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Only 13 studies of IP SRCs reported their outcomes. These studies have been grouped according to their study methods with outcomes classified using the modified Kirkpatrick typology (Barr et al 2000) (See Table 10). Outcomes included learner reactions (level 1), modification of attitudes and perceptions and acquisition of knowledge and skills (level 2), and results (level 4). No studies were found that addressed behaviour change (level 3).

2.4.8.1. Questionnaires and surveys

In the US, Shrader et al. (2010) used a pre-post email survey to assess student participants in an elective interprofessional course that included service in an IP SRC. The survey was a self-developed 17-item tool addressing student attitudes to IP healthcare, professional roles, and teamwork (Level 2a). Eight questions from the Readiness for Interprofessional Learning Scale (RIPLS) were included and the remaining questions, developed by the evaluators, addressed student confidence in working in IP teams, the role of IP teamwork in the future, and understanding the roles of specific professions. The survey was not validated. They found no difference pre to post-intervention for any of the RIPLS items but significant differences were found in the investigator developed items regarding professional role understanding with significant changes in participant understanding of the role of the PA in the IP team (Level 2b). Also in the US Sheu et al. (2011) surveyed medical, nursing, and pharmacy students who participated in a Hepatitis screening IP SRC identifying student self-reported increases in role understanding, teamwork, and collaboration.

Outcome Authors

Kirkpatrick Level 1: Learners’ reactions

Student satisfaction Morello et al. (2010); Wee et al. (2010; 2011); Westra et al. (2011); Holmqvist et al. (2012); Ambrose et al. (2015)

Kirkpatrick Level 2: 2a. Modification of attitudes /perceptions 2b. Acquisition of knowledge /skills

Attitudes to working with the homeless Beck (2005) Sociocultural attitudes Sheu et al. (2012)

Student confidence Morello et al. (2010); Westra et al. (2011)

Professional skills and competencies Morello et al. (2010); Westra et al. (2011)

Clinical reasoning Seif et al. (2014)

Kirkpatrick Level 4: 4a. Change in organizational practice 4b.Benefits to patients/clients

Patient Clinical Outcomes Hypertension - Wee et al. (2011); Sheu et al. (2010)

Patient satisfaction Wee et al. (2011); Lawrence et al. (2015)

System-based practice Sheu et al. (2013)

Quality Improvement Ambrose et al. (2015)

Cost Haines et al. (2014)

Faculty / clinician satisfaction Ambrose et al. (2015); Guirguis and Sidhu (2011); Sheu et al. (2013)

Table 10: Outcomes for IP SRCs classified by the modified Kirkpatrick typology

Sheu et al. (2012) compared IP attitudes and sociocultural attitudes (Level 2a) in 1st year medical, nursing and pharmacy students who did, and did not, participate in an IP SRC. Using the RIPLS and the Sociocultural Attitudes in Medicine Inventory (SAMI) they found no changes in RIPLS or SAMI items for those who participated in an IP SRC. Initial student scores were high and it is worth noting that the ceiling effect of the RIPLS is well

documented (Nørgaard et al. 2016). The authors suggest that the SRC experiences may not have been frequent enough to result in attitude change. Despite this finding over half of the students self-reported improved IP attitudes.

Two studies (Kent and Keating 2013; Lawrence et al. 2015) used questionnaires to examine patient satisfaction of care within an IP SRC. Kent and Keating (2013) reported on an IP SRC for older people following discharge from an acute care hospital in Australia. This involved student teams from nursing, medicine, occupational therapy, physical therapy and social work who used a standard screening tool to identify factors impacting patient

independence and health. Patients reported the programme was well received and

described the students as having provided them with useful self-management information.

Using a non-equivalent groups post-intervention only study design Lawrence et al. (2015) compared patient satisfaction in a US IP SRC to that in a traditional primary care (non-IP not student-run) clinic. Patients reported high levels of satisfaction with the care team with no

difference in satisfaction levels reported between the two clinics. However, IP SRC patients reported less satisfaction with their access to care and perceived the privacy of their protected health information as less secure in the IP SRC than in the more traditional clinic setting.

2.4.8.2. Qualitative interview studies

Guirguis and Sidhu (2011) reported on a qualitative study addressing pharmacy student and preceptor experiences of a Canadian IP SRC. Interviews with students and preceptors identified three main themes, dynamic team roles, interprofessional role understanding and personal benefits. Dynamic team roles concerned varied levels of student participation in the team depending on the students knowledge and experience level and the degree of IP role modelling by the supervising physician, interprofessional role understanding was thought to develop through exposure to different professions, and personal benefits arose as the students learnt about their own professional role and gained new perspective on the population served by the clinic.

Wee et al. (2011) reported the outcomes of their IP SRC (Singapore, Neighbourhood Health Screening) focussed on chronic disease management. They conducted 355 patient

interviews using a standardized list of yes / no response questions administered over a 3year period. Patient satisfaction with the service provided was high (83%). Over a one-year period, the percentage of individuals receiving treatment for hypertension rose from 63% – 93% and blood pressure (BP) control improved from 42%-79%. For those newly diagnosed with hypertension, 49% were reported as having their BP under control.

Sheu et al. (2013) used in-depth semi-structured interviews with students and faculty mentors to explore the types and context of systems based practice activities students experience when working in an SRC. They identified six major domains; interprofessional roles and collaboration, clinic organization, patient factors affecting access to care,

awareness of the larger healthcare system and continuity of care, resource acquisition, and allocation, and systems improvement.

An interesting finding from Sheu et al. (2013) was how students who served as clinic coordinators, with responsibility for managing the clinic, showed better understanding regarding system-based practice issues than students who were only involved in providing patient care. They suggest that the IP SRC is a suitable environment for students to learn about systems-based practice.

2.4.8.3. Cohort studies

In the US Seif et al.‘s (2014) prospective cohort study, used experimental and control groups and a pre-post test design to compare students who participated in an IP course plus an IP SRC, to students who had only experienced the IP SRC, and those who had experienced neither. They hypothesised that students who participated in the IP course and

worked at the IP SRC would demonstrate significant increases in their perceptions and attitudes for working in IP healthcare teams (Level 2a) and clinical reasoning skills (Level 2b), compared to students who did not participate. They applied the following assessment tools Interdisciplinary Education Perception Scale (IEPS), RIPLS, and Self-assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course

demonstrated improvements in IP perceptions and attitudes and perceptions of clinical reasoning skills compared to those in the control groups.

Sick et al. (2014) reported the results of a US prospective observational cohort study addressing IP attitudes and skills (communication, teamwork, attitudes to IP learning, relationships and interactions - Kirkpatrick levels 2a and 2b) in students who participated in an IP SRC compared to those who applied to participate and were not accepted, and those who never applied. They found decreased IP attitudes and skills for all groups after the first year. They suggest this decline is due to students confronting the reality of patients’ complex issues, which seem outside the capabilities of the team to resolve. In the next 2 years, they reported higher IP attitudes for those who participated in the IP SRC compared to the other groups, with those who were not accepted becoming similar to those who never applied. As discussed previously, they suggest participation may have a protective effect against declining IP attitudes and skills and suggested contact theory as a potential explanation for the development of this effect. Specific items reported to be higher in IP SRC participants included increased comfort in presenting care plans to supervisors and senior students and working in a group, improved communication skills with patients, peers and other professionals, strengthened confidence and comfort in relationships with peers and other professions, and improved patient care.

2.4.8.4. Mixed methods studies

Ambrose et al. (2015) conducted a quality improvement review of an IP SRC in Canada. Using retrospective data analysis and questionnaires addressing the questions of who participates and what do they learn. Although both students and faculty supervisors reported high levels of satisfaction with the experience, issues with student retention were highlighted with the majority of students reported as attending only one shift in the clinic, and with limited diversity in the professions represented in both the students and faculty.

2.4.8.5. Cost analysis studies

Haines et al. (2014) compared the cost of the Australian IP clinical experience described by Kent and Keating (2013) to a traditional hospital clinical placement (Level 4a). They

identified the IP SRC as the more expensive option but suggested that if better patient outcomes were indeed achieved through such IP collaboration (e.g. fewer readmissions) this might offset the additional cost.