Collaborative Practice Education: The Effect of an Interprofessional Teamwork Course on Students Knowledge and Skills

Transcription

1 MEDICAL SCIENCE EDUCATOR The Journal of the International Association of Medical Science Educators Med Sci Educ 2013; 23(3S): ORIGINAL RESEARCH Collaborative Practice Education: The Effect of an Interprofessional Teamwork Course on Students Knowledge and Skills Patty M. Vari 1, Judy Lash 1, Sara S. Brown 1, Ava G. Porter 1, Dave Trinkle 2, Jeannie S. Garber 1, Wilton Kennedy 1 & Richard C. Vari 2 1 Jefferson College of Health Sciences, Roanoke, VA, USA 2 Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA, USA Abstract An interprofessional leadership course for medical, nursing, and physician assistant students was the setting for teaching communication, self-reflection, and team skills. Students completed the Self-Efficacy for Interprofessional Experiential Learning (SEIEL) Scale, the Team Skills Scale Adjusted, and a survey assessing knowledge of healthcare professions, to evaluate changes in student s knowledge, confidence, and skills in interprofessional learning. Overall students rated their knowledge of role and scope of practice for health professions as significantly higher at the end of the course. This was also true of each of the individual profession groups. There was also a significant increase in overall students' confidence in their ability to carry out the student role in interprofessional learning and in self perceived team skills. However, when individual professions were analyzed separately, the nursing student group was the only group to show significant differences. The Core Competencies for Interprofessional Collaborative Practice, recommended by the Interprofessional Education Collaborative, address interprofessional leadership knowledge and skills that are critical to safe, high quality patient care. These core competencies speak collectively to our challenge to produce graduates with leadership skills for collaborative practice readiness. 1,2 Reports from the Institute of Medicine, American Hospital Association, Robert Wood Johnson Foundation, and the World Health Organization (WHO), make building a safer healthcare system a global challenge. 2-6 WHO asks that leaders in health and education work together to implement innovative ways of delivering interprofessional education for collaborative practice readiness. 2 A core competency of collaboration is effective communication, as poor communication patterns have the potential to break down the relationships that are so critical in teams and can result in medical errors. The ability to establish relationships Corresponding author: Patty M. Vari, PhD, RN, Jefferson College of Health Sciences, 101 Elm Avenue SE, Roanoke, VA USA; Tel: (540) ; Fax: (540) ; pmvari@jchs.edu is essential to learning to work together and effective communication enhances and sustains these relationships. Gittell stresses the importance of relationships in collaboration and defines relational coordination (RC) as coordinating work through relationships of shared goals, shared knowledge and mutual respect. 7 Jefferson College of Health Sciences (JCHS) and the new Virginia Tech Carilion School of Medicine (VTCSOM) seized the opportunity to create an environment where health professions students could not only learn with, from, and about each other but could also establish relationships that allowed for learning about the significance of communication skills. Learning communication concepts and skills during their educational process serves as the foundation and preparation to promote collaboration in the workplace. JCHS had established interprofessional education (IPE) as a quality enhancement project and VTCSOM had embodied interprofessionalism as one of four foundational domains in their curriculum. This partnership resulted in an interprofessional team of faculty from both schools developing a Medical Science Educator IAMSE 2013 Volume 23(3S) 494

2 yearlong interprofessional leadership (IPL) curriculum with a goal of preparing students for interprofessional collaboration. Diversity in the implementation of interprofessional education has made it difficult to determine best practice models. The execution of IPE is reflected in courses as varied as 4-8 hour sessions, required or elective new courses lasting a semester or a year, IPE concepts embedded in existing courses, and courses delivered completely online. No optimal IPE delivery model or valid and reliable measurement tools have been identified. 8,9 In the United States, the development of The Core Competencies for Interprofessional Collaborative Practice, recommended by the Interprofessional Education Collaborative, is the most current model of what an IPE course should have as its curricular components, but few recommendations about how those competencies should be taught or assessed are provided. 1 Curriculum Description The IPL curriculum, unique in both design and delivery, offered a new approach to health professions students through partnerships among educational institutions and community agencies. Nursing, physician assistant, and medical students were brought together to address the following objectives: First to develop individual insight in to their own communication behaviors, skills, and patterns that enhance and impede effective relationships; second to understand the values that they believe in and practice; third to use that knowledge from self-reflection to build upon their team and leadership skills; and fourth to apply those skills in an experiential setting as an interprofessional team. Students were placed in mixed-profession teams that remained together throughout the year long required course. The small group teams interacted with community agencies to complete an interprofessional service-learning project in order to operationalize their collaborative practice readiness skills. The course was a twosemester, required class that occurred in the first year of the medical and physician assistant student curricula, and in the final three semesters of study of the nursing student curriculum (baccalaureate nursing students were either second semester juniors or first semester seniors). The course consisted of four blocks of instruction, each with a particular focus. Instruction was given through didactic lectures and in facilitated Team Action Groups (TAG). Each student was assigned to an interprofessional TAG in which experiential activities utilizing the didactic information were facilitated by trained faculty. The Team Action Groups met right after the didactic session each week. Students remained in their specific TAG group for the duration of both semesters. Block 1 focused didactically on the roles, responsibilities, and scope of practice of various healthcare professions, and briefly introduced the practices and characteristics of effective teams. Week by week description of the five didactic sessions (D) and (TAG) sessions included: Week 1. (D) Overview of interprofessional collaboration in healthcare speaker, (TAG) Student team members (STM) begin introductions and participate in a scenario activity where the team had to solve a problem; Week 2. (D) Various health professionals describe their roles, responsibilities, and scope of practice, (TAG) STM disclose and discuss each students' personality assessment completed prior to the first class and debrief the previous week s scenario; Week 3. (D) Physician and Physician Assistant faculty members describe their history, roles, responsibilities, and scope of practice, (TAG) Student team members share why each chose their particular profession and analyze the oaths of the three professions; Week 4. (D) Nursing faculty member describes history, roles, responsibilities, and scope of practice for nursing, (TAG) STM create a pledge that applies to all professions; Week 5. (D) A physician and nurse team in the outpatient setting describe their interprofessional activities and an Emergency Department physician describes interprofessionalism in the midst of chaos, (TAG) STM participate in a team-building activity in which students build weight-bearing bridges from newspaper, balloons, and masking tape, with specific limiters and rules that require creative problem-solving. Block 2 didactics emphasized interpersonal and interprofessional communication for effective team functioning. TAG activities included sharing personal values, missions, and goals; conflict management activities; assessment of TAG team functioning; and the beginning of the development of service learning projects in each TAG group. The eight didactic sessions included: Week 1. (D) Overview of an interprofessional team from a hospital cardiac unit, (TAG) Student team members (STM) share This I Believe statement; Week 2. (D) Levels of Collaboration speaker, (TAG) STM continue with This I Believe statements; Week 3. (D) Five Dysfunctions of a Team video segments, (TAG) STM debrief conflict management scenario in relation to personality profiles; 10 Week 4. (D) Overcoming Team Dysfunction in a Healthcare Setting speaker, (TAG) same as week 3; Week 5. Medical Science Educator IAMSE 2013 Volume 23(3S) 495

3 (D) Video segments of functional and dysfunctional health care teams, (TAG) STM reflect on didactic video segments; Week 6. (D) Interprofessional Quality Initiative speaker, (TAG) STM conduct team assessment; Week 7. (D) Introduction to the Service Learning Project, (TAG) STM brainstorm options for Community Service Learning Project; Week 8. (D) Impact of IP Teamwork on Patient Safety speaker, (TAG) STM explore options for Community Service Learning Project. Block 3 didactic sessions met three times with speakers emphasizing collaborative leadership and patient safety. TAG sessions met four times with Student team members applying their knowledge of teamwork skills by planning service learning projects. Block 4 had one didactic which focused on teamwork in a culturally diverse environment, and STM continued to apply teamwork and leadership skills by carrying out their service learning projects in their TAG groups which met weekly. The final week consisted of Community Service Learning presentations to the class and community members by the Student Team Members. Purpose The purpose of this study was to evaluate the effect of an Interprofessional Leadership (IPL) curriculum on interprofessional self-efficacy, knowledge, and teamwork skills in health care students. The objective was to show a change in these factors as a result of the IPL course. Methodology An outline of the methods for the completion of this study follows. Study design, data analysis, population, sample, data collection methods, and instrumentation are described. Study Design, Population, Sample, Data Collection This study was a one group pre-test, post-test design. Descriptive and inferential statistics were computed. Paired t-tests were used to examine any significant differences in the mean scores of the three measurement instruments described below. One hundred and fifty students were enrolled in the second cohort of the IPL course. Of these, 40 were physician assistant students, 42 were medical students, and 68 were nursing students. All students were offered the opportunity to take part in the study. Students were informed that participation was optional and neither participating nor declining would affect their course grade. After IRB approval was obtained, students completed three written measures of evaluation prior to the start of the course in Fall 2011, and on the final day of class in Spring Students consented to their participation prior to filling out the surveys. A sample of 138 students chose to participate in the pre measures part of the study. Thirty-three students dropped out of the study and did not complete the post measures. Of these, five were medical students, 24 were nursing students, and four were physician assistant students. Although actual reasons for the 24% drop-out were not gathered, anecdotally, nursing students were known to be experiencing academic fatigue, as they were at the end of their curriculum. A 41% drop-out rate from the nursing student group impacts the ability to understand whether the nursing student final sample is representative of the group and is a limitation of the study. Final analyses were based on 105 participants (36 medical, 34 nursing, 35 physician assistant). Instrumentation The Self-Efficacy for Interprofessional Experiential Learning (SEIEL) Scale is a 16 item questionnaire assessing students' perceptions of their self-efficacy for interprofessional learning. 11 The SEIEL has two subscales: Interprofessional Team Evaluation and Feedback and Interprofessional Interactions. The measure reported high internal consistency of the scale and subscales and high content validity. 12 On each item, students were asked to rate their confidence in their ability to carry out aspects of their role as a student for interprofessional learning. Ratings were completed on a 10 point Likert scale, ranging from 1 (Low Confidence) to 10 (High Confidence). Scores for all 16 items were totaled and means were calculated. Subscales were also calculated. The Knowledge of Healthcare Professions survey is a 12-item questionnaire developed by the researcher asking students to rate their knowledge from 1 (Low Knowledge) to 10 (High Knowledge) of the role and scope of various professions. Content validity of the healthcare professions questionnaire was established by a panel of IPL faculty experts. Instructions and one example from the scale are as follows: Medical Science Educator IAMSE 2013 Volume 23(3S) 496

4 Please rate your knowledge of the role and scope of practice of the following professions: Physician Assistant (Low knowledge) (High knowledge) Scores for the 12 items were totaled and means were calculated. The Team Skills Scale Adjusted is a six-item questionnaire adapted from the Team Skills Scale (TSS). 13 The TSS is a 17-item, five-point Likert scale assessing self-report of interpersonal skills, discipline-specific skills, and geriatric care skills. The scale was developed to capture changes in selfassessed skills after exposure to team training. Items are summed and higher scores indicate a greater amount of the perceived skill. Internal consistency is reported to be excellent (Cronbach's alpha =.94). Item to total scale correlations ranged from.58 to For the purposes of the present study, six items of the TSS assessing teamwork skills were used. The six survey questions were chosen from the Team Skills Scale because they were the only items that closely matched the outcomes we hoped the students would achieve. Our panel of IPE faculty experts determined that the adjusted scale had content validity. Scores for all six items were totaled. Results Participant Characteristics Forty-one first-year medical students, 58 senior baccalaureate nursing students, and 39 first year master's level physician assistant students (total n = 138) agreed to participate in the study and completed the pre measures. All students who participated in the study gave informed consent. Seventy three percent of the students were female. Among the three groups the medical students were 40% female (17/42), the physician assistant students were 71% female (22/31) and the nursing students were 95% female (55/58). Sixty-eight percent of all groups had at least one year of previous healthcare experience. More than 75% were 27 years of age or younger. Only six out of 138 stated they had previous interprofessional education experience. Self-Efficacy for Interprofessional Experiential Learning (SEIEL) Paired t-tests were performed comparing pre and post assessments of students' perceptions of their confidence in their ability to work on a team interprofessionally with students of other professions. Results indicated only nursing students showed a significant increase in confidence at the conclusion of the course (see Tables 1 and 2 in Appendix). Pre and post comparisons of the subscales revealed significant differences for nursing students on the subscale Interprofessional Team Evaluation and Feedback. Scores had a possible range of Cronbach's alpha for the current sample was.81. Knowledge of Healthcare Professions Paired t-tests were performed comparing pre and post self-assessments of knowledge of role and scope of healthcare professions. Results indicated participants as a whole rated their knowledge as significantly better at the end of the course. This was true of each discipline when broken into groups (see Table 3). Scores had a possible range of Cronbach's alpha =.93. Discipline Medicine (n=36) Nursing (n=34) Physician Assistant (n=35) Overall (n=105) Pre Mean 6.06 (1.04) 5.92 (1.63) 6.02 (1.21) 6.00 (1.30) Post Mean 7.37 (1.07) 8.58 (1.67) 8.58 (0.84) 8.16 (1.35) p- value Table 3: Pre and Post Comparisons for Knowledge of Healthcare Professions. *significant at p <.01 Medical Science Educator IAMSE 2013 Volume 23(3S) 497

5 Team Skills Scale Adjusted Paired t-tests were performed comparing pre and post self-assessments of team skills. Overall, students indicated they were more skilled at team skills after the completion of the IPL course, but analysis by discipline revealed the nursing students to be the only group to indicate improvement (see Table 4). Scores had a possible range of Cronbach's alpha =.80. Discipline Medicine (n=36) Nursing (n=34) Physician Assistant (n=35) Overall (n=105) Pre Mean (2.86) (3.98) (3.02) (3.46) Post Mean (2.77) (5.20) (4.41) (4.25) p- value Table 4: Pre and Post Comparisons for the Team Skills Scale Adjusted. * significant at p <.01 Conclusions and Discussion There are many challenges when developing a new curricular component that is relatively novel in the world of health professions education. This is the case with interprofessional education (IPE). The creation of the IPEC competencies has provided a guiding framework to begin the process of teaching collaborative practice. 1 The measures used to obtain curricular information for the refinement and improvement of the process of IPE are as varied as the number of schools with IPE programs. In the process of choosing measures for the evaluation of our Interprofessional Leadership course, we carefully vetted tools utilized by other programs. The Self-Efficacy for Interprofessional Experiential Learning Scale was determined to best mirror the knowledge and skills we hoped our students would gain from participation in the course. 11 Students rated their confidence in their ability to carry out aspects of their role as a student in interprofessional learning on items such as: My ability to work with other students from different professions to form a team; My ability to provide feedback to an interprofessional team on our function and work as a team; My ability to provide feedback to individual team members of an interprofessional team on their function and work on the team. The results indicated that the students did significantly increase their confidence in their ability to carry out the Interprofessional Team Evaluation/Feedback aspect of their role as a student in interprofessional learning. When each health profession was viewed individually, however, nursing was the only group with significant differences in their confidence level. When broken down into the two SEIEL subscales, data indicated that the nursing group showed significant differences only on the Interprofessional Team Evaluation and Feedback subscale. We did not anticipate students would come into the course with already high levels of confidence in the aspects of carrying out their role as IPE students. More than once in the beginning, we heard students say, I know all about working in teams. I ve been doing that since kindergarten. Their survey answers reflected that self-confident attitude. Out of a 10-point scale of confidence, students rated themselves almost an eight, with the physician assistant students the highest at Consequently, they did not have much room to improve. Medical students moved from 7.53 to 7.67, with no significance noted. Nursing students made significant increases in their confidence level going from 7.87 to Physician assistant students' confidence decreased, although not significant, moving from 8.48 to Direct interpretation of results would indicate that increased levels of selfefficacy in carrying out their role as IPE students were not achieved by physician assistant and medical students, but were achieved by the nursing students. Anecdotal observations made by the Team Action Group (TAG) facilitators would corroborate the actions of group members according to health profession group; nursing students were less inclined to take on leadership roles than either of the other two professions, but by the end of the course the confidence level had shifted and the leadership roles were more equally shared. Comments made by students in their end of year reflection papers supported that physician assistant and medical students did not lack confidence in their abilities, but reiterated that their learning about interprofessionalism did increase over the year. Students were also very vocal about how they perceived what was helpful or not to their learning about interprofessionalism. Students were more positive about the TAG sessions where activities were a common strategy, than the didactic sessions where speakers were less inclined to use active learning. The sessions where a variety of professions described their roles and responsibilities were also viewed as positive by the students. The Community Service Learning projects received strong praise for the opportunity they provided to operationalize the interprofessional concepts. Medical Science Educator IAMSE 2013 Volume 23(3S) 498

6 The Team Skills Scale Adjusted is a measure used to help assess self-perceived interprofessional abilities, rather than the confidence to carry out those abilities. Examples of items included "help draw out team members who are not participating actively in meetings" and "recognize incorrect stereotypes which underpin professional s view of each other." 13 The overall results showed significant increase in the scores. When the data was analyzed by profession, however, the nursing students were the only group to significantly increase their selfperceived ability to carry out interprofessional tasks over the year-long course. Medical and physician assistant students did not show significant differences in the scale scores. Interestingly, the nursing students were the only group of students actively participating in clinical practicum experiences as a part of their curriculum during the two semesters the IPL course occurred. Quite possibly, this gave the nursing students a unique opportunity, compared to the other two student groups, to apply the interprofessional concepts in the "real world," thus potentially explaining the gains in self-perceived team skills in that group. All groups of students significantly increased their knowledge of the roles and scopes of practice of various health professions. Anecdotal comments included students remarking how much more informed they were now about the role in health care of professions other than their own. The challenge of shaping best practices in IPE lies in the determinants of identified skills and the valid tools to weigh the evidence. These processes are in the development stages. Creating an interprofessional curriculum that positively impacts educational and patient outcomes is the ultimate goal. This study contributes to the growing body of knowledge in interprofessional education by documenting improvements gained as a result of curricular components. Acknowledgement Funding received from the Southern Group on Educational Affairs of the American Association of Colleges of Medicine in Keywords Interprofessional education, teamwork, collaborative practice education Notes on Contributors PATTY M. VARI, PhD, RN, is Professor and MSN Program Director, Jefferson College of Health Sciences, Roanoke, VA, USA. JUDY LASH, PhD, is Associate Professor, Jefferson College of Health Sciences, Roanoke, VA, USA. SARA S. BROWN, DNP, RN, is Assistant Professor, Jefferson College of Health Sciences, Roanoke, VA, USA. AVA G. PORTER, DNP, RN, is Professor and Chair of the Department of Nursing, Jefferson College of Health Sciences, Roanoke, VA, USA. DAVE TRINKLE, MD, is Associate Professor and Associate Dean for Community and Culture, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA, USA. JEANNIE S. GARBER, DNP, RN, is Assistant Professor, Jefferson College of Health Sciences, Roanoke, VA, USA. WILTON KENNEDY, DHSc, PA-C, is Associate Professor, Jefferson College of Health Sciences, Roanoke, Virginia, USA. RICHARD C. VARI, PhD, is Professor and Associate Dean for Medical Education, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA, USA. Medical Science Educator IAMSE 2013 Volume 23(3S) 499

7 References 1. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative; World Health Organization. Health professions networks nursing & midwifery human resources for health: Framework for action on interprofessional education & collaborative practice [Internet]. Geneva, Switzerland: WHO Press; 2010 [cited April, 2012] Available from: n/ 3. Institute of Medicine. To err is human: Building a safer health system. Washington, DC: National Academies Press; Institute of Medicine. Health professions education: A bridge to quality. Washington, DC: National Academies Press; American Hospital Association. In our hands: How hospital leaders can build a thriving workforce. Washington, DC: Author; Kimball, B. & O Neill, E. Health care s human crisis: The American nursing shortage. Princeton, NJ: The Robert Wood Johnson Foundation; Gittell, J.H. Relational coordination: Coordinating work through relationships of shared goals, shared knowledge and mutual respect. In O. Kyriakidou, M. Ozbilgin, editors, Relational Perspectives in Organizational Studies: A Research Companion. Northampton, MA: Edward Elgar Publishing; Thistlethwaite, J. Interprofessional education: A review of context, learning and the research agenda. J Interprof Care 2012; 46: Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Koppel, I., & Hammick, M. The effectiveness of interprofessional education: Key findings from a new systematic review. J Interprof Care 2010; 24: Lencioni, P. The Five Dysfunctions of a Team, San Francisco, CA: Jossey-Bass; Mann, K.V., McFetridge-Durdle, J.A., Sarria, M.D., & Andreou, P. Seamless care: Interprofessional education and the development, content validation, and reliability study of a new evaluation instrument for students. Presented at Collaborating Across Borders; 2007; Minneapolis, MN. 12. Mann, K., McFetridge-Durdle, J., Breau, L., Clovis, J., Martin-Misener, R., Matheson, T, Beanlands, H., & Sarria, M. Development of a scale to measure health professions students' self-efficacy beliefs in interprofessional learning. J Interprof Care 2012; 26: Hepburn, K., Tsukuda, R.A., & Fasser, C. Team skills scale. In E.L. Siegler, K. Hyer, T. Fulmer, & M.Mezey, Editors, Geriatric Interdisciplinary Team Training. New York: Springer Publishing Company; pp. 14. Hyer, K., Heinemann, G.D., & Fulmer, T. Team skills scale. In G.D. Heinemann & A.M. Zeiss (Eds.). Team Performance in Health Care: Assessment and Development. New York: Kluwer Academic/Plenum Publishers; pp. Medical Science Educator IAMSE 2013 Volume 23(3S) 500

8 Appendix Discipline Pre Mean Post Mean p-value Medicine (n=36) 7.53 (1.28) 7.67 (1.07) 0.64 Nursing (n=34) 7.87 (1.45) 8.55 (1.87) 0.03* Physician Assistant (n=35) 8.48 (0.67) 8.34 (1.45) 0.56 Overall (n=105) 7.96 (1.23) 8.18 (1.53) 0.19 Table 1: Pre and Post Comparisons for Self-Efficacy for Interprofessional Experiential Learning (SEIEL) Scale - Overall Scale * significant at p <.05 Discipline Pre Mean Post Mean p-value Medicine Interprof. Team Eval/Feedback Interprof. Interactions 7.14 (1.45) 7.92 (1.21) 7.41 (1.12) 7.92 (1.11) Nursing Interprof. Team Eval/Feedback Interprof. Interactions 7.27 (1.60) 8.59 (2.21) 8.51 (1.82) 8.83 (1.75) 0.59 Physician Assistant Interprof. Team Eval/Feedback Interprof. Interactions 8.16 (0.81) 8.77 (0.65) 8.10 (1.73) 8.58 (1.34) Overall Interprof. Team Eval/Feedback Interprof. Interactions 7.52 (1.39) 8.41 (1.52) 7.99 (1.63) 8.43 (1.46) 0.01* 0.92 Table 2: Pre and Post Comparisons for Self-Efficacy for Interprofessional Experiential Learning (SEIEL) Scale - Subscales * significant at p <.01 Medical Science Educator IAMSE 2013 Volume 23(3S) 501