A best evidence systematic review of interprofessional education: BEME Guide no. 9

Using realist synthesis to understand the mechanisms of interprofessional teamwork in health and social care

Realist synthesis offers a novel and innovative way to interrogate the large literature on interprofessional teamwork in health and social care teams. This article introduces realist synthesis and its approach to identifying and testing the underpinning processes (or "mechanisms") that make an intervention work, the contexts that trigger those mechanisms and their subsequent outcomes. A realist synthesis of the evidence on interprofessional teamwork is described. Thirteen mechanisms were identified in the synthesis and findings for one mechanism, called "Support and value" are presented in this paper. The evidence for the other twelve mechanisms ("collaboration and coordination", "pooling of resources", "individual learning", "role blurring", "efficient, open and equitable communication", "tactical communication", "shared responsibility and influence", "team behavioural norms", "shared responsibility and influence", "critically reviewing performance and decisions", "generating and implementing new ideas" and "leadership") are reported in a further three papers in this series. The "support and value" mechanism referred to the ways in which team members supported one another, respected other's skills and abilities and valued each other's contributions. "Support and value" was present in some, but far from all, teams and a number of contexts that explained this variation were identified. The article concludes with a discussion of the challenges and benefits of undertaking this realist synthesis.

Interprofessional Education and Practice Guide No. 1: developing faculty to effectively facilitate interprofessional education

With the growth of interprofessional education (IPE) and practice in health professional schools, faculty members are being asked to assume new roles in leading or delivering interprofessional curriculum. Many existing faculty members feel ill-prepared to face the challenges of this curricular innovation. From 2012–2013, University of Missouri – Columbia and University of Washington partnered with six additional academic health centers to pilot a faculty development course to prepare faculty leaders for IPE. Using a variety of techniques, including didactic teaching, small group exercises, immersion participation in interprofessional education, local implementation of new IPE projects, and peer learning, the program positioned each site to successfully introduce an interprofessional innovation. Participating faculty confirmed the value of the program, and suggested that more widespread similar efforts were worthwhile. This guide briefly describes this faculty development program and identifies key lessons learned from the initiative. Peer learning arising from a faculty development community, adaptation of curricula to fit local context, experiential learning, and ongoing coaching/mentoring, especially as it related to actual participation in IPE activities, were among the key elements of this successful faculty development activity.

Moderating the stereotypical views of health and social care students: the role of interprofessional education

The potential of interprofessional education (IPE) to influence the perceptions and attitudes of health and social care professionals towards their colleagues in other disciplines is well recognized. However, empirical evidence for the positive impact of IPE on stereotypical beliefs has been limited. We report the findings of a pioneering, large scale study designed to assess the influence of IPE on these beliefs. A pre-test, post-test, quasi experimental design compared students' stereotypical views at the beginning and end of undergraduate studies. 580 students from 10 health and social care professional groups undertook assessed IPE modules over 3 years (the intervention group). Baseline and post-course stereotype ratings were compared with those of 672 students in a comparison group, not exposed to IPE modules. Baseline stereotype profiles showed clear variations in the way different professions were perceived, indicating stereotypical beliefs about the characteristics of each profession. Rating patterns were similar for intervention and comparison groups. At graduation, only minor changes were observed in the overall rating patterns for both groups. However, more ratings had decreased in the intervention group than the comparison group, suggesting that IPE may play a role in moderating more extreme stereotyping of colleagues in other professions.

"They have no idea of what we do or what we know": Australian graduates' perceptions of working in a health care team

Globally it has been suggested that interprofessional education can lead to improvements in patient safety as well as increased job satisfaction and understanding of professional roles and responsibilities. In many health care facilities staff report being committed to working collaboratively, however their practice does not always reflect their voiced ideologies. The inability to work effectively together can, in some measure, be attributed to a lack of knowledge and respect for others' professional roles, status and boundaries. In this paper, we will report on the findings of an interpretative study undertaken in Australia, focussing specifically on the experiences of new graduate nurses, doctors and pharmacists in relation to 'knowing about' and 'working with' other health care professionals. Findings indicated there was little understanding of the roles of other health professionals and this impacted negatively on communication and collaboration between and within disciplines. Furthermore, most new graduates recall interprofessional education as intermittent, largely optional, non-assessable, and of little value in relation to their roles, responsibilities and practice as graduate health professionals. Interprofessional education needs to be integrated into undergraduate health programs with an underlying philosophy of reciprocity, respect and role valuing, in order to achieve the proposed benefits for staff and patients.

Students improve patient care and prepare for professional practice: an interprofessional community-based study

BACKGROUND

We report on an education model that enables students to contribute to practice while experiencing the realities of complex team-working in the community.

AIMS

The study considers how interprofessional learning impacts on patient care and service delivery.

METHOD

A qualitative study using a realist approach. The views of practice-staff, patients and facilitators on how student team learning impacted on practice was obtained through focus groups, interviews and an e-questionnaire and compared to student analysis as feedback forms.

RESULTS

Staff from six Primary Health Care Teams (n = 23) stated that the student teams had offered solutions to improve the quality of patient care and on organisational systems. The positive value of the student work was confirmed by the course facilitators (n = 8). In addition, practitioners were propelled to maintain high professional standards. Patients (n = 23) recalled benefits directly attributable to the student work confirmed by the 434 student feedback forms.

CONCLUSION

Undergraduate interprofessional student teams in mid-training can support and help practice teams, and this subsequently benefits patient care. This practice-based interprofessional learning model offers learning, which is theory-based, and supports positive student contributions. This learning fits today's requirements for positive outcomes from education when mapped against the Kirkpatrick or the NHS (UK) education outcomes framework.

Teamwork assessment in internal medicine: a systematic review of validity evidence and outcomes

OBJECTIVE

Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties.

DATA SOURCES

We searched MEDLINE, MEDLINE In-process, CINAHL and PsycINFO from January 1979 through October 2012, references of included articles, and abstracts from four professional meetings. Two content experts were queried for additional studies.

STUDY ELIGIBILITY

Included studies described quantitative tools measuring teamwork among medical students, residents, fellows, and practicing physicians on single or multi-professional (interprofessional) teams.

STUDY APPRAISAL AND SYNTHESIS METHODS

Instrument validity and study quality were extracted using established frameworks with existing validity evidence. Two authors independently abstracted 30 % of articles and agreement was calculated.

RESULTS

Of 12,922 citations, 178 articles describing 73 unique teamwork assessment tools met inclusion criteria. Interrater agreement was intraclass correlation coefficient 0.73 (95 % CI 0.63-0.81). Studies involved practicing physicians (142, 80 %), residents/fellows (70, 39 %), and medical students (11, 6 %). The majority (152, 85 %) assessed interprofessional teams. Studies were conducted in inpatient (77, 43 %), outpatient (42, 24 %), simulation (37, 21 %), and classroom (13, 7 %) settings. Validity evidence for the 73 tools included content (54, 74 %), internal structure (51, 70 %), relationships to other variables (25, 34 %), and response process (12, 16 %). Attitudes and opinions were the most frequently assessed outcomes. Relationships between teamwork scores and patient outcomes were directly examined for 13 (18 %) of tools. Scores from the Safety Attitudes Questionnaire and Team Climate Inventory have substantial validity evidence and have been associated with improved patient outcomes.

LIMITATIONS

Review is limited to quantitative assessments of teamwork in internal medicine.

CONCLUSIONS

There is strong validity evidence for several published tools assessing teamwork in internal medicine. However, few teamwork assessments have been directly linked to patient outcomes.

Nurses’ professional values and attitudes toward collaboration with physicians

Background:

Growing evidence suggests that collaborative practice improves healthcare outcomes, but the precursors to collaborative behavior between nurses and physicians have not been fully explored.

Research question:

The purpose of this descriptive correlational study was to describe the professional values held by nurses and their attitudes toward physician–nurse collaboration and to explore the relationships between nurses’ characteristics (e.g. education, type of work) and professional values and their attitudes toward nurse–physician collaboration.

Research design:

This descriptive correlational study examines the relationship between nurses’ professional values (Nurses Professional Values Scale–Revised) and their attitudes toward nurse–physician collaboration (Jefferson Scale of Attitudes toward Physician–Nurse Collaboration).

Ethical considerations:

Permission to conduct the study was received from the hospital, and the Institutional Review Boards of the healthcare system and the participating university.

Participants/context:

A convenience sample of 231 registered nurses from a tertiary hospital in the United States was surveyed.

Findings:

A significant positive relationship was found between nurses’ professional values and better attitudes toward collaboration with physicians ( r = .26, p < .01). Attitude toward collaboration with physicians was also positively associated with master’s or higher levels of education ( F(3, 224) = 4.379, p = .005).

Discussion:

The results of this study can be helpful to nurse administrators who are responsible for developing highly collaborative healthcare teams and for nurse educators who are focused on developing professional values in future nurses.

[Does simulator-based team training improve patient safety?]

Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

Informed consent and nurses' roles: a survey of Indonesian practitioners

BACKGROUND

In Southeast Asia, the process of obtaining informed consent is influenced by both culture and policy at the hospital and national level. Both physicians and nurses play vital roles in this process, but physicians influence the roles of nurses.

OBJECTIVES

Since the physicians and nurses often have different perspectives, it is important to investigate their views about the informed consent process and nurses' roles therein and whether there is a difference between ideal and experienced practice (reality), and whether this differs across hospitals.

METHODS

A questionnaire was developed and a survey was conducted among physicians and nurses. Using exploratory factor analysis a three factor structure was determined: 'nurses' roles', 'barriers in informed consent', and 'adequacy of information'. Non-parametric tests were applied to compare nurses and physicians, and hospital setting.

PARTICIPANTS AND RESEARCH CONTEXT

Responses were obtained from 129 physicians and 616 nurses from two Indonesian hospitals. Those hospitals differ in ownership, location, and size.

ETHICAL CONSIDERATION

The study was reviewed by the hospital ethical committee. Participation was voluntary and confidentiality was ensured by keeping the responses anonymous.

FINDINGS

Physicians and nurses differ significantly on all three factors. The scores reflecting disparity between ideal and reality regarding nurses' roles varied across professions, while barriers in informed consent differed between hospitals.

DISCUSSION

The differences between ideal and reality indicated that improvement in the informed consent process and nurses' roles therein is called for. Varying views between physicians and nurses on nurses' roles may hinder collaboration. The differences between hospital settings showed interventions may have to be customized for different settings.

CONCLUSION

Views on nurses' roles vary across professions. Views on barriers in informed consent vary across hospitals. Therefore interprofessional education is needed to promote interprofessional collaboration and intervention to improve informed consent practice should be tailored to the hospital context.

Interprofessional education for whom? --challenges and lessons learned from its implementation in developed countries and their application to developing countries: a systematic review

BACKGROUND

Evidence is available on the potential efficacy of interprofessional education (IPE) to foster interprofessional cooperation, improve professional satisfaction, and improve patient care. While the intention of the World Health Organization (WHO) is to implement IPE in all countries, evidence comes from developed countries about its efficiency, challenges, and barriers to planning and implementing IPE. We therefore conducted this review to examine challenges of implementing IPE to suggest possible pathways to overcome the anticipated challenges in developing countries.

METHODS

We searched for literatures on IPE in PubMed/MEDLINE, CINAHL, PsycINFO, and ERIC databases. We examined challenges or barriers and initiatives to overcome them so as to suggest methods to solve the anticipated challenges in developing countries. We could not conduct a meta-analysis because of the qualitative nature of the research question and the data; instead we conducted a meta-narrative of evidence.

RESULTS

A total of 40 out of 2,146 articles were eligible for analyses in the current review. Only two articles were available from developing countries. Despite the known benefits of IPE, a total of ten challenges or barriers were common based on the retrieved evidence. They included curriculum, leadership, resources, stereotypes and attitudes, variety of students, IPE concept, teaching, enthusiasm, professional jargons, and accreditation. Out of ten, three had already been reported in developing countries: IPE curriculum, resource limitations, and stereotypes.

CONCLUSION

This study found ten important challenges on implementing IPE. They are curriculum, leadership, resources, stereotypes, students' diversity, IPE concept, teaching, enthusiasm, professional jargons, and accreditation. Although only three of them are already experienced in developing countries, the remaining seven are potentially important for developing countries, too. By knowing these challenges and barriers in advance, those who implement IPE programs in developing countries will be much more prepared, and can enhance the program's potential success.

Time for some home truths – exploring the relationship between GPs and social workers

Purpose

– The purpose of this paper is to explore the relationship between general practitioners (GPs) and social care professionals by reflecting on a project (the Home Truths project) which sought to improve joint working between general practice and social care though an action-research process.

Design/methodology/approach

– iMPOWER's Home Truths project involved gathering local data regarding joint working in local areas and using this data as a catalyst for change. The Institute of Local Government Studies and the Health Services Management Centre at the University of Birmingham were asked to act as a critical friend to the project. This involved supporting the design of the data collection, offering advice on the process and to carrying out a short evaluation of the impact of the first wave. The paper reflects on the collected data from the sites and information from the impact evaluation.

Findings

– The paper highlights the poor quality of the relationship between GPs and social workers. Findings that illustrate this include GPs’ poor knowledge of social care services; a perception that social care services were of poor quality and rating the quality of their relationships with social workers as poor. However GPs felt that knowing more about social care could help prevent their patients going into residential care earlier than necessary and wanted to work more closely with social care to exploit the benefits and opportunities. The interventions that have been put in place to try and improve relationships focus on the day-to-day working lives of the professionals rather than attempting to introduce new initiatives.

Research limitations/implications

– The response rate from GPs in the areas was low (average response rate was 10 per cent in each area) and it may be that only those GPs who are interested in working with social care responded. The initiatives that have been developed appear to be reasonable responses to the issues identified. However, a lack of discrete outcomes through which to measure improvement will make it difficult to demonstrate the impact of the interventions.

Originality/value

– This paper underlines that despite many years of policy makers promoting better integration, the relationship between the key gate-keepers within the health and social care systems is still poor. The findings from the Home Truths surveys and action plans has gone some way to address the gap identified in the evidence base about the relationships between GPs and social workers.

Development and evaluation of an innovative model of inter-professional education focused on asthma medication use

BACKGROUND

Inter-professional learning has been promoted as the solution to many clinical management issues. One such issue is the correct use of asthma inhaler devices. Up to 80% of people with asthma use their inhaler device incorrectly. The implications of this are poor asthma control and quality of life. Correct inhaler technique can be taught, however these educational instructions need to be repeated if correct technique is to be maintained. It is important to maximise the opportunities to deliver this education in primary care. In light of this, it is important to explore how health care providers, in particular pharmacists and general medical practitioners, can work together in delivering inhaler technique education to patients, over time. Therefore, there is a need to develop and evaluate effective inter-professional education, which will address the need to educate patients in the correct use of their inhalers as well as equip health care professionals with skills to engage in collaborative relationships with each other.

METHODS

This mixed methods study involves the development and evaluation of three modules of continuing education, Model 1, Model 2 and Model 3. A fourth group, Model 4, acting as a control.Model 1 consists of face-to-face continuing professional education on asthma inhaler technique, aimed at pharmacists, general medical practitioners and their practice nurses.Model 2 is an electronic online continuing education module based on Model 1 principles.Model 3 is also based on asthma inhaler technique education but employs a learning intervention targeting health care professional relationships and is based on sociocultural theory.This study took the form of a parallel group, repeated measure design. Following the completion of continuing professional education, health care professionals recruited people with asthma and followed them up for 6 months. During this period, inhaler device technique training was delivered and data on patient inhaler technique, clinical and humanistic outcomes were collected. Outcomes related to professional collaborative relationships were also measured.

DISCUSSION

Challenges presented included the requirement of significant financial resources for development of study materials and limited availability of validated tools to measure health care professional collaboration over time.

Development of a behaviour change intervention: a case study on the practical application of theory

BACKGROUND

Use of theory in implementation of complex interventions is widely recommended. A complex trial intervention, to enhance self-management support for people with osteoarthritis (OA) in primary care, needed to be implemented in the Managing Osteoarthritis in Consultations (MOSAICS) trial. One component of the trial intervention was delivery by general practitioners (GPs) of an enhanced consultation for patients with OA. The aim of our case study is to describe the systematic selection and use of theory to develop a behaviour change intervention to implement GP delivery of the enhanced consultation.

METHODS

The development of the behaviour change intervention was guided by four theoretical models/frameworks: i) an implementation of change model to guide overall approach, ii) the Theoretical Domains Framework (TDF) to identify relevant determinants of change, iii) a model for the selection of behaviour change techniques to address identified determinants of behaviour change, and iv) the principles of adult learning. Methods and measures to evaluate impact of the behaviour change intervention were identified.

RESULTS

The behaviour change intervention presented the GPs with a well-defined proposal for change; addressed seven of the TDF domains (e.g., knowledge, skills, motivation and goals); incorporated ten behaviour change techniques (e.g., information provision, skills rehearsal, persuasive communication); and was delivered in workshops that valued the expertise and professional values of GPs. The workshops used a mixture of interactive and didactic sessions, were facilitated by opinion leaders, and utilised 'context-bound communication skills training.' Methods and measures selected to evaluate the behaviour change intervention included: appraisal of satisfaction with workshops, GP report of intention to practise and an assessment of video-recorded consultations of GPs with patients with OA.

CONCLUSIONS

A stepped approach to the development of a behaviour change intervention, with the utilisation of theoretical frameworks to identify determinants of change matched with behaviour change techniques, has enabled a systematic and theory-driven development of an intervention designed to enhance consultations by GPs for patients with OA. The success of the behaviour change intervention in practice will be evaluated in the context of the MOSAICS trial as a whole, and will inform understanding of practice level and patient outcomes in the trial.

Transfer of learning and patient outcome in simulated crisis resource management: a systematic review

PURPOSE

Simulation-based learning is increasingly used by healthcare professionals as a safe method to learn and practice non-technical skills, such as communication and leadership, required for effective crisis resource management (CRM). This systematic review was conducted to gain a better understanding of the impact of simulation-based CRM teaching on transfer of learning to the workplace and subsequent changes in patient outcomes.

SOURCE

Studies on CRM, crisis management, crew resource management, teamwork, and simulation published up to September 2012 were searched in MEDLINE(®), EMBASE™, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC. All studies that used simulation-based CRM teaching with outcomes measured at Kirkpatrick Level 3 (transfer of learning to the workplace) or 4 (patient outcome) were included. Studies measuring only learners' reactions or simple learning (Kirkpatrick Level 1 or 2, respectively) were excluded. Two authors independently reviewed all identified titles and abstracts for eligibility.

PRINCIPAL FINDINGS

Nine articles were identified as meeting the inclusion criteria. Four studies measured transfer of simulation-based CRM learning into the clinical setting (Kirkpatrick Level 3). In three of these studies, simulation-enhanced CRM training was found significantly more effective than no intervention or didactic teaching. Five studies measured patient outcomes (Kirkpatrick Level 4). Only one of these studies found that simulation-based CRM training made a clearly significant impact on patient mortality.

CONCLUSIONS

Based on a small number of studies, this systematic review found that CRM skills learned at the simulation centre are transferred to clinical settings, and the acquired CRM skills may translate to improved patient outcomes, including a decrease in mortality.

The paradoxical effects of workforce shortages on rural interprofessional practice

RATIONALE AND AIM

While interprofessional practice has been promoted as a solution to the challenges besetting rural health services, current evidence does not offer a clear explanation as to why it is effective in some domains and yet is not successful in others. At the same time, rural clinicians are frequently faced with major workforce pressures and this has a significant influence on professional practice. The aim of this study was to explore how these pressures impact on rural interprofessional practice.

METHOD

This study is part of a larger project investigating factors that enhance and detract from effective interprofessional working. We utilised a modified realistic evaluation approach to analyse the context, mechanisms and outcomes of rural interprofessional practice. Approval for this study was granted by an accredited research ethics committee. Semi-structured interviews were conducted with 22 rural clinicians who were purposively recruited from a range of settings, roles, locations and professions.

FINDINGS AND DISCUSSION

We found that clinicians often invested in interprofessional practice because of the need to manage intense workloads and this necessitated sharing of responsibilities across disciplines and blurring of role boundaries. Paradoxically, participants noted that workload pressures hampered interprofessional working if there were long-term skill shortages. Sharing workload and responsibility is an important motivator for rural practitioners to engage in interprofessional practice; however, this driver is only effective under circumstances where there are sufficient resources to facilitate collaboration. In the context of intransient resource challenges, rural health service managers would be best to focus on enabling IPP through facilitating role understanding and respect between clinicians. This is most feasible via informal workplace learning and allowing time for teams to reflect on collaborative processes.

Nursing and medical student attitudes about communication and collaboration before and after an interprofessional education experience

AIM

The purpose of this study was to examine attitudes about interprofessional communication and collaboration as well as the effect of an interprofessional educational intervention on health care students.

BACKGROUND

Interprofessional education requires an understanding of student attitudes about interprofessional communication and collaboration, as well as whether those attitudes are affected by participation in such educational initiatives.

METHOD

Medical and nursing students were placed in health care teams. Attitudes about communication and collaboration were measured at the beginning and end of the project using the Jefferson scale of Attitudes Toward Physician-Nurse Collaboration and the Baggs Collaboration and Satisfaction About Care Decisions tool.

RESULTS

Significant differences were seen between the medical and nursing groups as well as across time.

CONCLUSION

Compared with nursing students, medical students began their student careers with less positive attitudes toward interprofessional communication and collaboration. In spite of the three-semester health care team program, these differences persisted.

Interprofessional education in allied health: a systematic review

OBJECTIVES

During the past decade, several studies have systematically reviewed interprofessional education (IPE), but few have inclusively reviewed this literature. None has focused primarily on IPE in allied health, despite differences in recruitment and socialisation across the health professions. This systematic review seeks to uncover the best approach to pre-licensure, university-based allied health IPE to determine which aspects require modification in which contexts to provide optimal learning experiences.

METHODS

A systematic search of 10 databases was conducted for articles published in English, between January 1998 and January 2013. Studies were included if they used quantitative or qualitative methodologies to report on the outcomes associated with IPE in allied health. Two independent reviewers identified studies that met the inclusion criteria, critically appraised the included studies and extracted data relating to the effectiveness of IPE in allied health. Data were synthesised narratively to address the study aims.

RESULTS

Large gaps - relating to methods, theory and context - remain within this body of literature. Studies measured students' attitudes and understanding of other health professional roles, teamwork and knowledge in response to IPE interventions using patient scenarios, lectures and small-group work. Differences in power and curriculum placement were described as factors affecting IPE effectiveness.

CONCLUSIONS

Evaluation remains the primary aim within this literature. Few studies use theory, take an inductive approach to understanding the processes behind IPE or include detailed participant descriptions. Therefore, we suggest that IPE research is currently caught in an epistemological struggle, between assumptions underpinning biomedical and health science research, and those underpinning education studies. As part of a systems approach to understanding interprofessional socialisation, we call for researchers to take a realistic approach to evaluation that is inclusive of, and responsive to, contextual factors to explore how IPE leads to improved long-term outcomes in differing circumstances.

General practitioners' perspectives of education and collaboration with physiotherapists in Primary Health Care: a discourse analysis

This paper explores the educational factors that underlie the poor collaboration between general practitioners (GPs) and physiotherapists (PTs) in Primary Health Care (PHC), from the GP's perspective. This study was conducted in Majorca, the Balearic Islands (Spain). Participants were nine GPs who graduated from different universities in mainland Spain. A discourse analysis study was developed employing the social-critical paradigm as theoretical framework and in-depth interviews for data collection. The perceived lack of knowledge about physiotherapy was considered by the interviewees as a major factor in the current poor communication between GPs and PTs. The individual learning during medical studies and poor interprofessional learning during clinical residency influenced their gatekeeper role, putting at risk the equity of the health system. Collaboration was considered beneficial for patients but challenging to improve in context due to multiple factors ranging from individual to systemic. The latter encompasses inadequate resources and organization for interprofessional learning. There is a need to further explore other factors influencing the poor collaboration, including PTs' views on this process.

Global health education programming as a model for inter-institutional collaboration in interprofessional health education

While global health (GH) opportunities have expanded at schools of medicine, nursing, and public health, few examples of interprofessional approaches to GH education have been described. The elective GH program at our university serves as an important opportunity for high-quality interprofessional education. We undertook a qualitative study to examine the experience of student, faculty and administrative leaders of the program. We used content analysis to code responses and analyze data. Among the leadership, key themes fell within the categories of interprofessional education, student-faculty collaboration, professional development, and practical considerations for the development of such programs. The principles described could be considered by institutions seeking to develop meaningful partnerships in an effort to develop or refine interprofessional global health education programs.

An interprofessional communication training using simulation to enhance safe care for a deteriorating patient

BACKGROUND

Communication and teamwork between doctors and nurses are critical for optimal patient care. Simulation and interprofessional team learning are emerging as significant learning strategies to promote teamwork and communication between different health professionals.

AIM

The aim of the study is to describe the development, implementation and evaluation of a simulation-based interprofessional educational (Sim-IPE) program, using a presage-process-product (3P) model, for improving medical and nursing students' communication skills in caring of a patient with physiological deterioration.

METHOD

The program was conducted using full-scale simulation and communication strategies adapted from Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). 127 medical and nursing students participated in a 3-hour small group interprofessional learning that incorporated simulation scenarios of deteriorating patients. Pre and post-tests were conducted to assess the students' self-confidence in interprofessional communication and perception in interprofessional learning. After the training, the students completed a satisfaction questionnaire.

RESULTS

Both medicine and nursing groups demonstrated a significant improvement on post-test score from pre-test score for self-confidence (p<.0001) and perception (p<.0001) with no significant differences detected between the two groups. The participants were highly satisfied with their simulation learning.

CONCLUSION

The Sim-IPE has better prepared the medical and nursing students in communicating with one another in providing safe care for deteriorating patient. In addition, it has improved their perception towards interprofessional learning. This pre-registration interprofessional education could prepare them for more comprehensive interprofessional team learning at post-registration level.

Interprofessional service improvement learning and patient safety: a content analysis of pre-registration students' assessments

A culture of continuous service improvement underpins safe, efficient and cost-effective health and social care. This paper reports a qualitative research study of assessment material from one cohort of final year pre-registration health and social care students' interprofessional service improvement learning experience. Initially introduced to the theory of service improvement, students were linked with an interprofessional buddy group, and subsequently planned and implemented, if possible, a small scale service improvement project within a practice placement setting. Assessment was by oral project presentation and written reflection on learning. Summative assessment materials from 150 students were subjected to content analysis to identify: service user triggers for service improvement; ideas to address the identified area for improvement; and perceptions of service improvement learning. Triggers for service improvements included service user disempowerment, poor communication, gaps in service provision, poor transitions, lack of information, lack of role clarity and role duplication, and differed between professions. Ideas for improvement included both the implementation of evidence based best practice protocols in a local context and also innovative approaches to problem solving. Students described both intrapersonal and interprofessional learning as a result of engaging with service improvement theory and practice. Service improvement learning in an interprofessional context has positive learning outcomes for health and social care students. Students can identify improvement opportunities that may otherwise go undetected. Engaging positively in interprofessional service improvement learning as a student is an important rehearsal for life as a qualified practitioner. It can help students to develop an ability to challenge unsafe practice elegantly, thereby acting as advocates for the people in their care. Universities can play a key support role by working collaboratively with service organisations; role modelling effective interprofessional working; and supporting research to measure the impact of education on practice.

Promoting interprofessional understandings through online learning: a qualitative examination

Interprofessional education is increasingly a core component of health professional curricula. It has been suggested that interprofessional education can directly enhance patient care outcomes. However, literature has reported many difficulties in its successful implementation. This study investigated students' perceptions of participating in an online, Web-based module to facilitate interprofessional education. Three focus groups, each with 13-15 students, from emergency health (paramedic), nursing, occupational therapy, physiotherapy, and nutrition and dietetics were conducted with students who participated in an online interprofessional education module at one Australian university. Thematic analysis was employed to analyze interview transcripts. Four themes emerged: professional understanding, patient-centeredness, comparison with other interprofessional education activities, and overcoming geographical boundaries. Students were overwhelmingly positive about their learning experiences and the value of the module in assisting their understandings of the roles of other health professionals. Online approaches to interprofessional education have the potential to enhance learning and overcome geographical and logistical issues inherent in delivering face-to-face interprofessional education. Furthermore, our design approach allowed students to watch how other health professionals worked in a way that they were unable to achieve in clinical practice.

Convergence and translation: attitudes to inter-professional learning and teaching of creative problem-solving among medical and engineering students and staff

BACKGROUND

Healthcare worldwide needs translation of basic ideas from engineering into the clinic. Consequently, there is increasing demand for graduates equipped with the knowledge and skills to apply interdisciplinary medicine/engineering approaches to the development of novel solutions for healthcare. The literature provides little guidance regarding barriers to, and facilitators of, effective interdisciplinary learning for engineering and medical students in a team-based project context.

METHODS

A quantitative survey was distributed to engineering and medical students and staff in two universities, one in Ireland and one in Belgium, to chart knowledge and practice in interdisciplinary learning and teaching, and of the teaching of innovation.

RESULTS

We report important differences for staff and students between the disciplines regarding attitudes towards, and perceptions of, the relevance of interdisciplinary learning opportunities, and the role of creativity and innovation. There was agreement across groups concerning preferred learning, instructional styles, and module content. Medical students showed greater resistance to the use of structured creativity tools and interdisciplinary teams.

CONCLUSIONS

The results of this international survey will help to define the optimal learning conditions under which undergraduate engineering and medicine students can learn to consider the diverse factors which determine the success or failure of a healthcare engineering solution.

Interprofessional workplace learning: a catalyst for strategic change?

The integrated care development programme (ICDP) was a continuing interprofessional educational programme for health and social care managers and commissioners. Multi-professional strategic teams from a single locality participated in university and workplace-based learning activities centred on the development of an integrated business plan to address a local priority for improvement. The evaluation used participant self-assessment, semi-structured interviews and group discussions to assess achievement of expected impacts on the participants, their organisations and partnerships, and patient/service user outcomes. The findings indicate that whilst those employed in management and commissioning roles had considerable experience of working across professional and agency boundaries they derived individual benefits from a workplace IPE programme. The principles of design and delivery developed in pre-registration and clinician/practitioner IPE courses also applied to those working at a more strategic level. Organisational impacts were reported, but 6 months post-programme evidence was not yet available of significant improvements in patient outcomes and /or financial efficiencies. Individual motivation, team dynamics and support from line managers all affected the extent to which individual and organisational impacts were achieved.

Improving chronic care through continuing education of interprofessional primary healthcare teams: a process evaluation

Process evaluations assess program structures and implementation processes so that outcomes can be accurately interpreted. This article reports the results of a process evaluation of Partnerships for Health, an initiative targeting interprofessional primary healthcare teams to improve chronic care in Southwestern Ontario, Canada. Program documentation, participant observation, and in-depth interviews were used to capture details about the program structure, implementation process, and experience of implementers and participants. Results suggest that the intended program was modified during implementation to better meet the needs of participants and to overcome participation barriers. Elements of program activities perceived as most effective included series of off-site learning/classroom sessions, practice-based/workplace information-technology (IT) support, and practice coaching because they provided: dedicated time to learn how to improve chronic care; team-building/networking within and across teams; hands-on IT training/guidance; and flexibility to meet individual practice needs. This process evaluation highlighted key program activities that were essential to the continuing education (CE) of interprofessional primary healthcare teams as they attempted to transform primary healthcare to improve chronic care.

Interprofessional experiences and attitudes toward interprofessional health care teams among health sciences students

This study examined how the interprofessional experience, including education and practice, affects graduate health science students' attitudes toward interprofessional practice in health care teams. Data were collected from 227 graduate students, using the Attitudes toward Health Care Teams (ATHCT) scale. Both social work and other health science students had positive attitudes toward interprofessional collaboration with regard to its ability to improve the quality of a patient's care. The results from hierarchical linear regression analyses demonstrated that female students, older students, and students with longer interprofessional practice experiences had more positive attitudes toward interprofessional collaboration in health care teams. Based on these results, implications for interprofessional education are discussed.

Caring For Kids Where They Live: interprofessional collaboration in teaching and learning in school settings

Across North America, educators are challenged with finding learning opportunities for students in the health professions. Faculty members with a pediatric specialization in nursing recognized that schools were an ideal setting to provide children with care from the health continuum including health promotion, assessment and treatment, and chronic disease management. The faculty of nursing at a Western Canadian University established a unique educational approach by creating an interprofessional pediatric clinical learning experience titled, Caring For Kids Where They Live. This practicum brings together students in the health professions (nurses, dentists, and kinesiologists) and students and their families from three urban schools; one elementary school and two high schools. The primary goals of this partnership were to create an interprofessional clinical learning experience and to promote health and wellness of children and youth. This initiative far exceeded the initial goals. This descriptive article with the use of reflective elements from student journals, identifies learning that occurred in an environment whereby students from the health professions had the opportunity to meet and interact, to collaborate, and to gain experience in caring for children and youth.

The making of the interprofessional arena in the United Kingdom: a social and political history

This article offers a critical sociological rendering of the making of the interprofessional arena in the United Kingdom. It offers an interpretation of the conditions that led to the formation, expansion and development of the interprofessional arena using a social worlds/arenas lens of secondary data. I propose that the making of the interprofessional arena has been achieved in three historiographical phases. First, the "recognition of the professionalisation conundrum" that led to the intuitive assumption that interprofessional education (IPE) could lead to improved collaboration in practice and improved outcomes. Second, the "legitimisation" of the interprofessional assumption through the development of networks, building consensus, nurturing an evidence base and negotiating with policymakers. Third, "Talking up and acting up" the interprofessional agenda by developing global communities of practice, pandering to a neoliberal agenda, disseminating exemplars of good practice and encouraging practical changes within diverse settings. Articulating these historical "moments" may allow us insights into the conditions that have created the contemporary interprofessional arena and offer us ways of considering how present conditions may re-shape the discourses that constitute the interprofessional arena of the future.

The CanMEDS role of Collaborator: How is it taught and assessed according to faculty and residents?

OBJECTIVE

To explore the perspectives of paediatric residents and faculty regarding how the Collaborator role is taught and assessed.

METHODS

Using a constructivist grounded theory approach, focus groups at four Canadian universities were conducted. Data were analyzed iteratively for emergent themes.

RESULTS

Residents reported learning about collaboration through faculty role modelling but did not perceive that it was part of the formal curriculum. Faculty reported that they were not trained in how to effectively model this role. Both groups reported a need for training in conflict management, particularly as it applies to intraprofessional (physician-to-physician) relationships. Finally, the participants asserted that current methods to assess residents on their performance as collaborators are suboptimal.

CONCLUSIONS

The Collaborator role should be a formal part of the residency curriculum. Residents need to be better educated with regard to managing conflict and handling intraprofessional relationships. Finally, innovative methods of assessing residents on this non-medical expert role need to be created.

A comparison of two scales for assessing health professional students' attitude toward interprofessional learning

RATIONALE

The validated 19-item Readiness for Interprofessional Learning Scale (RIPLS) is often used for assessing attitudes toward interprofessional education (IPE). The 12-item Interdisciplinary Education Perception Scale (IEPS), also used for this purpose, has not been validated among the professions of medicine, pharmacy, and physician assistants (PAs). The discriminatory ability of the two scales has not been directly compared. Comparison of the two will aid educators in selecting the optimal scale.

OBJECTIVE

To compare psychometric properties of the RIPLS and IEPS and to examine the ability of each scale to discriminate mean scores among student subgroups (gender, profession, seniority, and prior IPE exposure).

METHOD

We conducted a cross-sectional (Qualtrics(©)) survey (RIPLS and IEPS) of junior and senior students in medicine (n=360), pharmacy (n=360), and the PA profession (n=106). Descriptive statistics were used to report aggregate mean scores of subgroups. The internal consistency of each scale was assessed using Cronbach's α. Concurrent validity was measured by Pearson's correlation coefficients. Independent-sample t-tests and analysis of variances (ANOVAs) were performed to assess the discriminatory ability of each scale. Cohen's d effect sizes were calculated for all significant pair-wise comparisons.

RESULTS

Response rate was 82%. Cronbach's α was 0.85 (RIPLS) and 0.91 (IEPS). The RIPLS discriminated scores by gender among junior students only, and scores by IPE exposure among all students. The IEPS distinguished score differences for the three professions among junior students and by prior IPE exposure for all three professions. Neither scale detected differences in mean scores by profession among all students or by level of training among the three professions.

CONCLUSIONS

Neither the RIPLS nor the IEPS has greater discriminatory ability for detecting attitude differences among the student subgroups. Reason for differences may be explained by slightly different scale constructs. The RIPLS is designed to assess students' own attitude toward interprofessional learning, while the IEPS discerns perceived attitudes about team collaboration for students' own professions and may be more appropriate for more advanced students.

Reliability of team-based self-monitoring in critical events: a pilot study

BACKGROUND

Teamwork is a critical component during critical events. Assessment is mandatory for remediation and to target training programmes for observed performance gaps.

METHODS

The primary purpose was to test the feasibility of team-based self-monitoring of crisis resource management with a validated teamwork assessment tool. A secondary purpose was to assess item-specific reliability and content validity in order to develop a modified context-optimised assessment tool.We conducted a prospective, single-centre study to assess team-based self-monitoring of teamwork after in-situ inter-professional simulated critical events by comparison with an assessment by observers. The Mayo High Performance Teamwork Scale (MHPTS) was used as the assessment tool with evaluation of internal consistency, item-specific consensus estimates for agreement between participating teams and observers, and content validity.

RESULTS

105 participants and 58 observers completed the MHPTS after a total of 16 simulated critical events over 8 months. Summative internal consistency of the MHPTS calculated as Cronbach's alpha was acceptable with 0.712 for observers and 0.710 for participants. Overall consensus estimates for dichotomous data (agreement/non-agreement) was 0.62 (Cohen's kappa; IQ-range 0.31-0.87). 6/16 items had excellent (kappa > 0.8) and 3/16 good reliability (kappa > 0.6). Short questions concerning easy to observe behaviours were more likely to be reliable. The MHPTS was modified using a threshold for good reliability of kappa > 0.6. The result is a 9 item self-assessment tool (TeamMonitor) with a calculated median kappa of 0.86 (IQ-range: 0.67-1.0) and good content validity.

CONCLUSIONS

Team-based self-monitoring with the MHPTS to assess team performance during simulated critical events is feasible. A context-based modification of the tool is achievable with good internal consistency and content validity. Further studies are needed to investigate if team-based self-monitoring may be used as part of a programme of assessment to target training programmes for observed performance gaps.

Design and evaluation of a prelicensure interprofessional course on improving care transitions

Effective management of care transitions for older adults require the coordinated expertise of an interprofessional team. Unfortunately, different health care professions are rarely educated together or trained in teamwork skills. To address this issue, a team of professionally diverse faculty from the Duke University Geriatric Education Center designed an interprofessional course focused on improving transitions of care for older adults. This innovative prelicensure course provided interactive teaching sessions designed to promote critical thinking and foster effective communication among health care professionals, caregivers, and patients. Students were assessed by in-class and online participation, performance on individual assignments, and team-based proposals to improve care transitions for older patients with congestive heart failure. Twenty students representing six professions completed the course; 18 completed all self-efficacy and course evaluation surveys. Students rated their self-efficacy in several domains before and after the course and reported gains in teamwork skills (p < .001), transitions of care (p < .001), quality improvement (p < .001) and cultural competence (p < .001). Learner feedback emphasized the importance of enthusiastic and well-prepared faculty, interactive learning experiences, and engagement in relevant work. This course offers a promising approach to shifting the paradigm of health professions education to empower graduates to promote quality improvement through team-based care.

Views and experiences of nurse practitioners and medical practitioners with collaborative practice in primary health care - an integrative review

BACKGROUND

This integrative review synthesises research studies that have investigated the perceptions of nurse practitioners and medical practitioners working in primary health care. The aggregation of evidence on barriers and facilitators to working collaboratively and experiences about the processes of collaboration is of value to understand success factors and factors that impede collaborative working relationships.

METHODS

An integrative review, which used systematic review processes, was undertaken to summarise qualitative and quantitative studies published between 1990 and 2012. Databases searched were the Cochrane Library, the Joanna Briggs Institute Library, PubMed, Medline, CINAHL, Informit and ProQuest. Studies that met the inclusion criteria were assessed for quality. Study findings were extracted relating to a) barriers and facilitators to collaborative working and b) views and experiences about the process of collaboration. The findings were narratively synthesised, supported by tabulation.

RESULTS

27 studies conducted in seven different countries met the inclusion criteria. Content analysis identified a number of barriers and facilitators of collaboration between nurse practitioners and medical practitioners. By means of data comparison five themes were developed in relation to perceptions and understanding of collaboration. Nurse practitioners and medical practitioners have differing views on the essentials of collaboration and on supervision and autonomous nurse practitioner practice. Medical practitioners who have a working experience with NPs express more positive attitudes towards collaboration. Both professional groups report concerns and negative experiences with collaborative practice but also value certain advantages of collaboration.

CONCLUSIONS

The review shows that working in collaboration is a slow progression. Exposure to working together helps to overcome professional hurdles, dispel concerns and provide clarity around roles and the meaning of collaboration of NPs and MPs. Guidelines on liability and better funding strategies are necessary to facilitate collaborative practice whether barriers lie in individual behaviours or in broader policies.

An integrative review and evidence-based conceptual model of the essential components of pre-service education

BACKGROUND

With decreasing global resources, a pervasive critical shortage of skilled health workers, and a growing disease burden in many countries, the need to maximize the effectiveness and efficiency of pre-service education in low-and middle-income countries has never been greater.

METHODS

We performed an integrative review of the literature to analyse factors contributing to quality pre-service education and created a conceptual model that shows the links between essential elements of quality pre-service education and desired outcomes.

RESULTS

The literature contains a rich discussion of factors that contribute to quality pre-service education, including the following: (1) targeted recruitment of qualified students from rural and low-resource settings appears to be a particularly effective strategy for retaining students in vulnerable communities after graduation; (2) evidence supports a competency-based curriculum, but there is no clear evidence supporting specific curricular models such as problem-based learning; (3) the health workforce must be well prepared to address national health priorities; (4) the role of the preceptor and preceptors' skills in clinical teaching, identifying student learning needs, assessing student learning, and prioritizing and time management are particularly important; (5) modern, Internet-enabled medical libraries, skills and simulation laboratories, and computer laboratories to support computer-aided instruction are elements of infrastructure meriting strong consideration; and (6) all students must receive sufficient clinical practice opportunities in high-quality clinical learning environments in order to graduate with the competencies required for effective practice. Few studies make a link between PSE and impact on the health system. Nevertheless, it is logical that the production of a trained and competent staff through high-quality pre-service education and continuing professional development activities is the foundation required to achieve the desired health outcomes. Professional regulation, deployment practices, workplace environment upon graduation and other service delivery contextual factors were analysed as influencing factors that affect educational outcomes and health impact.

CONCLUSIONS

Our model for pre-service education reflects the investments that must be made by countries into programmes capable of leading to graduates who are competent for the health occupations and professions at the time of their entry into the workforce.

The impact of an interprofessional problem-based learning curriculum of clinical ethics on medical and nursing students' attitudes and ability of interprofessional collaboration: a pilot study

Clinical ethic situations in modern multiprofessional healthcare systems may involve different healthcare professions who work together for patient care. The undergraduate interprofessional education of clinical ethics would help to incubate healthcare students' ability of interprofessional collaboration in solving ethical problems. However, the impact from an interprofessional educational model on student's attitudes and confidence of interprofessional collaboration should be carefully evaluated during the process of curricular development. This study aimed to conduct a pilot interprofessional PBL curriculum of clinical ethics and evaluate the curricular impact on interprofessional students' attitude and confidence of collaborative teamwork. Thirty-six medical and nursing students volunteered to participate in this study and were divided into three groups (medical group, nursing group, and mixed group). Tutors were recruited from the Medical School and the College of Nursing. The pilot curriculum included one lecture of clinical ethics, one PBL case study with two tutorial sessions, and one session of group discussion and feedback. A narrative story with multiple story lines and a multiperspective problem analysis tool were used in the PBL tutorials. The students' self-evaluation of learning questionnaire was used to evaluate students' learning of clinical ethics and interprofessional collaborative skills and attitude. The internal consistency of the questionnaire was measured by Cronbach α, and the criterion-related validity of the questionnaire was evaluated through associations between the dimension scores with the student group by one-way analysis of variance test (ANOVA) test and Tukey-Kramer honestly significant difference (HSD) comparison. There was significant difference among different groups in students' ability and attitudes about "interprofessional communication and collaboration" (p = 0.0184). The scores in the mixed group (37.58 ± 3.26) were higher than the medical group (32.10 ± 4.98). In conclusion, our model for the interprofessional PBL curriculum of clinical ethics is practicable and will produce positive impacts on students' attitudes and confidence of interprofessional collaboration.

"We have to what?": lessons learned about engaging support staff in an interprofessional intervention to implement MVA for management of spontaneous abortion

BACKGROUND

Including support staff in practice change initiatives is a promising strategy to successfully implement new reproductive health services. The Resident Training Initiative in Miscarriage Management (RTI-MM) is an intervention designed to facilitate implementation of manual vacuum aspiration (MVA) for management of spontaneous abortion. The purpose of this study was to identify training program components that enhanced interprofessional training and provide lessons learned for engaging support staff in implementing uterine evacuation services.

STUDY DESIGN

We conducted a secondary analysis of qualitative data to identify themes within three broad areas: interprofessional education, the role of support staff, and RTI-MM program components that facilitated support staff engagement in the process of implementing MVA services.

RESULTS

We identified three key themes around interprofessional training and the role of support staff: "Training together is rare," "Support staff are crucial to practice change," and "Transparency, peers and champions."

CONCLUSIONS

We present lessons learned that may be transferrable to other clinic sites: engage site leadership in a commitment to interprofessional training; engage support staff as teachers and learners and in shared values and building professionalism.

IMPLICATIONS

This manuscript adds to what is known about how to employ interprofessional education and training to engage support staff in reproductive health services practice change initiatives. Lessons learned may provide guidance to clinical sites interested in interprofessional training, improving service delivery, or implementing new services.

Ten principles of good interdisciplinary team work

BACKGROUND

Interdisciplinary team work is increasingly prevalent, supported by policies and practices that bring care closer to the patient and challenge traditional professional boundaries. To date, there has been a great deal of emphasis on the processes of team work, and in some cases, outcomes.

METHOD

This study draws on two sources of knowledge to identify the attributes of a good interdisciplinary team; a published systematic review of the literature on interdisciplinary team work, and the perceptions of over 253 staff from 11 community rehabilitation and intermediate care teams in the UK. These data sources were merged using qualitative content analysis to arrive at a framework that identifies characteristics and proposes ten competencies that support effective interdisciplinary team work.

RESULTS

Ten characteristics underpinning effective interdisciplinary team work were identified: positive leadership and management attributes; communication strategies and structures; personal rewards, training and development; appropriate resources and procedures; appropriate skill mix; supportive team climate; individual characteristics that support interdisciplinary team work; clarity of vision; quality and outcomes of care; and respecting and understanding roles.

CONCLUSIONS

We propose competency statements that an effective interdisciplinary team functioning at a high level should demonstrate.