Interdisciplinary collisions: Bringing healthcare professionals together

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1 Collegian (2012) 19, Available online at jo ur nal homep age: Interdisciplinary collisions: Bringing healthcare professionals together Scott A. Engum, MD a,, Pamela R. Jeffries, PhD, RN, FAAN, ANEF b a 702 Barnhill Drive, Suite 2500, Division of Pediatric Surgery, James Whitcomb Riley Hospital for Children, Indianapolis, IN 46201, United States b Johns Hopkins University School of Nursing, Baltimore, MD 21205, United States Received 28 November 2011; received in revised form 21 May 2012; accepted 23 May 2012 KEYWORDS Interprofessional education (IPE); Partnership; Shared vision; Quality education for quality patient care Summary Since the publication of its reports, Health professions education: A bridge to quality (2003) and To err is human: Building a safer health system (2000), the Institute of Medicine has continued to emphasize interprofessional education (IPE), founded on quality improvement and informatics, as a better way to prepare healthcare professionals for practice. As this trend continues, healthcare education will need to implement administrative and educational processes that encourage different professions to collaborate and share resources. With greater numbers of students enrolled in health professional programs, combined with ethical imperatives for learning and reduced access to quality clinical experiences, medical and nursing education increasingly rely on simulation education to implement interdisciplinary patient safety initiatives. In this article, the authors describe one approach, based on the Core Competencies for Interprofessional Collaborative Practice released by the Interprofessional Education Collaborative (2011), toward providing IPE to an audience of diverse healthcare professionals in academia and clinical practice. This approach combines professional standards with the authors practical experience serving on a key operations committee, comprising members from a school of medicine, a school of nursing, and a large healthcare system, to design and implement a new state-of-the-art simulation center and its IPE-centered curriculum Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved. Introduction Corresponding author. Tel.: ; fax: addresses: sengum@iupui.edu (S.A. Engum), pjeffri2@son.jhmi.edu (P.R. Jeffries). Each year, critical numbers of patients die from medical errors, many of which are secondary to a lapse in communication (Klevens, Edwards, & Richards, 2002; Schiff, 2006). According to the Institute of Medicine (2000), preventable medical errors result in the deaths of 98,000 patients each year in United States hospitals, with an estimated /$ see front matter 2012 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

2 146 S.A. Engum, P.R. Jeffries cost of $17 billion. In the U.S., government and healthcare organizations have responded to this communication breakdown by developing standards of practice and education, as well as processes that prioritize interdisciplinary collaboration, which approaches health care as a joint investment by all health professionals on the care team. Following the publication of the Institute of Medicine s reports, Health professions education: A bridge to quality (2003) and To err is human: Building a safer health system (2000), which include interdisciplinary teamwork among its core competencies for healthcare students and professionals, the nation s Agency for Healthcare Research and Quality and Department of Defense have led a teamwork-oriented patient safety movement that aims to improve communication and collaboration skills among healthcare professionals. Despite this top-down support, processes for initiating and establishing IPE on the ground floor remain undefined. Based on their experience as members of an interdisciplinary team developing curricula for a large, state-of-the-art simulation center focusing on IPE, the authors suggest that simulation education, based on the Interprofessional Education Collaborative Core Competencies for Interprofessional Practice (2011). After healthcare education, areas for continuing research are also highlighted in this article. IPE and simulation training Despite the core values, knowledge, and skills shared by healthcare professionals, each discipline receives training in isolation from the others. As noted by Pecukonis, Doyle, and Bliss (2008), each health discipline possesses a separate professional culture that shapes the educational experience for learners by setting curricular content, core values, customs, dress, and salience of symbols and etiology of symptoms. The professional culture defines the means for distributing the power, how training will occur in the setting, and the level of inter-professional communication, conflict resolution and management of relationships within the team. These professional silos often foster relationships based on power, competition, and hierarchies, resulting in inadequate preparation for teamwork (McNair, 2005). When these cultures clash, opportunities for miscommunication and errors arise. IPE through simulation training allows healthcare professionals to connect across disciplines, learn and respect new communication techniques, and practice hands-on skills in real time. Preparation for teamwork in clinical practice, when these cultures clash in the work setting provides opportunities to learn and reflect from the incident. One way to address this is through IPE simulation training which allows individual teams to work together. This hands-on work through clinical simulations is critical to the success of IPE. Like many an armchair athlete or amateur musician, a nurse or physician does not become a team professional without hours of hands-on practice. He or she does not understand the orchestration or expectations of the team, or have the physical memory of the flow of work, without experiencing those things first-hand and in real time. Kenaszchuk, MacMillan, van Soeren, and Reeves (2011) note that a dedicated, shared simulation center provides a forum for students and Guiding Principles Patient First PATIENT SAFETY competencies Quality Care Teamwork Figure 1 Guiding concepts for IPE curricula. practitioners in all healthcare disciplines to interact and explore collaborative ways of improving practice and clinical care. When to introduce IPE continues to be a subject of great debate among healthcare professionals and academics. Previous recommendations by Horder (1995) suggest that early adoption of IPE curriculum might prevent negative attitudes and stereotypes. Other studies show that negative stereotypes exist amongst students even prior to their professional education (Cooper, Spencer-Dawe, & McLean, 2005; Tunstall-Pedoe, Rink, & Hilton, 2003), and Hammick, Barr, Freeth, Koppel, and Reeves (2002) propose that IPE is best offered after licensure, when participants have secure professional identities and experiences to share. More recent work by Hoffman and Harnish (2007) argues that, lacking a personal and intimate stake in turf wars, students may be better suited to achieve an interprofessional mentality and respect for their colleagues. Based on our experience, we strongly recommend building IPE into a simulation curriculum holistically, from the ground up, so that the teamwork process becomes integrated into the learning experience. Values and ethics for interprofessional practice Guiding concepts for the simulation curriculum As one of our first steps, the IPE committee established guiding concepts for the simulation center s curriculum that would reflect specific values and beliefs about practice and the interdisciplinary discipline: (1) patient first, (2) teamwork, and (3) quality care (see Fig. 1). Within this paradigm, teamwork serves as the platform to provide quality care to the patient. With three separate institutions (representing members of academia and practice from a school of medicine, a school of nursing, and a healthcare system) invested in the simulation center and its training, a focus on teamwork was integrated within the curriculum-building process

3 Interdisciplinary collisions 147 Table 1 Shared competencies for IPE curricula. Competencies Communication Professionalism Life-long learning Moral & ethical reasoning Self-awareness System-based practice System Community Knowledge Problem-solving at the start. When academia interfaces with professionals, issues arise with divergent learning and assessment styles, different curricular demands, battles for professional boundaries, and differences in professional values and cultures (Gill & Ling, 1995; Ho et al., 2008; Horsburgh, Lamdin, & Williamson, 2001). In our case, we chose to leverage the similarities between programs to launch our curriculum. For example, by cross-referencing the School of Medicine and School of Nursing program competencies, we discovered parallels in program competencies that provided a clear direction for the IPE team to focus its work. The areas of overlap and, ultimately, the IPE focus (competencies) are included in Table 1. It remains important to note differences across curricula and how they affect faculty and student attitudes toward their peers. Negative biases in curricula and faculty strongly influence trainees, weight curricula unfairly, and deny students the broad perspective of professional roles that true collaboration requires (McNair, 2005; Parsell & Bligh, 1999). One study by Lewitt, Ehrenborg, Scheja, and Brauner (2010) suggests that existing prejudices may have negatively affected the outcomes of IPE shared by medical and biomedical students. Such findings argue strongly that IPE should actively take biases into consideration during curriculum-building. Biases of professional identity can be further complicated by societal power dynamics that relate to gender, social class, and racial identity (Evetts, 2000; Frank & MacLeod, 2005; Martin, 2006; Scott & Thurston, 2004). Anderson and Thorpe (2008) have also shown positive and negative stereotyping between younger and older students, and noted that while mature entrants valued IPE, they often preferred to interact with students of similar age, and demanded more challenging and relevant sets of learning resources that were sensitive to their prior life experiences. Positive and negative stereotyping was noted between younger and older students. For IPE to thrive, these factors must be included in the implementation process. At the beginning of our IPE program development when ideas were being discussed, the key players from each institution became aware early on that respecting each other, although members were from different schools and organizations, was an important step to consider. Working together on a major project with large, multi-tiered goals, it is important that team members demonstrate respect and value when working together. Whether visiting other simulation centers, meeting with the architect to build the center, to early evening gatherings to develop interprofessional simulation scenarios together, there was always an expectation of valuing the other disciplines input and demonstrating respect for the others ideas, recommendations, and solutions. This collegiality within the center carries over to the staff working in the center, to faculty working with students and students working with each other. Modeling the way, demonstrating values, respect, and collegiality, are all important for interprofessional work and creating the type of collegial culture needed in an interprofessional simulation center. Roles and responsibilities Goals of the professional and impact on roles and responsibilities Health professional s roles and responsibilities are often determined by the knowledge, skills, and goals of a team and its individual members. For instance, the overall goal of a patient s healthcare team is to ensure the physical wellbeing of the patient. To achieve that goal, each member has different responsibilities. The physician s role is to determine a medical diagnosis and treatment, while the nursing staff typically implement that treatment and provide patient education, discharge planning, and other types of patient interventions. The aim of health education curricula is to teach not only the knowledge and skills for good practice, but to immerse students into the roles they will demonstrate while providing patient-centered care. Simulation exercises allow students to embody these roles in real time and in relation to other team members, while implementing their practical techniques and decision-making skills in a hands-on environment. As healthcare institutions need to build these roles and responsibilities into their team building and development processes, so that individual health professionals can continue to grow their understanding of team dynamics. Role challenges Interdisciplinary healthcare teams come with specific challenges, particularly in regard to issues of leadership and status. Often in healthcare the leadership position is delegated to the member with the highest seniority; however, an effective team needs that position held by the member with the most expertise, not necessarily linked to a professional group or status (Capko, 1996). Strong leadership becomes particularly important when team composition is inconsistent. In preparing healthcare teams, there are often challenges due to varying roles and responsibilities of its members and variability, such as one s personal experiences and educational backgrounds, in individuals participating within the team. Practicing a range of roles, students have the opportunity to demonstrate their knowledge, skills, and role flexibility in caring for all types of patients, in all settings and situations. In other clinical specialties, teams are often stable, with consistent members or roles, for an

4 148 S.A. Engum, P.R. Jeffries extended period of time. In contrast, the composition of a healthcare team in a large medical center changes continuously. On any given day, a physician or nurse could participate in numerous teams that require separate skill sets. For instance, in the operating room, the surgeon may be the primary leader in patient care; however, in the day-to-day care of the hospitalized patient, the nurse may be in the leadership position. Research by the University of Michigan (Andreatta, Bullough, & Marzano, 2010) has revealed 4 types of healthcare teams that vary in stable membership and functions of each team member include: (1) stable role/stable personnel, (2) variable role/stable personnel, (3) stable role/variable personnel, and (4) variable role/variable personnel. Because each team has varying competencies, team training should be contexualized tailored accordingly. For instance, Andreatta et al. suggest that a stable role/stable personnel team or a variable role/stable personnel team might benefit from training efforts that encourage understanding of each other s task-related knowledge, skills, and personality-related characteristics, so that fewer misinterpretations of behavior occur and conflicts are minimized. Stable role/variable personnel teams may perform well within a hierarchical leadership structure because it provides clear definitions of role behaviors. To achieve optimal performance, each team type will require adaptable training strategies and assessment of competences. Within the IPE simulation center incorporating interprofessional education and developing simulations around what has become important for the participants (learners) to understand difference roles and responsibilities of each of the disciplines. For example, when medical and nursing students were immersed in the same simulation to care for a patient having arrhythmias and multi-focal PVCs, the physician portrayed by a medical student was surprised to know that nurses knew how to interpret arrhythmias. When immersing two disciplines in the same simulation, it is interesting to note in debriefing what one discipline participant does not know about the skills set of the other discipline. Conversations in debriefing are now centered around the knowledge and skills each discipline bring to care for patients in a safe, quality manner. Interprofessional communication Interprofessional taxonomy Before curriculum discussions began, our committee enhanced the IPE taxonomy to avoid discipline-specific jargon that was not common among individual professional silos. We adopted areas of a physiologic system language approach (cardiovascular, respiratory, etc.), which allowed for matrix evaluation of the curriculum for areas of deficiency. This type of interprofessional communication and collaboration should serve as fundamental building blocks for IPE in the healthcare setting. Rice et al. (2010) explored an interprofessional intervention designed to improve communication and collaboration between different professions on a general internal medicine hospital ward in Canada. Despite initially offering verbal support, the healthcare professionals minimally explained the intervention to their junior colleagues and rarely role-modeled or reiterated support for it. Findings demonstrate that the desired changes in communication and collaboration did not occur; suggesting that in the absence of management support and ground-level process changes, simple and potentially beneficial communication changes are insufficient to improve care on the floor. In traditional healthcare structures, collaboration, communication, and coordination of care are limited by isolated health provider education, regulations under which teams practice, and the historic hierarchy in hospital settings (Zwarenstein & Reeves, 2006). By placing students in real-time practice situations, the simulation environment for interprofessional training allows participants to explore collaborative ways of improving communicative aspects of clinical care, including decision-making and conflict resolution. Role of communication in decision-making Decision-making can be problematic in a healthcare environment where some group members are professionally rewarded for isolated outcomes that do not have the team at the center of the process. Team members find themselves viewing the situation from 4 different positions: autocratic ( I decide ), democratic ( one person, one vote ), consultative ( I decide with input from you ), or consensus ( we decide ). All of these cases require strong conflict management and mediation strategies. Early research by Maple (1987) proposed that an effective team is able to discuss each person s assumptions and openly negotiate differences centering on a positive patient outcome. Without this open environment, team relationships can cause physical and emotional stress. Constructive feedback can ensure that all team members understand the line of authority and are aligned properly to achieve the team goal. Traditional medical education emphasizes the importance of error-free practice, utilizing intense peer pressure to achieve perfection during both diagnosis and treatment. Mistakes are perceived normatively as an expression of failure. This atmosphere creates an environment that precludes the fair, open discussion of mistakes required if organizational learning is to take place. Rather, team debriefing following an event a common technique in urgent military environments provides invaluable information to medical teams undergoing training and those on the job by encouraging discussion to review team errors, tactics, and possible future options and alternatives. This learning process is invaluable to medical teams undergoing training and those on the job (Blickensderfer, Cannon-Bowers, & Salas, 1997; Cannon-Bowers & Salas, 1997). The practice application of incorporating communication in simulation experiences is a simple one since almost all the simulations designed have a communication component. In one such simulation, the focus was with an interdisciplinary

5 Interdisciplinary collisions 149 Table 2 IPE team training strategies. Simulator-based Team coordination Team self-correction Cross-training Stress-exposure team of second level (junior) nursing students and third year medical students assigned to care for a patient with a critical lab value indicating hypokalemia (K+ of 2.6 mmol/l). In the scenario, the medical student who is playing the physician orders extra potassium to be given intravenously immediately as an IV bolus (push). The student playing the nurse, through facial expressions reflected she did not want to give the ordered medication, gave the potassium IV push, which resulted in the patient immediately going into a cardiac arrest. It was discovered that students do not always have the right communication tools and skills to disagree and/or question their counterpart. The student who was portraying the nurse did not think her action of pushing the potassium was correct, but the physician told her to do it; she thought physicians were always correct, therefore why question the order. In debriefing it became very clear that students, across disciplines, need effective, therapeutic communication skills so there are tools that healthcare professionals can use when there is a disagreement with the other professional. Setting up simulations using an interprofessional model can be very helpful to engage the learners in this type of scenario that enhances and builds communication skills and competencies. Teams and teamwork Quality, safe patient care requires high functioning interdisciplinary teams. Simulation-based training strategies allow trainees to perfect responses to situations that they would experience in real-life settings, while team competencies allow members to assess the health of their teams. Simulation-based team training strategies Strategies agreed by the IPE curriculum development team as key concepts are shown in Table 2. Some of these concepts and related context will be discussed. During simulatorbased training, fidelity involves stimulus (environmental), response (psychological) and equipment (Beaubien & Baker, 2004). Stimulus fidelity is present when trainees are exposed to the same behavioral triggers experienced in the clinical teams. Response fidelity is present when trainees react to the triggers with the same behaviors they exhibit on the job. Lastly, with equipment fidelity, trainees use the same materials and equipment that they would normally deploy in the workplace (Guzzo & Shea, 1992). Realistic simulations do not always translate directly into training effectiveness, but simulators do allow both team- and task-related skills to be practiced simultaneously (Cannon-Bowers & Salas, 1997). Cross training, where individuals are learning each others roles, is vital in healthcare teams and exposes team members to the basic tasks, duties, and responsibilities of their peers. This form of training promotes coordination, communication and team performance. Cross-trained teams have shown they anticipate the informational needs of their teammates, commit fewer errors, and display higher quality team process (Volpe, Cannon-Bowers, Salas, & Spector, 1996). Team competencies Team competencies serve as the principles and concepts underlying a team s effective task performance. Early work by Cannon-Bowers, Tannenbaum, Salas, and Volpe (1995) identified the following three types of competencies that are critical for competent collaboration: (1) teamwork-related knowledge, (2) skills and (3) attitudes. Each member should know the team mission, goals, and each member s role/responsibility in coordinating the team s tasks. In addition, team members should, and subsequently, know the range of skills required by the team, which behaviors are appropriate at what time and how these allow the team to function properly. Often in healthcare, teams are too large and as such it makes work cumbersome and inefficient (Maple, 1987). Large teams can become dysfunctional by falling into the paralysis by analysis trap. Furthermore, healthcare professionals tend to prioritize training that relates to their clinical demands, rather than that which serves the health of the team. Team process requires cohesion, which results from education and understanding of teamwork (Loxley, 1997). Team skill competencies, members at a minimal, refer to the ability to interact with other team members at some minimal level of proficiency. Studying team skills that are crucial, according to Cannon-Bowers et al. (1995), teamwork skills can be divided into 8 categories: (1) adaptability, (2) situation awareness, (3) performance monitoring/feedback, (4) leadership, (5) interpersonal relations, (6) coordination, (7) communication, and (8) decision making. However, it is difficult to measure these skills in any given simulation scenario and further research should focus on studying those skills that are crucial, teachable, and measurable. Team attitude competencies define an internal state that influences a team member s actions (Cannon-Bowers et al., 1995; Dick, Carey, & Carey, 1990). A high performing team has a positive attitude about its work and its members. It perceives that it serves the organization s key strategic goals, is will to share labor, and its members know, respect, and trust each other. Studies have shown that group-oriented team members performed a team decisionmaking task significantly better than their independently minded colleagues. Furthermore, membership in a team contributes to a positive group attitude (Driskell & Salas, 1992; Vaziri, Lee, & Krieger, 1998). Within the Simulation Center, IPE is demonstrated through team work when medical and nursing students are placed in different types of simulations where they are required to work together. For example, in one interprofessional simulation in the adult health I course, second level or junior

6 150 S.A. Engum, P.R. Jeffries nursing students are paired with third year medical students to care for a deteriorating patient. The simulated patient complains of chest pain, is short of breath (SOB), and having multi-focal PVCs; the nurse calls the physician to come to the room. Upon entering, the physician and nurse (role-played by the medical student and nursing student, respectively), they are required to work together, adapt, coordinate, communicate, and make decisions. At this level, the team experiences are just beginning; however, upon debriefing both groups of students state how important it is to create opportunities to work together and care for patients. Reese, Jeffries, and Engum (2010), using the Collaborative Scale to measure the perceived collaboration of the two groups working together, the researchers found a high collaboration score of 4.4 on a 1 5 Likert Scale (5 = strong collaboration) within this research indicating high collaboration. Qualitative participant comments included working with other health team members helps me to provide quality patient care. Another comment included Working together for the greatest outcome for the patient. Simulations are a better way to learning in a non-threatening environment that provides more real learning than books or observation. Determining specific IPE curricula goals provides a clear framework for all parties. Concepts included in our IPE curriculum focus on patient safety, teamwork, quality care, and the patient first. Detailed analyses of critical aspects for successful IPE have been provided, along with examples from our experiences. Conclusion The current approach to healthcare education does not adequately prepare our professionals to navigate an increasingly complex health care system (Margalit et al., 2009). IPE offers institutions a way to build professional support, communication skills, and team-building into practice, but developing health care professionals who demonstrate the IOM core competencies requires more than single, isolated IPE experience. This type of education requires an immersive approach supported by organizational and individual commitment at the curriculum level. IPE through simulation training allows healthcare providers at all levels and disciplines to nurture lifelong learning skills, analyze practice and interpersonal performance, and learn decision-making techniques in a safe environment that actually improve patient outcomes. References Anderson, E. S., & Thorpe, L. N. (2008). Early interprofessional interactions: Does student age matter? Journal of Interprofessional Care, 22(3), Andreatta, P. B., Bullough, A. S., & Marzano, D. (2010). Simulation and team training. Clinical Obstetrics and Gynecology, 53(3), Beaubien, J. M., & Baker, D. P. (2004). 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