The task-based strategy provides situations for students to learn the tasks that correspond to their future job duties and acquire the necessary competencies. In this study, a task-based interprofessional training program was developed for different learners of the occupational health team. Different groups are involved in providing occupational health services, among which occupational medicine and occupational hygiene specialists have the most important role in providing the services in our country.
The expected duties of people involved in providing occupational health services need to be reformed proportionately in response to changes in the work environment, technological developments, production processes and the emergence of new hazards in the work environment, and changes in the framework of occupational health laws and guidelines [2, 16, 35,36,37,38,39,40]. Several studies have been conducted to explain the competencies, skills, and duties of occupational health team members worldwide [2, 16, 35,36,37,38,39,40]. Their results can be used for reforming and modifying existing curricula and improving the level of occupational health services [41]. In the present study, the integration of interprofessional education and task-based education strategies was used. Interprofessional education provides opportunities for learners to learn technical skills (identifying and assessing the risk of workplace hazards, controlling occupational hazards, determining the appropriate job position, occupational health examinations, and managing work-related/occupational diseases) and soft and non-technical skills (interprofessional collaboration, communication, teamwork, and professionalism) through, from, with and about each other to improve collaboration and the quality of services. The interprofessional competencies as a general competency including role and responsibility, values and professionalism, interprofessional communication, teamwork, and collaboration were considered in different extracted areas.
In the present study, the interprofessional competencies which were introduced by the Interprofessional Education Collaborative Report (IPEC) were used [28]. A planned educational process provides interprofessional situations, where learners learn the tasks expected in their future careers in the real environment and with colleagues from different disciplines with whom they will work in the future [42].
Occupational health is a multidisciplinary, interprofessional, inter-departmental, and inter-organizational field that goes beyond the boundaries of the health sector [43]. Even in the health sector, many people are influential in providing and promoting occupational health, including general physicians, specialists in occupational medicine, and professionals in occupational hygiene, safety, ergonomics, environmental health, etc. Therefore, to ensure the highest level of occupational health for workers and their families, the cooperation of different people in these fields is needed, along with the cooperation of employers, insurance organizations, and other institutions [15].
Interprofessional collaboration is sharing responsibilities while defining the roles and goals of each profession, and integration and shared identities are less important than collaboration as teamwork [44]. Integrating the inter-professional or task-based method that takes advantage of the essential elements of problem-based education and education in small groups can provide an excellent opportunity to understand the course material, teach the material more effectively, and increase the efficiency of the teaching–learning process. Although traditional teaching methods such as lectures are still used in many educational institutions in our country as the primary teaching method, task-based teaching has been implemented in many studies, and its effect on people’s learning has been proven [23, 45, 46].
Changing the teaching methods and moving towards more practical training is always challenging at first and faces resistance. In a study in Pakistan, Ayub Khan and his colleagues implemented training on how to prevent surgical wound infection based on interprofessional task-based training, and the results of the study showed a positive effect on knowledge and performance in addition to student satisfaction [23]. In our program, the teaching–learning and assessment methods were designed in real and simulated interprofessional situations. The teaching–learning methods were designed to provide simulated situations and real environments for learners to learn their competencies. The interprofessional small group setting, simulation (case-based learning, scenario, and reasoning teaching methods), and workplace-based learning method (ambulatory-based learning, interprofessional rounds, and project-based learning) were defined as the primary methods. In addition, learner assessment methods were designed to assess the competencies in different domains such as knowledge, skills, and attitudes by different assessment methods in simulated and real situations. The assessment methods included modified essays, team objective structured examinations, and observational examinations, such as mini-clinical exams (Mini-CEX), and direct observation of procedural skills (DOPS). The learners must show their competencies to conduct the expected tasks in their future careers.
In the current study, the tasks of the members of the occupational health team were summarized in seven axes with emphasis on two fields of occupational hygiene and occupational medicine, including: “identifying and assessing the risk of workplace hazards”, “controlling occupational hazards”, “determining the appropriate job position for each person”, “occupational health examinations”, “managing work-related/occupational diseases”, “inter-organizational and inter-disciplinary relations and legal judgment”, and “education and scholarship in providing occupational health services. “
The “Identifying and assessing the risk of workplace hazards” axis is known as one of the most fundamental tasks of the occupational health team. In this task, members of occupational health team, especially occupational hygiene specialists, identify and assess all types of hazards and exposures in the workplace based on existing standards. The provision of any occupational health service depends on the correct and complete performance of this task and appropriate reporting of its results. The diversity of job exposures in different environments shows the complexity of this task and the need to have skills to perform it [47]. Incomplete or incorrect information in this regard can lead to incorrect decisions in all areas of occupational health, including selecting a suitable person for a job, diagnosing a disease as occupational, and even legal decisions. Therefore, interprofessional team members must acquire the necessary skills such as methods of measurement, interpretation, and reporting of the assessments to perform this task in different situations. In this task, students must evaluate hazards, including chemical, physical, ergonomic, biological, and psychological exposures in the real environment of the workplace. Based on the initial assessment results, the learners should formulate a plan for individual and environmental quantitative measurements and compile a matrix of occupational exposures of the employees. In the next step, the learners should compile, interpret, and report the results of assessments and measurements of the hazardous factors of the work environment in cooperation with the members of the occupational health team.
The axis of “controlling occupational hazards” deals with the standardization of exposure to hazardous factors in the workplace. The basis of this task is to reduce the hazards caused by occupational exposures. Therefore, especially for perilous hazards such as ionizing radiation or carcinogenic agents, the goal is to eliminate the exposure or control it as much as possible. For other exposures, when there is an exposure that exceeds the permissible limits based on the report of exposures in the work environment (previous task), it is necessary to put exposure control on the agenda. There are various methods to control exposures, from replacing a highly hazardous exposure with a less hazardous exposure as the highest level of exposure control to reducing the concentration or intensity of exposure using measures such as installing ventilation, and finally using personal protective equipment [48]. Planning to prioritize to control chemical, physical, biological, psychological, and ergonomic hazards are explained in this task. It is expected that members of occupational health team can play an influential role in reducing the burden of occupational diseases, increasing job satisfaction, and increasing productivity with interprofessional cooperation. In hazard control, the control of hazardous chemical, physical, and psychological factors was emphasized in this study, and control of chemical and physical hazards was considered a task exclusively performed by occupational hygiene professionals, and it is less commonly considered as a team task. Determining, managing, and controlling psychological hazards in the work environment is another task emphasized in this axis. The importance of this category in work environments is that it has a significant effect on job satisfaction, reducing the mental burden of the work and increasing productivity; the educational curricula of the disciplines related to occupational health have not paid enough attention to this task regarding psychological hazards, therefore, in practice, occupational health teams do not pay much attention to this critical occupational hazard in the assessments of the work environment.
One of the essential tasks of the occupational health team is to determine the appropriate job position for each person, taking into account physical, mental, and social limitations and abilities. In this task, after identifying the occupational tasks of the person, determining the exposures, evaluating the individual’s physical and mental health status, and evaluation of his (her) functional capacity, it is necessary to put these categories together to select the right person for the job. Accordingly, in this task, the occupational health team must decide whether the job applicant can perform the main tasks of the job efficiently or not and what changes are needed in the workplace so that the person can work more efficiently. This task is very sensitive because a mistake in a decision can lead to aggravating or inducing an occupational disease or, on the contrary, prevent a person from employment in a job that he (she) is capable of doing it. In this task, the following decisions may be made for the job applicant: “fit for the job”, “fit subject to changes in the workplace”, “fit with occupational restrictions/limitations”, and “unfit for the job” [49]. Due to the variety of jobs and significant differences between work environments, even in similar industries, there is no reliable standard in this field [49], so this task is performed based on available reports and individual assessments. In this task, the members of the occupational health team must work together, based on the estimation of the burden of occupational hazards and hazardous factors identified in the workplace and underlying diseases, to determine the appropriate job position for the employees.
Another focus of the tasks of the occupational health team, especially general practitioners and occupational medicine specialists, is “occupational health examinations.” In this task, occupational medicine specialists design various types of occupational health examinations based on the reports of the occupational health team. These examinations include “pre-employment (pre-placement)”, “periodic (screening)”, “return to work”, “fitness for work”, and “exit” examinations. In most countries, entry into any job requires an initial examination of the applicant based on workplace exposures, which are carried out as pre-employment or pre-placement examinations. People working in different workplaces need to be examined periodically to detect the possible effect of occupational exposures on the employee’s health, i.e., early case finding, which is done in the form of periodic examinations based on the guidelines in each country [50]. Any person who is away from work for a period due to a serious illness must be re-evaluated in terms of fitness for work when returning to work, which is done in the form of return-to-work examinations. In addition, according to the employer’s report, any employed person who cannot perform the assigned tasks must be re-evaluated in terms of fitness for work. Another time a person needs to be checked is when he (she) leaves any work environment for any reason (dismissal, retirement, job change, etc.). In most of the examinations that are performed, in addition to determining the level of health, the condition of fitness of the individual for work is also evaluated [51]. In this task, the learners of occupational health must design and implement occupational examinations and make decisions based on the results and related national and international standards and requirements. Reporting the results of the examinations to different stakeholders based on different perspectives is also performed in this task.
In the current study, “managing occupational/work-related diseases”, focuses on diagnosing, treating, and rehabilitating work-related diseases. Occupational health services play an essential role in preventing, treating, and rehabilitating work-related diseases [52]. To reach the strategy of the World Health Organization, “occupational health for all”, it is necessary to provide effective occupational health services to all employees by competent people in this field [53]. This requires empowerment and proper training based on the professional needs and practical tasks of the individuals involved in providing occupational health services. Considering the importance of health care in people’s familial, social and economic life, evaluation and monitoring of the efficiency and effectiveness of occupational health services are performed by many people and organizations involved in this field and outside the occupational health team, such as insurance companies, employers, health departments of universities of medical sciences, etc. In this task, learners of different professions are expected to actively cooperate in diagnosing occupational diseases. They suggest suitable methods for preventing and treating occupational diseases, appropriate rehabilitation, and early or progressive return to work. Identifying the relationship between disease and hazardous factors in the work environment is also essential. The results must be recorded and reported by occupational health team based on national and international guidelines. One of the neglected tasks in providing occupational health services is using proper rehabilitation methods for rehabilitation and early return to work of employees. In this category, the authority of the occupational health team is somewhat limited, and many factors are involved in this decision. The factors include the certificate of the treating physicians for when and how to return to work, the policies of insurance companies, the policies of the workplace, leave benefits, etc.
One of the duties of the members of occupational health team, especially occupational medicine specialists, is defined in the axis of “inter-organizational, interdisciplinary relations and legal judgment.” One of the world’s most essential costs of occupational health is the cost of occupational compensation due to occupational diseases or accidents. In this axis, the tasks of the occupational health team include determining whether the disease is occupational, determining the percentage of occupational involvement in causing the disease (apportionment), and determining impairment and disability [54], which is performed in the form of consulting relevant institutions, including forensic medicine organization, labor office, insurance companies, health departments of universities, etc. In this task, consultation with external organizations and various stakeholders and monitoring the provision of occupational health is essential. Involvement in intra and extra-organizational activities, such as cooperation with forensic medicine organization, Health system, judiciary, and labor office related to the provision of occupational health services is explained in this axis. Neglecting interprofessional and inter-departmental cooperation for health team members can be due to the lack of a comprehensive view of the activities of the occupational health team. This can be improved by using the strategy of interprofessional education and the development of professional commitment competencies.
Finally, the axis of “education and scholarship in the provision of occupational health services” emphasizes the two primary tasks of teaching different stakeholders and using the scholarly strategy in professional activities. The occupational health team needs to train different stakeholders such as employees, employers, colleagues, etc.; therefore, it is necessary to design, implement and evaluate the appropriate training process. In this axis, a scholarly strategy for all professional activities has been considered.
In this study a task-competency matrix was compiled in line with a competency-based framework of ACGME (Accreditation Council for Graduate Medical Education) [55]. In this matrix, the principal competencies to perform each task was defined. In each axis two kinds of competencies, including general competencies (communication skills, interprofessional collaboration, professionalism, and evidence-based decision making), and specialized competencies (identification of occupational exposures, mastery in exposure measurement, interpretation of results, medical history taking, occupational history taking, physical exam, professional judgment, and mastery in the methods of exposure control) were emphasized and scored according to the importance and applicability of each competency to perform each task, for example “professional judgment” as a competency was important in “determining appropriate job position” task, less important in “walkthrough survey”, and not important in “measuring the psychological hazards of the workplace”. This classification was done for the required competencies in each axis.
In this regard, “interpretation of results”, “identification of occupational exposures”, “professional judgment”, and “mastery in the methods of exposure control” were emphasized as the most important specialized competencies in “controlling occupational hazards” axis. In the second axis, i.e. “fitness for work”, interpretation of the initial assessments and judgment to find the appropriate job for a person or find a person completely fit for performing essential tasks of the job is very important, therefore, the following competencies were rated important: “interpretation of results”, “occupational history taking”, “medical history taking”, “professional judgment”, “physical exam”, and “identification of occupational exposures”. In the axis of “health risk assessment”, two specialized competencies, i.e. “occupational history taking”, and “professional judgment” were considered as the most important competencies. This axis is performed mostly by occupational physicians, so there was not a competency with high degree of necessity for all tasks. The forth axis was “managing work-related/occupational diseases”, an important task which is again performed by physicians, especially occupational medicine specialists; in this axis, the physician should diagnose, treat, rehabilitate, and most importantly prevent occupational diseases, so the following tasks which are mostly medical tasks were scored as the most important: “medical history taking”, “occupational history taking”, “physical exam”, “selecting appropriate paraclinical tests”, “interpretation of paraclinical tests”, “diagnosis of disease”, and “diagnosis of disease as work-induced”.
The results showed that general competencies such as “communication skills”, “evidence-based decision making”, “interprofessional collaboration’, and “professionalism” had an effective role in all tasks. Performing tasks related to occupational health services there is a need for collaboration of the members of different professions such as occupational medicine, industrial hygiene, and ergonomics. In addition, due to the emergence of new exposures and hazards in the workplaces after a process change or a change in the materials or equipment, being skillful in evidence-based decision-making as a means for response to the changing nature of the workplace hazards is important. Considering the characteristics and importance of occupational health services, and legal and juridical aspects of these services, observing the principles of professionalism is emphasized.
According to the outcomes-based framework of Can Meds [56], the matrix between tasks and expected roles of the providers of occupational health services was compiled. The results showed that in the axis of “exposure risk assessment”, performing tasks in the role of an evaluator has the highest importance for providers of occupational health services, in the axis of “controlling occupational hazards” consultant and evaluator roles were important, and in the axis of “fitness for work” and “health risk assessment” the people are prepared for playing the role of evaluator, screener and professional/expert. The educators are prepared to play the role of a therapist and professional/expert in the axis of “managing occupational diseases”, and the role of screener and professional/expert in “inter-organizational and inter-disciplinary relations and legal judgment” axis.
In this study, task- teaching–learning and evaluation methods matrix showed that various methods of teaching and evaluation are considered. In teaching methods, different interactive methods in small group, simulation and PBL settings based on inter-professional education was emphasized. The learners experience the exposure to problems similar to the real world and learn how to manage them. In addition, teaching in the real environment in inter-professional teams provides valuable opportunities for them to experience the situations which they will face in their future career. Evaluation methods of the learners’ competencies in performing their tasks, was designed in different levels of cognition, performance and attitude, using various tools.
The present study used the content validity methodology introduced by Lynn [27]. This method categorizes the framework of content validity into two stages including development and assessment. Recently, content validity methodology has gained special attention especially in developing instruments [24, 25, 57]. In this model, it is possible to compile content and structure and evaluate their validity. In this study, in the development stage, there was a possibility to extract the tasks from different sources such as literature review and expert opinion, which provided a complete content coverage of all tasks. In the next step, subtasks were determined for each task. In this step, the expert opinions in the panel helped us determine a set of essential subtasks by careful concentration on each task. General and specialized competencies were also paid attention to in this stage. In the next stage, tasks and subtasks were categorized according to Lynn’s study [27]. This step helped structured categorization as well (convergence phase). Besides, the participants in the panel had the opportunity to re-evaluate the content coverage of the categories and be confident of the complete content coverage of the framework. In the second stage, the framework and tasks were assessed separately and validity indices were measured for each item and the whole framework.
Halek et al. similar to the present study used the content analysis method introduced by Lynn. They performed their study in three categories (evaluation, development, and judgment and quantification) and five stages. The stages included a literature review in two stages, an expert panel for their first evaluation of the instrument and a second and third evaluation in a workshop and the field [58]. They used only a literature review in the development phase and expert opinions were used in the second stage by assessing validity indices. They also used their instrument in the real environment to assess its applicability and practical use, but in the current study, expert opinion was used in the first stage as well to gain complete content coverage. Zamanzadeh et al. consistent with the present study, used content validity assessment in both stages of development and judgment, and the content validity indices were measured in the second stage [59]. In the current study, different sources (such as literature review and expert opinion) and methods (consensus-based methods such as the Delphi technique) were applied in the development stage. When there is a limitation of access to the participants, the Delphi method is suitable [60, 61], so in the current study, considering the participation of individuals from five different universities, the Delphi technique was used.
Limitations
In this study, the tasks were compiled based on the different views of experts in one country. The limitation of number of participants in one environment is one of the limitations of the present study. Due to the differences in the domestic laws and guidelines in the occupational health field, this framework’s generalizability to other environments is limited.
Advantages: To the best of our knowledge, this was the first study to develop an interprofessional task-based learning program and its related matrices in Iran which can be used for future studies in this field and also for curriculum development of the disciplines in which graduates are involved in providing occupational health services.
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