This article examines the benefits of a Solution Focused Learning (SFL) curriculum for public health students. Interprofessional education and leadership training are an integral part of the SFL program. Through the incorporation of families of children with chronic health needs, graduate students receive instruction and practical experience working with a variety of health care disciplines, health administrators, direct service providers, and other representatives of the health system.

The benefits of the SFL model (an adaptation of problem based learning) for public health education are numerous. Students form more cohesive interprofessional relationships, acquire an appreciation of health policy issues, and become actively engaged in the learning process and develop leadership skills. They also learn about the impact of policy implementation on families.

Key words:
Interprofessional education
Special Health Care Needs
Disability
Public health education
Collaboration
Solution Focused Learning

There is a transition in the field of public health that is changing the educational domain of public health professionals. Public health professionals frequently interact with individuals with disabilities and their families to address a myriad of special health care needs. To effectively meet the needs of individuals with a disability they must use team approaches for collaboration and problem solving with representatives from community organizations, non-profit agencies, as well as local, state and federal government officials. These professionals are practicing in a number of varied settings. Health professionals are often required to provide leadership to improve systems of care, policies and services for individuals with a disability and their families (Clark and Weist 2000; Wright, Hann et al. 2003). Solution Focused Learning (SFL), an innovative and interdisciplinary curriculum, addresses these challenges. The purpose of this article is to

1. Describe SFL
2. Explain how SFL promotes interprofessionalism and leadership
3. Explain the relevance of SFL for disability studies.

The faculty at Partners for Inclusive Communities use SFL to promote leadership skills in graduate students. The SFL model of interprofessional education provides direction toward building respectful, collaborative partnerships among professionals. This curriculum is currently beginning the fifth year of implementation and more than 100 graduate students have attended SFL classes. SFL was developed as a part of the Leadership Education in Neurodevelopmental and Related Disabilities (LEND) Program funded by the Maternal and Child Health Bureau of the Health Resources Service Administration (Association of University Centers on Disabilities, 2004).

Partners for Inclusive Communities is affiliated with the Department of Pediatrics at the University of Arkansas for Medical Sciences, and is one of 63 programs established by the federal Developmental Disabilities Act as the University Center for Excellence in Developmental Disabilities Education, Research and Service (UCEDD). Core funding is provided by the Administration of Developmental Disabilities, with at least one UCEDD located in each state and in several U.S. territories. UCEDDs have a mission to promote self-determination, independence, productivity, and inclusion in all facets of community life for people with developmental disabilities (Gonzales, Gangluff, & Eaton 2004).

One of the projects of Partners for Inclusive Communities is the LEND Program, which is a leadership program for graduate and postgraduate students. The students represent a variety of disciplines: health services administration, public health, audiology, dentistry, nursing, nutrition, occupational therapy, pediatrics, physical therapy, psychology, speech pathology, and social work. The purpose of the grant is to prepare students to enhance and impact systems of care for children with chronic illness and related disabilities. Another purpose is to prevent development of secondary conditions by forging a community-based partnership of health resources and community leadership while helping families of children with disabilities participate in community life. This is accomplished through student participation in interprofessional clinical teams, research training, and SFL. Faculty members from each of the disciplines are represented in all SFL sessions and serve as coordinators for their respective students. In addition, students are expected to work with service providers, health administrators, state agencies, professional organizations and various health care boards or committees, and attend professional workshops and conferences.

Interprofessional Collaboration

Interprofessional collaboration is an essential component of disability related studies. The term interprofessional care is used rather than interdisciplinary care since those in the field of health care refer to themselves as professionals who practice in a specific discipline. The international heath care community has used the term interprofessional care in place of interdisciplinary care for a number of years (World Health Organization, 1988).

Today's public health professionals often interact closely with representatives from other health disciplines (Clark and Weist 2000). The need for collaboration among health-care disciplines is well documented in the research and has been found to enhance communication and improve teamwork (Neill 1999). There is a need to provide public health students with interprofessional collaboration and learning opportunities in addition to traditional graduate training (Dosser, Handron; et al. 2001).

A major barrier for full collaboration in the healthcare system can be due to lack of knowledge regarding other professions' expertise, skills, training, values, and theory (Lister 1980). A paradigm shift in the education of public health students is needed to work effectively in the public health domain, recognize the need for collaboration in a rapidly changing healthcare system, and shape policy to provide coordinated and improved health care for everyone (Gates and Sandoval 1998; Cronenwett 2002). SFL is a method to promote and encourage interprofessional collaboration through the interaction of various disciplines.

Leadership

There is growing recognition of the need for public health leadership as a national priority and the value of community/family collaboration in public health implementation as evidenced by inclusion in the literature (Wright, Hann et al. 2003). Leadership is defined as "the ability (or process) to influence, lead, or guide others so as to accomplish a mission in the manner desired by providing purpose, direction, and motivation" (Bell and Smith 2002). The emphasis is to train our students to become collaborative leaders. A collaborative leader will inspire commitment and action, lead as a peer problem solver, build broad-based support and participation, foster hope among the families, and promote policy and systems change to maximize public health (Wilson 2002).

Family interactions through SFL sessions enable public health students to develop leadership skills including shared learning, problem solving, reflection, and collaboration between health-care disciplines. Families of children with chronic illnesses and disabilities should be a part of public health education. It is important to educate public health students to become leaders and influential decision makers so a higher priority is placed on disability issues. Influential public health leaders are needed to increase understanding of the impact of health and disability policy on families. There are few interprofessional health care educational programs using families as part of their faculty to teach professionals how to provide family-centered care (Heller and McKlindon, 1996; Dunst, Boyd et al. 2002; Bailey 2003).

Solution Focused Learning

SFL is a method of instruction that incorporates "teaching families," who are encountering health systems challenges, as a stimulus for promoting leadership skills and family-centered care. This approach to learning emphasizes utilization of resources and solutions to address identified family needs. At Partners for Inclusive Communities, teaching families play a key role in the SFL process. Teaching families provide an account of the family and medical history and challenges to care. As families present their own problems, the discussion moves beyond philosophy to the reality of care (Heller and McKlindon 1996). Families are recruited from a variety of sources and receive training regarding their role as SFL instructors. Teaching families receive compensation for their time. Selection of the families is critical to the process due to the fact that they drive learning experiences for the students. Families are selected based on different types of diagnoses/conditions, age ranges, socioeconomic status, ethnicity, comfort level speaking before a group of people, and the type of challenges they have encountered with the health care system. Many of the families live in rural communities and often deal with multiple medical, education, and service delivery challenges. This diversity helps promote an exploration of various issues relating to the cultural components of health services.

Program Description

Prior to beginning SFL, students receive an orientation of the role of allied health disciplines in the health care system. Each faculty member discusses their discipline in detail including its history, expertise, unique aspects of the profession, job opportunities, educational requirements, professional development, and future trends. The overall goal is to demonstrate their unique commonalities with other disciplines (Reese and Sontag 2001). This arrangement fosters awareness of interprofessional collaboration by exposing students to different values, identities, and language of other disciplines in actual team interactions. These presentations allow public health students to understand the role of various disciplines and how they relate to one another in the provision of care for individuals with disabilities.

Approximately 20-25 students are selected each year according to established leadership criteria. Future public health practitioners are recruited from the University of Arkansas for Medical Sciences, College of Public Health; the University of Central Arkansas at Conway; and the University of Arkansas at Little Rock, Health Services Administration program. SFL classes meet during the fall and spring semesters on Friday afternoons. Three teaching families are selected each year, with each family being seen for three to four class sessions.

During the initial SFL session, all students and faculty meet with the family and conduct a joint interview to discover issues and to begin exploring possible solutions. The topics covered in the interview are related to concerns of the family, demographics, history of services received, reimbursement sources, medical, psycho-social, motor development, communication, and nutrition. Information obtained during the interview is used to define learning issues.

Learning issues expand upon information obtained during the family history and interview sessions. The following are guidelines for selection of learning issues (Barrows, 1996):

-Students are encouraged to select learning issues related to their awareness of a personal learning need or because of an interest in the subject.
-Students are encouraged to select learning issues that involve an area, or areas, in which they lack sufficient background knowledge.
-Students are encouraged to select some learning issues that are outside their usual disciplinary focus in order to promote interdisciplinary perspectives.

After the family interview, the class divides into smaller tutorial groups to outline the concerns raised by the family and begin to prioritize learning issues. Two to three faculty members are assigned as tutors to each group with one faculty member serving as lead tutor. The role of the tutor is not that of expert in directing and telling the group, but rather as a facilitator for group discussions of learning issues (Reynolds 2003).

During following 2-3 sessions, students present individual learning issues and resources used to obtain information related to the issue.

Each group investigates learning issues to include the following: the child's diagnosis including etiology, variations, and associated symptoms and specific interventions; effects on the family and community; financial implications; insurance; federal and state programs; transportation; and existing community support. Learning issues are based on the needs of the student, scope of the issues and family concerns. Students are encouraged to use resources including current textbooks, peer reviewed journal articles, on-line resources such as Medline and the Internet, faculty experts, experts in the community and around the nation. Discussion of the resources allows students to become more sophisticated in their search for accurate and reliable information. As learning issues are presented, students often modify their original perceptions of the identified family concerns. The family is available to answer further questions from any of the groups.

At the final session with each family, all tutorial groups meet to discuss findings, recommendations and suggestions. Students become aware that interventions and information considered important and valuable by professionals may be viewed differently by families. At the conclusion of the final session with each family, a master list of recommendations and suggestions is given to the family. Recommendations are based on the concerns expressed by the family and may include any of the following: financial and community resources, public policy needs, available health services, research findings, and family rights under current state and federal law.

Another activity of SFL involves student leadership projects. These projects involve policy and advocacy issues and often directly relate to issues raised in SFL discussions. Previous leadership projects have included researching grant opportunities, and preparing and submitting grant applications (some of which were funded and successfully implemented). Another project involved collaboration with local leaders to develop clinical guidelines and manuals for a new interprofessional developmental clinic in their community. This clinic was located in a rural area in which residents had no other source of medical care. The following year, another student assisted community leaders in writing bylaws and completing the forms needed to apply for 501(c)3 non-profit to provide resources for the community. Each student presents their leadership project to the faculty and other students at the end of the year.

Case Study

The following case study illustrates the process of SFL and the manner in which students develop leadership and interprofessionalism skills while learning from families living with a disability.

Rachel was diagnosed with cerebral palsy and failure to thrive as an infant. She was five years old when adopted by her foster mother. No contact has been made by her biological family. Rachel has attended public schools and has received extensive physical therapy, occupational therapy, speech therapy, and special education services throughout the years. Primary means of mobility is a wheelchair. Rachel verbally communicates but is difficult to understand at times. She uses a communication device called a Liberator while at school. She uses a computer but is frustrated because it is "slow". She is independent with feeding but needs assistance with toileting and other self care. Rachel has several close friends at her high school. She is currently enrolled in a Medicaid waiver program in addition to receiving Medicaid medical coverage.

Rachel was 16 years old when the LEND faculty and staff met with her and her mother. The primary concern was Rachel's transition from high school to college in the next year. Rachel wants to move to her own apartment. Her mother wants to know what future employment opportunities are available for Rachel.

The learning issues identified for Rachel and her mother were numerous and provided students an opportunity to problem solve in an interprofessional setting. Learning issues included: cerebral palsy, prognosis, treatment options, types of wheelchairs and assistive devices, adaptive equipment including kitchen and bathroom aides, employment opportunities, Medicaid coverage and Medicaid waivers, support groups for college students with a disability, use of direct service providers, security systems for apartments, accessibility at state colleges, therapy services for college students, social opportunities, emergency medical services, and community supports. In addition, a number of the students toured an apartment complex that Rachel was considering, visited the local grocery store, and interviewed police, emergency medical personnel, and fire department personnel to identify potential barriers and challenges for an individual with a disability. Following this informal community assessment, some additional learning issues were identified: wheelchair accessible apartments, transportation alternatives, accessible buildings and parks.

After meeting with Rachel and her mother for three sessions, a final meeting was held to share the relevant researched learning issues. To address the mother's primary concern of employment opportunities, a list of professions and the educational requirements for each was discussed by several different students. Descriptions and ordering information for various adaptive equipment and security systems was given to the mother and Rachel. Other topics discussed were social activities, community services, transportation possibilities, other accessible colleges, and national and state organizations for college students with a disability. Throughout the sharing process, the perspective of the family was considered and decisions were based on their needs and interests.

Discussion

SFL is a successful model for promoting public health leadership and interprofessional family-centered care as demonstrated in the qualitative evaluation results. Students are prepared to assume leadership roles that enhance systems of care for children with health care needs and their families. SFL and leadership activities prepare students to assist families of children with health needs to meaningfully participate in community life, effect systems change and prevent disabilities and secondary conditions by forging a community-based partnership of health resources and community leadership.

Students were asked to respond to a series of 15 semi-structured questions regarding their experiences and perceptions of SFL. The responses were then entered into NVIVO, a qualitative analysis software package. Each transcript was subsequently analyzed for emerging themes and trends. The qualitative analysis identified four major themes related to attitudes of graduate students participating in SFL. These themes included (a) appreciation of other disciplines, (b) lack of previous experience in interprofessional teams, (c) appreciation of SFL, and (d) unique role of faculty tutors. Within these themes, several overlapped with one another.

One of the continuing themes heard from students participating in SFL was the appreciation of other health disciplines. As one student commented, SFL "provided me with a better understanding and appreciation of the contributions of other disciplines and encouraged collaboration instead of competition." Another student reported the experience as "a unique opportunity to work with other healthcare professionals in reaching a common goal of helping families with their healthcare needs." A third student expressed an appreciation of the way in which the interprofessional team communication is "tailored around what the families need. Families should be given the opportunity to communicate openly about their feelings/concerns/needs."

The second theme related to students' lack of previous experience with interprofessional teams. A number of students expressed a limited knowledge of the role of other health disciplines. One student reported, "observing the group dynamics of health care disciplines has been beneficial in preparing me to meet the challenges in providing quality family-oriented service delivery."

The third theme identified was an appreciation of SFL as a method of instruction. As one student reported, "SFL, to me is like practical training in an education system. We get to learn from textbooks and theories, but the knowledge is incomplete and not up-to-date without SFL." This theme was also heard in the following response, "SFL gave me the freedom to explore my knowledge."

The unique role of the faculty as tutor was the fourth theme identified. Students traditionally interact with faculty in a classroom or lecture setting. The transition to viewing faculty as a tutor was a new experience for a majority of students participating in SFL. This sentiment was expressed by the following statement, the "tutor serves as a guide". Another student described faculty tutors as "mentors".

The benefits of a SFL model for interprofessional education are numerous. Based upon qualitative evaluation of written and verbal feedback, students and faculty enjoyed classes more than a lecture format, gained a greater depth of knowledge regarding interprofessional collaboration, formed more cohesive interprofessional relationships, and developed a keener sense of issues surrounding children with disabilities and their families. Students participating in SFL became actively engaged and developed ownership in the learning process, integrated previous knowledge and experiences with new problems, became more efficient at applying theory to practical concerns, enhanced their problem solving skills, and learned approaches they can use throughout a process of life-long learning. As noted by Slack and McEwen (1997), students learned to solve real-world problems with real families. In addition, one of the most significant advantages of SFL related to students' developing interprofessional learning strategies. These can be used to continually improve their collaborative leadership skills as they assume responsibility for their own learning after their formal education is completed.

The use of SFL as a method of promoting interprofessional education and leadership is strongly encouraged in a public health care educational program. SFL was successfully adapted and used during the spring of 2004 in the Children with Special Health Care Needs course, University of Arkansas for Medical Sciences, College of Public Health, Maternal and Child Health Section.

Conclusions

The SFL model represents an important step in operationalizing collaboration among health-care professionals within a public health care model. With a commitment to collaboration, leadership, and respect for family and individual choice, this model has implications for education, research and practice. Faculty involvement is critical to the success of the model. As stated by Cronenwett (2002), "If faculty members are not involved in interprofessional work, students lose the opportunity to learn from some of their most important role models." A commitment to interprofessional collaboration should be a core goal that permeates health education.

It has been suggested that interprofessional training occur earlier in the health care professional's educational process (Gates and Sandoval 1998; Cronenwett 2002; Leipzig 2002). We support that concept and suggest that SFL include undergraduate students with graduate students. This would provide opportunities for undergraduate students to be exposed earlier in their academic programs to interprofessional education, decision making process, critical thinking and problem-solving.

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Acknowledgments

The authors would like to express their appreciation to John Wayne, Ph.D. and Richard Nugent, M.D. for their support of Solution Focused Learning in the College of Public Health, University of Arkansas for Medical Sciences.