Balke, Johannes; Busch, Susanne; Herzig, Lita; Käuper, Kristin-Maria; Westenhöfer, Joachim

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1 Expectations concerning a future health care system the view of physiotherapists, occupational therapists, speech and language therapists, and midwives. Development of a bachelor program at the Competence Center Health at Hamburg University of Applied Sciences, Germany. Balke, Johannes; Busch, Susanne; Herzig, Lita; Käuper, Kristin-Maria; Westenhöfer, Joachim Abstract Background: Increasing chronic diseases and multimorbidity in society, growing numbers of caesarean sections and interventions in pregnancy and birth have caused a change in the tasks of non-medical therapists and midwives. Vocational schools provide only insufficient training to meet the resulting responsibilities. The Hamburg University of Applied Sciences intends to develop an interdisciplinary bachelor program for four health professions. Methods: Experts of each profession are interviewed in a three-step Delphi online survey. During the first phase a qualitative questionnaire is used to identify current and future challenges of healthcare as well as the required competencies. Followed by a quantitative questionnaire based on the results of phase one, the second phase is to assess the required contents and competency needs. The third survey intends to map a group consensus regarding curricula content. Results: Scientific competencies which are linked to an academization of education are considered necessary. In achieving a client-centered health care system, the building of competencies to participate in the development of new healthcare structures ranks high. Further focuses lie on building competencies concerning leadership, communication and tutelage of learners. Discussion: An interdisciplinary bachelor program imparting the necessary competencies for future requirements may contribute to developing a sustainable health care system. 1

2 Introduction In the Bologna Declaration (1999) the European Ministers of Education committed themselves to support lifelong learning. Providing bachelor programs for vocationally trained health professionals is a good way to reach this target. Germany is the last European country where midwives, occupational therapists, physiotherapists and speech and language therapists in the majority of cases are still trained at vocational schools (COTEC 2012, CPLOL 2009, WFPT n. d.). In the national contest Advancement through Education: Open universities' ( Aufstieg durch Bildung: Offene Hochschulen ) the German Federal Ministry of Education and Research (BMBF) promotes projects of advanced scientific training at universities. The participating project at Hamburg University of Applied Sciences (HAW Hamburg) is funded by the BMBF and the European Social Fund (ESF). One bachelor program is developed for four health professionals at the Competence Center Health (CCG) of HAW Hamburg. Background The German health sector constitutes a considerable economic factor with total expenditures of bn (11.3% of GDP) (Destatis 2013a). In the health services 4.9 million persons are employed (Destatis 2013b) which represent 11.7% of the total workforce (Destatis 2013c). In % of health care employees ( ) are occupational therapists, physiotherapists, and speech and language therapists. Midwives represent 0.4% (21.000) (Destatis 2013d). As the employment rates in Germany s health services increase by 2% p.a., the number of people working in therapeutical health professions increases by 6% p.a. (Wissenschaftsrat 2012: 22 f.). Growing employment rates in spite of Germany s declining birth rate can be observed in midwifery as well (Destatis 2013d). Changes in health care prerequisites significantly change requirements on health professionals work. Facing the challenge the German Council of Science and Humanities (Wissenschaftsrat 2012) recommends that up to 20% of physiotherapists, occupational therapists, speech and language therapists and midwives should graduate from universities. In addition academic advanced trainings should be developed for those who are already trained (WR 2012:8). Although a slow process of academization in Germany has started there is still a lack of top-up bachelor programs. The CCG at HAW Hamburg follows the recommendation and is developing an interdisciplinary bachelor program for the aforementioned health professions. The format of a part-time program facilitates compatibility of study and work-life 2

3 balance. The interdisciplinary character and the new target group set special requirements for the development of a demand-related study program. Therefore a comprehensive empirical survey supports the curriculum development. Research approach Up to now no robust data for Germany exists on interdisciplinary study concepts and needs of prospective students and the labour market. The development of a demand-oriented curriculum requires an evaluation of necessary competencies and a needs assessment. In order to determine the content as well as the structure of the study program an empirical approach is carried out. It aims to gain and evaluate expectations directly from the practitioners groups about emerging challenges, demands in health care, requirements regarding interdisciplinary teamwork and motivation starting studying or not. A qualitative and quantitative research study consisting of a three-step Delphi survey and expert interviews with lecturers of scientific disciplines is conducted. Delphi method The approach of Delphi method is a systematic group communication process in which experts express their opinions about complex issues. Therefore an iterative process is initiated in which results of previous rounds are fed back, anonymously, to a group of experts for new evaluation (Häder 2010). However, Cuhls points out that the Delphi method exists in various approaches as panel sizes and the number of survey rounds differ (2009). In the survey the expert panel is decided to consist of n = 48 experts so that from each professional group n = 12 experts should be interviewed. The panel represents five different areas: professional political level (one expert), professional training (two experts), research and science (two experts), employees (five experts), and employer level (two experts). However, some of the contacted experts unexpectedly answered several weeks later. In the meantime replacements are invited into the expert panel, so it widened up to n = 54. As the first survey round focuses on qualitative data and not on a quantitative comparison of answers the panel enlargement does not influence the quality of the survey. 3

4 Procedure In May 2013 a pre-tested qualitative questionnaire regarding current and future challenges of health care, experience with interdisciplinarity, required competencies, motivation to study and structural study formats is designed for the Delphi survey. The experts are asked to answer the first round either online or via paper and pencil questionnaire. Drawing upon these results a quantitative questionnaire is designed for the second round. In July 2013, the experts are assessing the pre-tested questionnaire by using a four-point Likert scale from 1 (unimportant) to 4 (very important). 179 items concerning teaching and learning objectives and skills to be achieved and 13 items concerning part-time study structure are identified. They shall be used to develop a demand-oriented program. The second round data is reflected, discussed and completed by lecturers of scientific disciplines. In the third round feedback on single modules is given by the expert panel. Figure 1 shows the planned research process. figure 1: flowchart Delphi survey 1. online expert round with health care professionals QUALITATIVE Expertsurveys with lecturers of scientific disciplines 2. online expert round with health care professionals QUANTITATIVE 3. online expert round with health care professionals QUANTITATIVE Impulses for content design of the study program Results first round The data of n = 48 experts (89%) is used for a qualitative content analysis following Mayring (2011). Concerning the motivation related to a part-time study program reasons or obstacles named can be subsumed under seven categories (figure 2). 4

5 figure 2: reasons pro and contra part-time higher education number of named reasons pro and contra part-time higher education pro: development of advanced skills pro: promotion of the professional group pro: promotion of career opportunities pro: promotion of interdisciplinary teamwork contra: negative cost-benefit-ratio contra: high weight of theory contra: workload of part-time academic training Motives related to development of advanced skills in science and professional practice are named most frequently by the experts. Promotion of the professional group and promotion of career opportunities are frequent motives as well. Worth mentioning is a possibly low economic benefit of a bachelor degree in these professions. Being graduated does not cause higher payment in Germany s health reimbursement system. Regarding learning issues 438 analysis units emerge from the analysis. Contents of learning are clustered into eleven main categories: discipline specific skills, basics of science and research, leadership actions, communication and tutelage of learners, interdisciplinary teamwork, professional environment, new health services, ethics, personal skills, and others. Most frequently the experts name discipline-specific skills, basics of science and research, business administration, and communication. For the quantitative questionnaire of the second round these eleven categories are transferred into teaching and learning objectives. Results second round 40 (83%) out of 48 of those surveyed have also attended in the second round. Considering all professional groups the highest means of teaching and learning objectives are in the areas conversational skills (M = 3.8, SD = 0.4), counseling (M = 3.7, SD = 0.5), basics of communication (M = 3.7, SD = 0.5), interdisciplinary communication (M = 3.7, SD = 0.5) and theory of treatment approaches (M = 3.7, SD = 0.5) followed by practical experiences in the context of evidence based practice (M = 3.6, SD = 0.6). Teaching and learning objectives regarding human genetics (M = 2.4, SD = 0.6), political science (M = 2.4, SD = 5

6 0.7), and knowledge about the current state of research of the other health professionals (M = 2.5, SD = 0.6) show the lowest means (table 1a, b). table 1a: learn objectives - highest means Learn objectives: highest means Mean ± SD Conversation skills 3.8 ± 0.4 counseling 3.7 ± 0.5 basics of communication 3.7 ± 0.5 interdisciplinary communication 3.7 ± 0.5 theory of treatment approaches 3.7 ± 0.5 practical experiences in the context of evidence based practice 3.6 ± 0.6 table 1b: learn objectives - lowest means Learn objectives: lowest means Mean ± SD human genetics 2.4 ± 0.6 political science 2.4 ± 0.7 knowledge about state of research of other health professionals 2.5 ± 0.6 According to the first round results there is strong interest in topics regarding leadership action and basics of science and research. Therefore, table 2 and table 3 demonstrate the average rating (Mean ± SD) of teaching and learning objectives to these two topics on a scale from 1 (unimportant) to 4 (important). Interdisciplinary teamwork (M = 3.6, SD = 0.5) and process management (M = 3.5, SD = 0.6) resulted to be very important learning issues. Tax law (M = 2.9, SD = 0.8) and MS- Office skills (M = 2.7, SD = 0.8) appear to be less important as the lowest means demonstrate. All these results solely reflect the opinions of experts in practical work without consideration of lecturers. 6

7 table 2: topics of the category leadership actions topics - category leadership actions Mean ± SD interdisciplinary teamwork 3.6 ± 0.5 process management 3.5 ± 0.6 quality management 3.5 ± 0.6 general organization of treatment centers 3.5 ± 0.6 documentation 3.5 ± 0.6 team guidance 3.4 ± 0.7 basics of leadership actions 3.4 ± 0.7 development of new services 3.3 ± 0.7 data protection 3.3 ± 0.7 economics 3.3 ± 0.8 acquisition 3.1 ± 0.8 project management 3.1± 0.8 Ensure the business success 3.1 ± 0.8 liability laws 3.1 ± 0.8 organizational development 3.1 ± 0.7 human resources development 3.0±0.8 business start up 3.0±0.8 labor law 3.0±0.7 organization software 3.0±0.6 conduct of negotiations 2.9±0.8 tax law 2.9±0.8 MS-Office skills 2.7 ±0.8 7

8 table 3: topics of the category basics in science and research topics - category basics in science Mean ± SD theory of treatment approaches 3.7 ± 0.5 diagnostic procedures 3.6 ± 0.6 benefits and limitations of evaluation concepts 3.6 ± 0.5 practical experiences in the context of evidence based practice 3.6 ± 0.6 developing individual evaluation concepts 3.5 ± 0.6 traditional knowledge and missing evidence 3.5 ± 0.6 understanding research process 3.5 ± 0.8 understanding study results 3.4 ± 0.6 scientific work techniques 3.4 ± 0.6 health service research 3.4 ± 0.7 guidelines 3.4 ± 0.7 understanding scientific literature 3.4 ± 0.8 literature search 3.3 ± 0.9 epidemiology 3.0± 0.7 statistics 3.0± 0.7 scientific communication 2.9± 0.8 experimental research designs 2.9± 0.9 scientific theory 2.8± 0.7 While theory of treatment approaches (M = 3.7, SD = 0.5) and reflecting practical experiences in the context of evidence based practice (M = 3.6, SD = 0.6) are rated as very important learning issues, scientific theory (M = 2.8, SD = 0.7) and scientific communication (M = 3.0, SD = 0.7) are resulting in the lowest means. Likewise epidemiology (M= 3.0, SD = 0.7) and statistics (M = 3.0, SD = 0.7) have low means. However, basic knowledge to these two issues is essential for understanding research approaches and evidence-based practice. 8

9 The expert panel weights as well personal competencies needed in daily practice as shown in table 4. table 4: personal competencies after graduating personal competencies Mean ± SD reflection about individual skills and limitations 3.7 ± 0.5 network thinking 3.6 ± 0.5 dealing with success and failure of treatment 3.6 ± 0.5 empathy 3.5 ± 0.6 self-organization and time management 3.5 ± 0.6 emotional self-protection 3.4 ± 0.6 reflection about self- conception as therapist or midwife 3.4 ± 0.6 dealing with closeness and distance to patients 3.4 ± 0.6 dealing with migrant background 3.1 ± 0.7 dealing with mental and/or physical handicapped persons 3.1 ± 0.7 dealing with severely ill patients or newborns 3.0 ± 0.7 reflection about closeness and distance 3.0 ± 0.6 dealing with psychogeriatric disorders 3.0 ± 0.8 The expert panel values reflection about one s skills and their limitations (M = 3.7, SD = 0.5) and network thinking (M = 3.6, SD = 0.5) as very important competencies. Reflection about closeness and distance (M = 3.0, SD = 0.6), and dealing with psychogeriatric disorders (M = 3.0, SD = 0.8) are valued least. However, data is analyzed across all professional groups and the particular item dealing with psychogeriatric disorders relates most to the field of occupational therapy and is of no interest to the field of midwifery. 9

10 Discussion: The purpose of the Delphi survey was to identify expectations and needs of physiotherapists, occupational therapists, speech and language therapists and midwives towards an interdisciplinary study program. Since no data of comparable study programs is available and regarding prospective changes in the German health sector necessary competencies for health care professions need to be addressed. The original intention was to determine challenges and demands in health care system giving clues to the development of modules. However, an university curriculum cannot be developed based on this data. One reason is the definition of working professionals as Delphi experts. The direct involvement of the target groups is one of Delphi methods advantages as empirical knowledge about expectations and needs concerning the future health system is delivered. Vice versa this tends to be a limitation as the necessary perspective of professional scientists for the curriculum development is missing. Therefore additional expert interviews with lecturers shall found a basis for preliminary learning modules. They will be significantly involved in curriculum development. These modules are to be discussed in the third round. Another difficulty is the heterogeneity between professional groups as well as within each professional group including specific terminology and perceptions. The gathered data shows that a unified survey across all four professions seems to be accompanied with different understandings of several items. Hence it would have to be discussed whether it leads to different results to subdivide professional groups in spite of a common survey. Reference List: Comité Permanent de Liaison des Orthophonistes-Logopèdes de l UE (CPLOL) (2009): Annual Statistics of Initial SLT Education Data in Europe 31 December 2007 and [ ] COTEC Summary of the occupational therapy profession in Europe 2012 updated 06/06/ seen [ ] 10

11 Cuhls K. (2009): Delphi Befragungen in der Zukunftsforschung? In: Popp R., Schüll E.: Zukunftsforschung und Zukunftsgestaltung. Berlin & Heidelberg, Springer Verlag Destatis (2013a): Gesundheitsausgaben ben/aktuell.html [ ] Destatis (2013b): Gesundheitsberichterstattung des Bundes, Beschäftigte im Gesundheitswesen. install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/&p _aid=i&p_aid= &nummer=85&p_sprache=d&p_indsp=-&p_aid= [ ] Destatis (2013c): Erwerbstätigenrechnung. taetigkeit/erwerbstaetigenrechnung/erwerbstaetigenrechnung.html [ ] Destatis (2013d): Gesundheitsberichterstattung des Bundes, Beschäftigte im Gesundheitswesen (Hebammen). install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/&p _aid=3&p_aid= &nummer=85&p_sprache=d&p_indsp= &p_aid= [ ] European Ministers of Education (1999): The Bologna Declaration of 19 June [ ] Häder M. (2010): Empirische Sozialforschung: Eine Einführung. 2. Auflage. Wiesbaden, Verlag für Sozialwissenschaften. Mayring P. (2010): Qualitative Inhaltsanalyse: Grundlagen und Techniken. 11. Auflage. Weinheim & Basel, Beltz. Wissenschaftsrat (2012): Empfehlungen zu hochschulischen Qualifikationen für das Gesundheitswesen, Wissenschaftsrat Drucksache , Berlin. World Federation for Physical Therapy (WFPT, n. d.): Entry level physical therapy education programmes. [ ] 11

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