How do interprofessional student teams interact in a primary care clinic? A qualitative analysis using activity theory

The work performed through interprofessional meeting discourse: an observational study

The effectiveness of work performed through interprofessional practice is contingent on the nature and extent of communication between professionals. To date, there is little research exploring how the patterns of communication may impact interprofessional work. This study focused on communication during interprofessional meetings to better understand the interprofessional work performed through these encounters. Specifically, it examined how interactional discourse, that is, the patterns of language, influenced work performed during interprofessional meetings. A series of four interprofessional meetings in a rehabilitation unit were observed. Twenty-one participants were observed, including medical, nursing, allied health clinicians, and health professions students. Follow-up stimulated-recall interviews were conducted with five meeting participants. The data collection consisted of video and audio recordings and detailed field notes. Data were analyzed using a combination of genre analysis, a form of discourse analysis, and activity system analysis, drawing on Cultural Historical Activity Theory. This facilitated an in-depth examination of the structure of discourse and its influence on meeting outcomes. The meeting structure was defined and predictable. Two distinct forms of discourse were identified and labeled scripted and unscripted. Scripted discourse was prompted by standardized documents and facilitated the completion of organizational work. In contrast, unscripted discourse was spontaneous dialogue used to co-construct knowledge and contributed to collaboration. There was constant shifting between scripted and unscripted discourse throughout meetings which was orchestrated by experienced clinicians. Rather than fragmenting the discussion, this shifting enabled shared decision making. This research provides further insights into the interprofessional work performed during interprofessional meetings. The scripted discourse was highly influenced by artifacts (communication tools) in meetings, and these were used to ensure organizational imperatives were met. Unscripted discourse facilitated not only new insights and decisions but also social cohesion that may influence work within and outside the meeting.

Behavioural outcomes of interprofessional education within clinical settings for health professional students: A systematic literature review

Interprofessional education facilitates collaborative practice, which promotes high-quality patient care and patient safety. Interprofessional education (IPE) experiences within clinical settings provide an opportunity for the development of interprofessional collaborative practice competence. The aim of this systematic review was to review the literature evaluating interprofessional education for health professional students within clinical settings and summarize the behavioral outcomes. Databases searched were PubMed, Embase, Scopus, Web of Science, Taylor & Francis Online, ERIC and PsycINFO. Full-text articles were independently screened by two reviewers and included if agreed. Outcomes were analyzed using Kirkpatrick's model modified for IPE. Studies with behavioral change outcomes were analyzed and synthesized using narrative methods. Included studies provided evidence that IPE experiences in clinical settings can enable students to develop and integrate interprofessional collaborative practice competencies, across diverse types of settings. Key tasks enabling students to achieve these learning outcomes included synchronous patient consultations, collaborative development of integrative health-care plans outside of patient consultations, and participation in socialization with health-care teams. There were limitations in the methodological design of the included studies, with limited use of comparator groups and validated tools, high usage of self-report data and serious risk of bias identified across all quantitative included studies. In conclusion, high-quality research designed to measure the construct of behavioral change is lacking. Such research could further investigate the key tasks in IPE experiences in clinical settings that are necessary for students to develop the range of required collaborative practice competencies and integrate these. This could provide clarification regarding if and how this could be achieved across different types of clinical placements.

Exploring experiential learning within interprofessional practice education initiatives for pre-licensure healthcare students: a scoping review

BACKGROUND

Interprofessional collaborative team-based approaches to care in health service delivery has been identified as important to health care reform around the world. Many academic institutions have integrated interprofessional education (IPE) into curricula for pre-licensure students in healthcare disciplines, but few provide formal initiatives for interprofessional practice (IPP). It is recognized that experiential learning (EL) can play a significant role supporting IPP education initiatives; however, little is known of how EL is used within education for IPP in healthcare settings.

METHODS

We conducted a scoping review to map peer-reviewed literature describing IPP education initiatives involving EL for pre-licensure students in healthcare disciplines. A literature search was executed in MEDLINE, CINAHL, EMBASE, ERIC, PsycINFO, Scopus, and Social Services Abstracts. After deduplication, two independent reviewers screened titles and abstracts of 5664 records and then 252 full-text articles that yielded 100 articles for data extraction. Data was extracted using an Excel template, and results synthesized for presentation in narrative and tabular formats.

RESULTS

The 100 included articles represented 12 countries and IPP education initiatives were described in three main typologies of literature - primary research, program descriptions, and program evaluations. Forty-three articles used a theory, framework, or model for design of their initiatives with only eight specific to EL. A variety of teaching and learning strategies were employed, such as small interprofessional groups of students, team huddles, direct provision of care, and reflective activities, but few initiatives utilized a full EL cycle. A range of perspectives and outcomes were evaluated such as student learning outcomes, including competencies associated with IPP, impacts and perceptions of the IPP initiatives, and others such as client satisfaction.

CONCLUSION

Few educational frameworks specific to EL have been used to inform EL teaching and learning strategies to consolidate IPE learning and prepare students for IPP in healthcare settings. Further development and evaluation of existing EL frameworks and models would be beneficial in supporting robust IPP educational initiatives for students in healthcare disciplines. Intentional, thoughtful, and comprehensive use of EL informed by theory can contribute important advances in IPP educational approaches and the preparation of a future health care workforce.

Do you see what I see? Feeding interprofessional workplace learning using a diversity of theories

In this Commentary, Stalmeijer and Varpio highlight the importance of using different theoretical frameworks to make visible the potential of and need for research into interprofessional learning and guidance during workplace-based learning in the health professions.

Getting real in interprofessional clinical placements: patient-centeredness in student teams' collaborative learning

Collaboration between healthcare providers helps tackle the increasing complexity of healthcare. When learning teamwork, interprofessional students are expected to work patient-centered; recognizing the patient's expertise and partnering with them. Research on interprofessional education (IPE) for undergraduates has illuminated learning outcomes, organization of learning activities, change in attitudes, etc. But, we know little about the interaction between patients and interprofessional student teams. This study aimed to explore how interprofessional student teams and patients interact in interprofessional clinical placements. With a focused ethnographic approach, participant observation and qualitative interviews were conducted in two contexts; a physical and an online arrangement. Central ideas in Goffman's dramaturgy constituted a theoretical lens. A reflexive thematic analysis generated three themes: (1) Preparing safe and comfortable encounters with patients, (2) Including and excluding the patient in the encounter, and (3) Adjusting to the patient's situation. We identified students' intentions of patient-centeredness when preparing encounters, but patients did not always feel included and listened to in encounters. After encountering patients, student teams adjusted their teamwork, by changing the team composition or the planned clinical interventions to better meet the patients' needs. Notably, team-based patient encounters led to a different view of the patient, their health issues, and how to collaborate. Our findings can inform educators of the importance of addressing patient-centered care in interprofessional learning arrangements. Today, clinical interprofessional placements may not exploit the potential for learning about patient-centeredness. A thematization of this, e.g., in supervision in future clinical placements can ensure an enhanced focus on this in interprofessional teamwork.

Activity theory as a framework for teaching mathematics: An experimental study

This article introduces activity theory and how it can be employed to instruct the topic of straight-line equations in a plane - Geometry 10. Using the activity theory approach, we studied and developed a teaching process. The procedure is divided into three stages: Phase 1: Motivation and goal orientation, in which teachers present situations to attract students to the lesson; Phase 2: Knowledge formation, in which students engage in a variety of learning activities to build the knowledge they need to learn; Phase 3: Practice and consolidation, in which many exercises are assigned to students to solve in order to consolidate their knowledge and assist teachers in detecting and correcting students' misconceptions. To examine the effectiveness of applying the proposed three-phase model, we used a two-group pretest-posttest experimental model to determine whether or not teaching with the activity theory approach is more effective than the traditional teaching method by testing four research hypotheses. The experimental teaching took place in the Mo Cay district of Ben Tre province, Vietnam. Both the experimental and control classes began with the same level of mathematics, which was then tested using inferential statistics. After completing the pedagogical experiment, we discovered that students in the experimental class who were taught using activity theory achieved better learning outcomes than students in the control class, who were taught using the traditional teaching method; in the experimental class, the number of weak students decreased in comparison to the original; however, the number of good students did not increase. This is an issue that requires further studies to find ways to influence a wide range of students with different levels of mathematics so that the effectiveness of teaching according to the activity theory approach is improved.

Ethnographic research as an evolving method for supporting healthcare improvement skills: a scoping review

BACKGROUND

The relationship between ethnography and healthcare improvement has been the subject of methodological concern. We conducted a scoping review of ethnographic literature on healthcare improvement topics, with two aims: (1) to describe current ethnographic methods and practices in healthcare improvement research and (2) to consider how these may affect habit and skill formation in the service of healthcare improvement.

METHODS

We used a scoping review methodology drawing on Arksey and O'Malley's methods and more recent guidance. We systematically searched electronic databases including Medline, PsychINFO, EMBASE and CINAHL for papers published between April 2013 - April 2018, with an update in September 2019. Information about study aims, methodology and recommendations for improvement were extracted. We used a theoretical framework outlining the habits and skills required for healthcare improvement to consider how ethnographic research may foster improvement skills.

RESULTS

We included 283 studies covering a wide range of healthcare topics and methods. Ethnography was commonly used for healthcare improvement research about vulnerable populations, e.g. elderly, psychiatry. Focussed ethnography was a prominent method, using a rapid feedback loop into improvement through focus and insider status. Ethnographic approaches such as the use of theory and focus on every day practices can foster improvement skills and habits such as creativity, learning and systems thinking.

CONCLUSIONS

We have identified that a variety of ethnographic approaches can be relevant to improvement. The skills and habits we identified may help ethnographers reflect on their approaches in planning healthcare improvement studies and guide peer-review in this field. An important area of future research will be to understand how ethnographic findings are received by decision-makers.

Sustainability of an IPCP program within a federally qualified health center including interprofessional student team placements

In an effort to improve teamwork and collaborative care at a Federally Qualified Health Center (FQHC), the Midwest Interprofessional Practice, Education, and Research Center (MIPERC) collaborated on the implementation of an interprofessional collaborative practice (IPCP) program that included placement of multidisciplinary student teams. The MIPERC IPCP program supported staff, preceptor and student teams through interprofessional education and structured interprofessional activities for students, including daily huddles, interprofessional student team visits, and nurse triage phone calls. Results from the project's first year were previously reported (Nagelkerk et al., 2017b). Ongoing effects of IPCP on staff morale, IPE knowledge and practice efficiency were measured. Study tools included demographic forms, pre/post module knowledge tests, focus groups and program evaluations. The mean number of clinic patient visits per hour per medical provider was calculated to evaluate practice efficiency. Students (n = 26) and staff (n = 30) demonstrated improvement (p ≤.05) in knowledge test scores for Patient Safety, Team Dynamics and Tips for Behavioral Changes. Providers increased the number of patients seen per hour. Program evaluations and focus group data from providers, staff, and students indicated IPCP programs can be sustainable with ongoing intentional team care strategies.

Getting outside the box: exploring role fluidity in interprofessional student groups through the lens of activity theory

Health professionals' roles and scopes often overlap, creating a need for role clarity in interprofessional teamwork. Yet, such clarity does not mean roles are fixed within teams and some literature suggests role flexibility can enhance team functioning. Interprofessional practice competencies and learning activities often emphasize knowledge and definition of roles, but rarely attend to the dynamic nature of roles and influential contextual factors. This study explores role fluidity in interprofessional student groups using an activity theory framework. Using a collective instrumental case study approach, the authors examine the fluidity of one physical therapy (PT) student's role within 3 different interprofessional (medical, pharmacy, PT) student groups completing nursing home patient care plans. Field notes, group debriefing interviews, and care plans were collected and coded from all care planning sessions. Codes mapped to group-specific activity systems that compared role-influencing interactions and tensions. The PT student's role fluidity varied in each group's activity system, influenced primarily by system tensions from implicit rules (e.g., encouraging questions), division of labor (e.g., rigid profession-based task assignment), and tool use (e.g., computers). Attention to modifiable system elements, such as tool use and explicit rules of inclusivity, could foster role fluidity and improve interprofessional teamwork and learning environments.

Weight Loss and Improvement of Metabolic Alterations in Overweight and Obese Children Through the I2AO2 Family Program: A Randomized Controlled Clinical Trial

Childhood obesity is a major public health concern. We wanted to evaluate the effectiveness of a multidisciplinary program based on healthy eating, exercise, cognitive-behavioral therapy, and health education to achieve weight loss and improve metabolic parameters in overweight and obese children. A randomized, controlled clinical trial with long-term follow-up (24 months) was conducted at a community care center in overweight and obese individuals aged 6-12 years. A sample of 108 children was divided into an experimental and a control group receiving a standard care program. The experimental groups received a 12-month interdisciplinary program; the results were evaluated at 4 months, the end of the intervention, and at follow-up 12 months later. Anthropometric and biological marker measurements related to metabolic alterations, dyslipidemia (based on total cholesterol), hyperglycemia, fasting glycaemia, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol in blood were recorded. The intervention had a significant effect (p < 0.001) in terms of decreased body mass index, skinfolds, and waist and arm circumferences. These changes were accompanied by biochemical changes underlying an improvement in metabolic parameters, such as a significant reduction in total cholesterol, low-density lipoprotein-cholesterol, triglycerides, and hyperglycemia and a significant increase in high-density lipoprotein-cholesterol. These effects were still significant for markers of excess weight or obesity in the experimental group 12 months after the end of the intervention, suggesting that an enduring change in healthy lifestyles had been maintained period. This interdisciplinary, nurse-led program helped to reduce childhood and adolescent excess weight and obesity and had long-lasting effects.

Communication in interprofessional rehabilitation teams: a scoping review

PURPOSE

Effective communication in interprofessional rehabilitation teams is essential for optimal patient care. Despite the established importance, it remains unclear how interprofessional communication (IPC) within teams contributes to rehabilitation service delivery. The aim of this scoping review was to investigate how IPC has been described in rehabilitation literature.

METHODS

Databases (Medline, CINAHL, ERIC, Embase, PsychInfo, and Academic Search Complete) were searched for studies including rehabilitation interprofessional communication. Inclusion and exclusion criteria were identified and applied, data were charted, and thematic analysis conducted.

RESULTS

Twenty-nine papers were identified, and analysis revealed interrelated themes: communication processes, and inputs and effects. Formal communication processes were most prevalent, portraying variability in professional participation and a lack of patient involvement in dialogue and decision making. Inputs and effects were described at an organisational, team and individual level, highlighting the importance of communication throughout the healthcare hierarchy.

CONCLUSIONS

IPC in rehabilitation is central to effective team function and patient care. To further our understanding, empirical studies examining everyday informal IPC, as well as formal ritualised encounters are needed. Additionally, conceptualisations of IPC would benefit from including the patients' perspective and by using theoretical framing to attend to places, spaces, and artefacts identified in this review.

Nursing Students Learn Online Interprofessional Education on Substance Use

Background

Interprofessional education strategies are becoming more prevalent as nursing schools integrate interprofessional practice activities into their curricula.

Purpose

This paper presents the results of a federally funded project to deliver online interprofessional education to nursing students on screening for alcohol and substance use in rural areas, in which their perceptions about interprofessional education were measured.

Methods

A quasi-experimental within-subjects repeated measures design was utilized. Students in the bachelor or associate degree program were recruited from two rural nursing schools. A demographic questionnaire, Alcohol and Alcohol Problems Questionnaire, Drug and Drug Problems Questionnaire, and Interprofessional Education Perception Scale were utilized. General linear modeling was used to determine changes in these measurements over time. Data collection was performed at pretraining, posttraining, and following an online interprofessional dialogue.

Results

The study consisted of 89 nursing students. The participants were 87% female (n = 77/89) and 91% white (n = 81/89); their mean age was 24.9 years (standard deviation = 10.36). Analysis of evaluation questionnaires demonstrated increased levels of confidence in working with patients who consume alcohol or other drugs and on certain aspects of interprofessional education.

Conclusion

Online interprofessional preservice education holds the potential to positively increase nursing students’ confidence in working with patients and to increase their interprofessional practice.

Contradictions in clinical teachers' engagement in educational development: an activity theory analysis

Many medical universities offer educational development activities to support clinical teachers in their teaching role. Research has focused on the scope and effectiveness of such activities and on why individual teachers attend. However, systemic perspectives that go beyond a focus on individual participants are scarce in the existing literature. Employing activity theory, we explored how clinical teachers' engagement in educational development was affected by the systems they act within. Three focus groups were held with clinical teachers from different professions. A thematic analysis was used to map the contradictions between the systems that the participants were part of and the manifestations of these contradictions in the system of education. In our model, clinical teachers were part of three activity systems directed by the objects of patient care, research and education respectively. Contradictions arose between these systems as their objects were not aligned. This manifested through the enacted values of the academic hospital, difficulties establishing educational discussions in the clinical workplace, the transient nature of educational employments, and impediments to developing a teacher identity. These findings offer insights into the complexities of engaging in educational development as clinical teachers' priorities interact with the practices and values of the academic hospital, suggesting that attention needs to shift from individual teachers to developing the systems in which they work.

Implementing interprofessional learning curriculum: how problems might also be answers

BACKGROUND

Despite interprofessional learning (IPL) being widely recognised as important for health care professions, embedding IPL within core curriculum remains a significant challenge. The aim of this study was to identify tensions associated with implementing IPL curriculum for educators and clinical supervisors, and to examine these findings from the perspective of activity theory and the expansive learning cycle (ELC).

METHODS

We interviewed 12 faculty staff and ten health practitioners regarding IPL. Interviews were semi-structured. Following initial thematic analysis, further analysis was undertaken to characterise existing activity systems and the contradictions associated with implementing IPL. These findings were then mapped to the ELC.

RESULTS

Five clusters of contradictions were identified: the lack of a workable definition; when and what is best for students; the leadership hot potato; big expectations of IPL; and, resisting cultural change. When mapped to the ELC, it was apparent that although experienced as challenges, these contradictions had not yet generated sufficient tension to trigger 'break through' novel thinking, or contemplation and modelling of new solutions.

CONCLUSIONS

The application of activity theory and the ELC offered an approach in which the most troublesome challenges might be reframed as opportunities for change. Seemingly intractable problems could be worked on to identify and address underlying fears and assumptions. If sufficient tension can be generated, an ELC could then be triggered. In reframing challenges as opportunities, the power of tensions and contradictions as potential levers for effective change might be more successfully accessed.

Effectiveness of the I2AO2 interdisciplinary programme led by nurses on metabolic syndrome and cardiovascular risk: a randomized, controlled trial

Objective To evaluate the effectiveness of an interdisciplinary programme led by nurses in relation to metabolic syndrome (MS) and cardiovascular risk (CVR). Methods This randomized, controlled, clinical trial included 74 patients diagnosed with MS (experimental group [EG], n = 37; control group [CG], n = 37). The intervention consisted of a 12-month interdisciplinary programme (pre-test, 6 months of intervention, 12 months of intervention, and 1-year follow-up post-intervention) coordinated by nursing. Results We found a progressive and significant reduction for all clinical, biochemical, and anthropometric parameters analysed at different time points. In the EG, remission of MS by 48.1% in the short term was observed (83.8% in the medium term) and maintained at 1 year post-intervention. In the CG, the prevalence of MS increased by 2.7% from the initial evaluation to study completion. A similar trend was observed for CVR. In the EG, 100% of subjects had a moderate-low risk of CVR at 1 year post-intervention, whereas the CG had CVR in all categories. Conclusion An interdisciplinary, nurse-led programme improves participants' metabolic and cardiovascular health, while maintaining long-term effects. Our findings suggest an important role of the professional nurse as a nexus between the patient, different professionals, and the community.