workshops. CM designed the study, acquired data, led the workshops and contributed to the manuscript. LCF designed and performed the statistical analyses and contributed to the manuscript. GSA led the workshops, acquired data and contributed to the manuscript. JB, EP and CFJ led the workshops and acquired data. LW helped with the organisation of the workshops and contributed to the curriculum.

Funding: Health Education Thames Valley gave a small grant to support and develop IPE course.

Competing interests: ST, CM and LCF were supported by HETV grant.

Patient and public involvement statement: There was no patient and public involvement.

Patient consent for publication: Not required.

Ethics approval: Students consented to participate in this study and had the right to withdraw at any point. This study was approved by the Research Ethics Committees (CUREC); the reference number for this project is MSD-IDREC-C1-2014-027.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: All data relevant to the study are included in the article or uploaded as supplementary information.

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