Interprofessional education (IPE) is a relatively new approach to health care education (HCE) with evidence supporting positive perceptions of its effects on improving students' clinical skills and sense of teamwork (TW). Consequently, the World Health Organization, in 2013, issued guidelines recommending more IPE in HCE. Despite its identified importance, IPE integration into HCE curricula still poses challenges (Moran, Steketee, Forman, & Dunston, 2015). This study reports on the perceived benefits of IPE training and the need for ongoing research into the complexities surrounding TW.
BACKGROUND
Recent IPE literature reviews present the following as important landmarks in IPE territory: a) Perceptions and attitudes toward IPE as part of health care curricula are commonly positive (Bolesta & Chmil, 2014; World Health Organization, 2013). b) IPE studies, which predominantly use nursing and medical student (MS) participants, reveal four key themes to the IPE experience: communication, collaboration/TW, learning in practice, and understanding of roles (Granheim, Shaw, & Mansah, 2018). c) Pursuing studies with qualitative strands examining processes relating to IPE is one way to obtain better evidence for grounding IPE design (Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). d) Student readiness to participate in IPE improves via laboratory/simulation experiences (Bolesta & Chmil, 2014), and simulation experiences enhance students' understanding of professional roles and team building (Pinar, 2015). Standardized patient (SP) simulations, especially, help caregivers recognize patients as central to health care teams (University of Minnesota AHC Simulation Center/IPE and Resource Center, 2016).
The goals of this pilot study were twofold: 1) determine perceptions of IPE among third-year MSs and nurses enrolled in family nurse practitioner (FNP) courses and 2) determine the cohorts' perceptions about TW. The two main research questions were as follows: 1) How do students in preparation for a career in health care perceive the experience of one episode of training when teamed with another health care professional? (hypothesis: positively). 2) How do students perceive TW? (hypothesis: TW contributes to safe, quality health care).
As noted, the key themes of IPE and simulation are communication, collaboration/TW, learning in practice, and understanding of roles (Granheim et al., 2018). Complementary to these, the TeamSTEPPS approach outlines major elements of a successful TW design and provides tools for training teams for an effective transition to the health care work environment (Agency for Healthcare Research and Quality, 2013). The study employed TeamSTEPPS pocket guide tools in its design.
METHOD
On approval of the institutional review board of a large university-based health science institution, investigators designed an exploratory, descriptive, quantitative/qualitative research pilot study to assess student perceptions of IPE usefulness as a preparatory tool in HCE. Ten third-year MS students at the university's school of medicine and 10 students enrolled in the FNP program at that university's school of nursing between January 2016 and June 2016 participated in an IPE exercise in an outpatient setting using SPs. The emergency scenario concerned a leg fracture due to untreated osteoporosis. Participants were volunteers but may have been influenced by institutional values as well as personal enthusiasm about the pilot study: MS participants could show leadership by participating in the pilot; FNP participants came from a pool of students who could counter noted typical clinical performance weaknesses.
Participants responded to pre- and postexercise data-gathering tools. One tool posed questions to elicit information for content analysis. The second tool was a Likert-type questionnaire. For content analysis, five questions aimed at perceptions about IPE; five aimed at perceptions of TW. Among these, four questions directed responses toward IPE and TW "usefulness" and participant "confidence" after the simulation; four aimed to elicit participant-generated "contributing factors" and "disrupting factors" in the participants' IPE/TW experiences. Prior to the SP simulation, students received, via email, the TeamSTEPPS Pocket Guide.
Participants completed pre- and postsimulation paper surveys responding to Likert-type statements. In all cases, students responded voluntarily, and all student responses were anonymous. The study aggregated all results; no specific responses had links to individual participants. The study employed the Statistical Package for Social Sciences to analyze item data, the conventional quantitative content analysis as elaborated by Hsieh and Shannon (2005) to analyze narrative survey responses, and the Wilcoxin signed-rank test to analyze the Likert results.
KEY FINDINGS
Overall support emerged for the two main hypotheses: 1) The majority of participants perceived IPE team training as beneficial to their health care careers (null hypothesis rejected) and 2) TW leads to perceptions of safer, higher quality care (null hypothesis retained). (See supplemental digital content, Table 1: Hypothesis Test Summary and Table 2: IPE and Teamwork Content Analysis, available at http://links.lww.com/NEP/A136 and http://links.lww.com/NEP/A137, respectively.) Forty percent of the participants explicitly said there were "no negatives" to the IPE experience, and 20 percent of the FNP cohort specifically mentioned that IPE helped reveal personal strengths and weaknesses (a positive; authors' italics); another 20 percent said that IPE satisfied the TeamSTEPPS function of providing realistic practice for applying knowledge.
FNP and MS narrative response profiles to the directed concept "confidence" were essentially similar; over 50 percent of both cohorts mentioning increased confidence resulting from the experience, though for different reasons. Most MS students tied the idea of increased confidence to the experience of interdisciplinary interaction; most FNP students tied the idea of increased confidence to perceptions of accrued validation of and trust in their knowledge and perspectives by others on the team.
IPE participant response-determined categories were mainly positive, but some negatives were also mentioned. Participants most often mentioned collaboration, communication, and increased IPE/TW event complexity. Collaboration (which included patients on the team for some participants) allowed for a useful "big picture" upon which to base an effective care plan; participants perceived effective communication as crucial to safe, desirable patient outcomes. Concerns about increased complexity in TW situations revolved around perceived possible communication difficulties (e.g., more communicants, coping with various personalities, communication styles), time management pressures, and role determination difficulties, possibly due to perceived power hierarchies in IPE/TW events. Other perceived negatives included: "[IPE/TW is] too idealistic"; one participant concluded that IPE/TW events were relevant "only to MSs, not FNPs" (no reason was offered).
TW participant response-determined categories were also mainly positive. Often mentioned were benefits to the work environment (greater efficiency, trust, morale) and the conviction that interprofessional knowledge sharing served as a resource for executing better care plans. TW negatives echoed the above-mentioned concerns about IPE/TW event complexity and its pressures.
DISCUSSION
Both FNPs and MSs perceived the SP simulation as having an overall positive value in their health care curricula and to their eventual professional clinical performances, thus corroborating current research (Phillips & Keys, 2018). This pilot study's use of an SP simulation supports the idea that such simulations offer a field of evidence for further understanding the four identified key themes of IPE (Granheim et al., 2018). Each of the four themes manifested, in participants' views, positive and negative traits. In general, perceived increased complexity in interprofessional TW events concerned participants most, but counters to it exist: a) communication: clear communication underlies all TW success, and team member trust counters its increased complexity; b) TW: increased efficiency and shared knowledge counter TW complexity; c) learning-in-practice: clarifying personal strengths and weaknesses injects confidence into team members; and d) understanding of roles: recognition of cross-disciplinary knowledge and interdisciplinary respect undergird willing and satisfying collaboration (Oxelmark, Nordahl Amoroe, Carlzon, & Rystedt, 2017).
Second, the study bolstered the expressed need for more research with qualitative strands (including mixed qualitative/quantitative content analysis) for better understanding IPE processes (Hsieh & Shannon, 2005; Reeves et al., 2013). Third, the simulation offered students the chance to express their perceptions and insights about IPE/TW; such personal insights are valuable to the effective integration of IPE into HCE (Cook & Stoecker, 2014). Moreover, participant response-determined categories also indicated that the simulation addressed all four key IPE elements as mentioned by Granheim et al. (2018): communication, collaboration/TW, learning in practice, and understanding of roles. Overall, participants saw these IPE elements as essential contributors to safe, effective caregiving, but not without recognizing that the increased complexity of IPE/TW events could create obstacles to each.
Obstacles, one might infer from the study results, could emerge either from the objective characteristics of IPE/TW (e.g., more participants, time pressures, more frequent communication contributing perhaps to information errors, duplicating procedures) or more subjective characteristics such as individual attitudes toward communication or communication styles, attitudes toward hierarchies and leadership, and cooperation with team members with different levels of experience and different knowledge bases. In the best scenario, assessment and application of different interprofessional strengths and weaknesses become elements in the foundation of trust necessary to drive collaborative care efforts; in the worst scenario, cohort differences of this sort may weaken confidence, undermine trust, create ill-defined caregiver roles, and thwart effective communication. Although a couple of participants suggested that IPE was too idealistic to work, the majority of participants, even when expressing worries about increased complexity, indicated that trust among team members would ease communication difficulties and make care strategies easier to design and amend in practice.
RECOMMENDATIONS FOR NURSING EDUCATION
If communication among caregivers remains strong, efficient collaboration emerges to meet the demands of increased TW complexity; if, however, there are obstacles to effective communication, successful collaboration becomes harder to achieve. This study suggests that team member trust fuels optimal communication. The important implication for nursing education, then, is that IPE design in HCE would be wise to focus initially on strategies, didactically and clinically, for establishing and maintaining a sense of trust among members of interprofessional teams.
CONCLUSION
Simulated clinical experiences using SPs, designed to require TW among different cohorts of caregivers, remain valuable, positive elements of IPE, especially in terms of strengthening team member confidence. Perceived connections between IPE/TW events and safer, higher quality care are common, and successful communication among interprofessionals is the likely bedrock to optimizing IPE/TW events. However, perceptions exist indicating that the greater complexity of IPE/TW events can be an obstacle to communication efficiency and, thus, optimal TW outcomes. Important relevant research trajectories might include the following: a) What situational/objective and personal/individual elements contribute specifically to perceptions of IPE/TW complexity? b) At what point does TW complexity become a liability, and why? c) What counts as good communication, and how is it best created and maintained, both in curricular theory and in simulation practice?
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