Inter-professional learning: discussion groups in a minor surgery skills course for nurses

Transcription

1 Nurse Education in Practice (2004) 4, Nurse Education in Practice Inter-professional learning: discussion groups in a minor surgery skills course for nurses Debra Nestel a, *, Roger Kneebone b, Shirley Martin c a Senior Lecturer, Centre for Medical and Health Sciences Education, Monash University, Building 15, Clayton, Vic. 3800, Australia b Senior Lecturer in Surgical Education, Department of Surgical Oncology and Technology, Imperial College, London, UK c Nurse Practitioner in Surgical Technology, Minor Surgical Nurse Practitioner, St. Mary s NHS Trust, London, UK Accepted 7 October 2003 KEYWORDS Inter professional education; Anxiety and learning; Summative assessments Summary Inter-professional teaching and learning takes many forms. This paper describes an inter-professional educational intervention using structured discussion groups of nurses and medical students within an innovative course on minor surgery for nurses. During an initial course, nurses were required to demonstrate competence in technical and communication skills by undergoing scenario-based assessments. Unhelpful levels of anxiety before and after these assessments interfered with learning and performance. Semi-structured discussion groups facilitated by medical students were introduced during a second course, running parallel with assessments and replacing the self-directed activities scheduled in the pilot course. Written evaluations and group interviews explored participants experiences of taking part in these discussion groups. Results indicate that the groups were successful in reducing unhelpful anxiety and that they conferred additional benefits for both nurses and medical students. Future courses incorporating these inter-professional learning opportunities will evaluate immediate and longer-term benefits in greater depth. c 2003 Elsevier Ltd. All rights reserved. Introduction Numerous reports highlight the need for different professional groups to learn and work together (Ross and Southgate, 2000). Although inter-professional education (IPE) is commonly advocated as * Corresponding author. addresses: debra.nestel@med.monash.edu.au, r.kneebone@imperial.ac.uk, shirley.martin@st-marys.nhs.uk. a means of enhancing professional collaboration, there is very little evidence that it works. Systematic reviews of studies of the benefits and outcomes of IPE have found none that were appropriately designed and evaluated (Barr et al., 2000; Barr, 2002) although such programmes have been implemented for several decades and on a very large scale (Barr, 2002). Principles of adult learning strongly support the notion of IPE. However, measuring the long-term benefits of isolated educational experiences is problematic /$ - see front matter c 2003 Elsevier Ltd. All rights reserved. doi: /s (03)

2 Inter-professional learning: discussion groups in a minor surgery 237 Several authors have tried to articulate outcomes and competencies associated with IPE and include those which are common (shared by all professions), complementary (distinguish one profession from another) and collaborative (those necessary to work effectively with others) (Barr, 1998). In health care IPE most often occurs postqualification, across diverse areas of practice and uses wide-ranging methods. Evaluations are largely descriptive and report participants appreciation of learning with and from other health care professionals (Owens et al., 1999). This paper describes a small scale IPE intervention that draws on data from two iterations of an innovative course for nurse practitioners in minor surgery, developed at St. Mary s Hospital, London. A key component of this four-day course is scenario-based assessment of a clinical procedure, requiring participants to integrate technical with communication skills. Such assessments were first developed for use in undergraduate medical education (Kneebone et al., 2002). Each procedure is conducted within a quasi-clinical setting, using an actor who has a skin pad attached to his or her arm beneath a fenestrated drape (Fig. 1). During a 20- min assessment, the nurse has to make an ellipse excision to remove a mole and then close the resulting wound, while talking appropriately to the patient. The procedure is observed, rated and videotaped by technical and communication skills tutors, working in an adjacent room equipped with remotely controlled recording equipment. During a pilot course in 2001 (Course 1), scenarios were used for both formative and summative assessments. Nurses demonstrated high levels of anxiety before and after taking part in these assessments. This anxiety interfered both with their performance and their ability to learn (Nestel et al., 2002). This was especially noticeable on the final day of the course, when each nurse underwent summative assessment leading to a certificate of competence. Moreover, scenario-based summative assessments are a time consuming process. Despite running two sessions concurrently, the entire process for 12 nurse participants lasted more than 4 h. Since each nurse s assessment only takes approximately 30 min, some nurses necessarily spend a considerable amount of time waiting for their turn. This raises anxiety levels further. In Course 1, time not involved in actual scenariobased assessments was scheduled for self-directed learning. Facilities were provided for nurses to practise suturing on simulated tissue skin pads or review CD ROMs. Interview studies after the course revealed that nurses anxiety over the forthcoming assessment was so profound that few had felt able to engage in any self-directed learning. We therefore considered ways to reduce anxiety for future participants. We hypothesised that structured group work might be an effective approach. For the second course (Course 2), discussion groups were scheduled to run in parallel with the assessments. Undergraduate medical students were invited to co-facilitate Figure 1 Simulated patient prepared for scenario-based assessment.

3 238 D. Nestel et al. these groups. Eight discussion scenarios were developed, addressing issues of autonomy, expressed emotion, local anaesthesia, written consent and bleeding. Two examples are provided in Fig. 2 while other scenarios are available on request form the authors. These scenarios were intended to consolidate the broad range of knowledge and skills presented during the course as well as helping nurses to consider and plan for the challenges they might face in practice. This paper describes the responses of the participating nurses and the medical students to this inter-professional discussion group. Methods Two research questions are addressed in this project: Can participation in discussion groups prior to scenario-based assessments reduce unhelpful levels of anxiety? To what extent can medical students function as effective facilitators of discussion groups with qualified nurses? The study took place on Day 4 of Course 2 (the day allocated to summative assessments). Volunteer third-year medical students were selected as discussion group facilitators, because they had completed previous training in facilitation skills and had experience in facilitating communication skills with their peers (Nestel and Kidd, 2002). In preparation for the session, all medical students were ed the scenarios in the preceding week and were encouraged to contact a course tutor (DN) if they had any questions. The students underwent a 1-h briefing before the session began in order to deal with any outstanding questions. Each discussion group was facilitated by two or three students. After presenting each scenario, the students moderated a discussion with the nurses who were in their group at that time. The composition of the group was not static, since nurses would join and leave the group every 30 min for their scheduled scenario-based assessment. The facilitators discussion strategy was designed to take advantage of this flux and to build in some overlap between scenarios. The discussion group session evaluation was integrated into the course evaluation in two ways: 1. After the discussions, all nurses completed evaluation forms designed to elicit their views on specific aspects of the experience and its effect on their levels of anxiety before and after assessments. Each form used a 3-point scale (not at all useful, partially useful, andvery useful). The small sample size precluded sophisticated data analysis. 2. Nurses and medical students participated in separate group interviews to explore their responses to the discussion groups. Interviews were recorded and thematically analysed using standard qualitative methods. Researchers (DN & RK) separately identified themes emerging from interviews and then negotiated agreement on key areas. Results Two concurrent discussion groups took place during the day, consisting of seven nurses and five medical students. Over the 2 h each nurse discussed between three and five scenarios with at least one other nursing colleague and either two or three medical students. All scenarios were discussed by at least two nurses and two or three medical students. Written evaluations Nurses Five nurses rated the discussion groups overall as very useful and two as partially useful in learning about the challenges they may face in practice (Table 1). All nurses rated the experience of learning with nursing colleagues as very useful. Six nurses rated learning with medical students as very useful and one nurse rated this experience as partially useful. When asked to specify what had worked well in the discussion groups, nurses recorded the equality of contributions, the exchange of medical and nursing views, the opportunity for discussion of potential problems and the contribution of different individual perspectives. The small group size, the informality and relaxed atmosphere were also appreciated. The only suggestion for improving the discussion groups was to allocate more time. Four nurses reported no change in their level of anxiety in relation to performing an ellipse excision and suturing the resulting wound before and after their assessment. One nurse was more anxious after the assessment while two nurses were less anxious. None experienced extreme levels of anxiety before or after the assessment. Group interviews Nurses Nurses reported that the discussion groups were extremely useful and enjoyable. They perceived the written scenarios to be relevant and useful.

4 Inter-professional learning: discussion groups in a minor surgery 239 Figure 2 Scenarios and discussion points.

5 240 D. Nestel et al. Table 1 Nurses ratings of usefulness of discussion groups (n ¼ 7) Not at all useful Partially useful Very useful For addressing the challenges they may face in practice Learning with nursing colleagues Learning with medical students It was good enjoyable really. They were really helpful because it gave us a chance to really join up what we d been learning about. All participants felt engaged by the discussions and found them effective in lowering their levels of anxiety about the concurrent scenario-based assessments. I was nervous about the assessment but the discussions were really interesting so it did distract me a bit from what was going to happen and I had the worse time because I was last in the assessment timetable. Nurses especially valued the opportunity to share ideas and experiences with one another. It was helpful raising these issues because this is all new to us. Knowing how someone else would handle a similar situation made me think about my own practice. All found the medical students to be supportive, respectful, mature and competent in leading the discussions and felt that the students contributed a valuable perspective. It was hard to believe they (medical students) were just in their third year they worked really well with us. Very helpful. The students seemed to want to learn from us. I sensed they were getting a lot out of this. They (the students) asked a lot of questions and you could tell they were really listening. They seemed surprised to know about some of the things we (nurses) do. Medical students Medical students thought the sessions worked well. They summarised their strategies for facilitation as follows. We nudged it and guided it and summarised at the end then introduced the next scenario. On the whole in each scenario we played an equal role as the nurses. We also posed them problems, made up roles so we extended the scenarios to other examples. It got them thinking about the issues in different ways. The nurses mentioned anecdotes from their practice to illustrate the discussion scenarios. We were keen to get them to give the ideas. They responded really well to it. They are very experienced nurses. They seemed to quite like talking about things. It was definitely not a one-way process. The whole process was interesting. Initially it was like a question and answer session. They would always answer to us but towards the end they were speaking with each other rather than directing answers to us, exchanging ideas. When asked what they had learned from the experience of facilitating the session, most students focused on their increased understanding of professional roles and the benefit of inter-professional learning rather than the knowledge and skills required for minor surgical procedures I think generally realizing the expanded role that nurses are having now. Changing your perceptions of them. You realise that many doctors don t take them seriously... that they need support. They are taking on roles that were once medical. Ambition and limitation of the two main professions in health care. Basically we had nurses within the group nurses that were quite ambitious... while another just wanted to help out more in the clinic. For me it was realizing how much of the workload in health care can be taken up by other professions. Usefulness of inter-professional teaching and learning really because there were a lot of things they picked up from us and we from them... I had no idea that nurses did things like ellipse excision. Having a multi-disciplinary team. Different people can do different things such as perform ellipse excision. It is not always the doctor that has to do this. So people get to do different things. Some people can take on different roles. Especially these days as the nurse s role is expanding to take over what doctors would once have done routinely. Students commented on the impact of the changes in group composition resulting from the concurrent scenario-based assessments. Group dynamics kept changing as nurses left for their assessments. Kept the flow going in some ways.

6 Inter-professional learning: discussion groups in a minor surgery 241 We did not really experience any disruption or problems at all. Students highlighted specific discussions on consent and autonomy as especially successful. The wound closure ones stood out because we did not know as much about this. This made it more difficult to facilitate. You kind of got the impression that they knew most of the information. The purpose seemed to get them to really think outside of the scenarios. The students appreciated the importance of the discussions in raising awareness of potential challenges in minor surgery and thinking about solutions. We tried to get them to agree on a protocol before they start making an incision, what happens if this potential complication occurs, what do I do, who do I call. So that they know how to get themselves out of it... Once they get in there, they can start thinking about the process. When asked what most impressed them, students commented on the nurses knowledge of their professional boundaries. It was their ideas about professionalism. They know what their role is and what it isn t. When asked about their own preparation for the session, students commented on the participants and the course rather than the content of the scenarios. I d like to know more about the participants, who we are dealing with, what their experience is. I had expectations about them but they were inaccurate. I preferred not knowing so much about them. It was quite nice starting the session with them introducing themselves and them telling us about what they had done. Perhaps something about the course itself, what they had done. Discussion The inter-professional discussion groups described in this paper were initially conceived as a way of reducing unacceptably high anxiety levels for nurses attending the summative assessment component of a new course. The nurses written evaluations and interviews with all who participated are encouraging, suggesting that a high level of engagement in relevant discussion ameliorated the severe discomfort experienced by nurses on the previous course. In addition, the content of the discussion groups enabled nurses to exchange ideas about potential difficulties they may experience as they use their new skills in practice enabling rehearsal of possible solutions. Interestingly, the scenarios on consent and autonomy were thought most effective. This may reflect the unclear boundaries of the new roles in which nurses are working and highlights the need for IPE when what were once complementary competencies become common and/or collaborative. The effect of the discussion groups on the facilitating medical students was, if anything, more striking. The students evidently found the experience an illuminating one, and they gained considerable insight into the thoughts and feelings of a professional group with which they will work closely but about which they knew little. Indeed, this exchange of information and of views was valued by both nurses and medical students, and led to an increased understanding of each by the other. The nurses evident enjoyment of the discussion groups suggests that this process encouraged feelings conducive to learning. These results add weight to the growing body of literature on inter-professional education in relation to enhanced understanding of roles (Owens et al., 1999; Barr, 2002) and explores an under studied area of IPE in which under- and post-graduates from different professional groups learn together. Since we had no baseline data on self-rated levels of anxiety from the previous course in which nurses completed scenario-based assessments, we must rely for comparison on the levels of anxiety which the nurses described in the group interviews. Nurses in Course 2 reported much less anxiety than nurses in Course 1. From this it appears that anxiety was managed more effectively in the second course. Factors other than the discussion groups may have contributed to these reduced levels of anxiety. For example, the tutors awareness of heightened anxiety as a potential problem may have influenced the way they approached the nurses. In Course 2, tutors paid particular attention to introducing the assessment process, striving to provide clear instructions. Increased administrative support ensured that the assessments ran more smoothly than during Course 1. The benefits of small group work are well documented (Elwyn et al., 2001). The use of a range of learning methods can increase participants engagement with the process. In our study, the nature of the semi-structured discussion groups, the novel but applied scenarios and the fact that the facilitators were not known to

7 242 D. Nestel et al. the nurses created an atmosphere that involved all participants. Such exchange-based learning is well described within IPE (McMichael et al., 1984) and reflects principles of adult learning (Barr, 2002). Facilitating a professional group discussion demands a high level of skill and insight. Although these are indispensible professional skills, they rarely form part of undergraduate curricula. The medical students in our study volunteered to undergo training in facilitation skills as an adjunct to their communication programme. In addition, the students previous experiences in facilitation may have contributed to their flexibility in the skills that they used. We anticipated that students in groups of two or three would feel more secure than working alone. The students comments reflect their perception of the value of joint facilitation. The success of these discussion groups may have been related to the personal qualities of the individual students who took part. This selfselected group of facilitators may differ from their peers, many of whom have less experience in the skills of facilitation. More importantly, perhaps these students hold different attitudes towards learning, especially in new situations. Moreover, the students insight into the benefits of learner-centredness enabled them to encourage the nurses to work from personal experiences when identifying key issues in each scenario. Although the medical student facilitators were provided with the discussion scenarios in advance of the session and had opportunities to review them, some content remained unfamiliar to them. This may have enhanced their facilitation, since the students were unable to assume a teaching role in the way that a content expert might have done in a similar situation. The medical students comments suggest their awareness of this experience as a learning opportunity for themselves and drew on the three competencies described by Barr (1998) in relation to outcomes associated with IPE. The evaluation methodologies written evaluations and group interviews were chosen to minimise intrusion into an already highly scheduled course and at a potentially stressful time surrounding assessments. We also wanted to capture immediate responses to the discussion groups. The approach is limited by the small sample. However, the research findings provide insight into the experiences of a highly specialised group of nurses entering a new professional sphere together with the benefits of providing opportunities for medical students to develop professional knowledge and skills. Conclusions Semi-structured discussion groups for nurses in a minor surgery skills course were facilitated by small groups of undergraduate medical students. The opportunity for medical students to work with experienced nurses provided benefits to all. Although originally intended as a strategy to reduce nurses anxiety associated with assessment, the discussion groups proved valuable in other ways, giving nurses an opportunity to explore issues arising from the course and relate them to clinical practice. The importance of the opportunity for discussing potential challenges is heightened by the relatively uncharted professional territory in which these nurses are working. Medical students gained insight into the role of nurses and appreciated the opportunity to learn with them. The students also gained experience in facilitating small groups. Prior training in facilitation skills may have been integral to the success of the project together with the personal qualities of these students. The results of this pilot study are very encouraging and further work is required to explore and develop the elements that constituted its success. References Barr, H., Competent to collaborate: towards a competency-based model for interprofessional education. Journal of Interprofessional Education 12 (2), Barr H., Freeth D., Hammick M., Koppel I., Reeves, S., Evaluations of Interprofessional Education: A United Kingdom Review For Health and Social Care. CAIPE, London. Barr, H., Interprofessional Education: Today, Yesterday and Tomorrow. LTSN for Health Services and Practice, London. Elwyn G., Greenhalgh T., Macfarlane, F., Groups: A Guide to Small Group Work in Healthcare, Management, Education and Research. Radcliffe Medical Press, Oxon. Kneebone R.L., Kidd J., Nestel D., Asvall S., Paraskeva P., Darzi, A., An innovative model for teaching and learning clinical procedures. Medical Education 36 (7), McMichael P., Irvine R., Gilloran, A., Pathways to the Professions: Research Report. Moray House College of Education, Edinburgh. Nestel D., Kidd, J., Evaluation of a teaching workshop for medical students. Medical Education 36,

8 Inter-professional learning: discussion groups in a minor surgery 243 Nestel D., Kneebone R.L., Kidd, J., Teaching and learning about skills in minor surgery an innovative course for nurses. Journal of Clinical Nursing 11, 1 6. Owens C., Goble R., Pereira Gray, D., Involvement in multiprofessional continuing education: a local survey of 24 health care professions. Journal of Interprofessional Care 13 (3), Ross F., Southgate, L., Learning together in medical and nursing training: aspirations and activity. Medical Education 34,