Nurse Educator

Nurse Educator Vol. 40, No. 5, pp. 249-253 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.

Interprofessional Education Finding a Place to Start Mary Anna Gordon, DNP, RN & Kathie Lasater, EdD, RN, ANEF, FAAN & Patrick Brunett, MD, FACEP Nathan F. Dieckmann, PhD The Institute of Medicine has recommended interprofessional education (IPE) to improve patient safety and quality outcomes. However, getting started in IPE can be overwhelming and fraught with barriers. One health science university began by offering a 2-week intensive course that was integrated into existing courses. The evaluation validated the need for more understanding about professional roles and preparation as well as for faculty to learn from each other. Keywords: collaboration; collaborative learning; faculty development; interprofessional; interprofessional education

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oday’s health care environment is increasingly complex. The escalating needs of patients demand that individuals from different professions communicate and collaborate to provide the best care.1,2 In addition, coordination among contexts of care and aging of the population require better collaborative, team-based care.3 Presently, most prelicensure programs in the health professions are educating students solely in their chosen professions, offering little opportunity to learn about others’ roles and responsibilities.4 Students rarely have meaningful contact with members of other professions until entry into professional life. Shared educational experiences may be uncommon, and collegial relationships necessary to provide integrated and holistic patient care are not adequately established.5 The current means for ensuring effective interprofessional (IP) teamwork and communication necessary for safe, high-quality patient care are often inadequate.2(pii47) One health science university began its IP journey by offering a course focused on IP collaboration to nursing and medical students. The purpose of this article is to describe the planning and implementation, evaluation plan and outcomes, and lessons learned from this first collaborative interprofessional education (IPE) effort. The authors recognize that the specific issues from this experience may not coincide with others’ issues; however, they represent a wide range of issues that should be addressed before an IPE course is offered.

Author Affiliations: Nursing Development Consultant (Dr Gordon), Multnomah County Health Department, Portland, Oregon; Professor, School of Nursing (Dr Lasater); Associate Dean for Graduate Medical Education, Clinical Professor, Department of Emergency Medicine (Dr Brunett); Assistant Professor, School of Nursing (Dr Dieckmann), Oregon Health & Science University, Portland. The authors declare no conflicts of interest. Correspondence: Dr Gordon, Multnomah County Health Department, 426 SW Stark, 8th Flr, Portland, OR 97204 ([email protected]). Accepted for publication: February 24, 2015 Published ahead of print: April 16, 2015 DOI: 10.1097/NNE.0000000000000164

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Course Planning and Implementation Planning began 6 months before the rollout of our elective IPE course. The planning committee consisted of faculty from the schools of nursing and medicine, as well as some nonfaculty thought leaders.6 The charge of the committee included administrative coordination of the course, content planning, identifying experts to teach in the course, and evaluating it. Initially, the committee reviewed IPE guidelines from around the globe7-11 but ultimately chose the Canadian Interprofessional Health Collaborative’s National Interprofessional Competency Framework to shape the course, using the competency domains and their descriptors within the framework as a general outline.10 The committee met monthly to solve challenges to implementation and devise a course outline, including content and faculty. Developing the course outcomes was a critical step to further guide the course planning (Table 1).

Course Content Three best practices models provided support for learning strategies: didactic, community based, and simulation.12 Using these models, the committee determined that the course learning activities would include observation at a community practice site for a collaborative project and shared simulation experiences, one of which was focused on poverty, in addition to didactic sessions.13 Inherent in the university’s vision is the provision of health care for a diverse citizenry in the state, including underserved populations.14 On the basis of the need for students to grasp determinants of health to fulfill this vision, the committee decided that a collaborative group project, focused on underserved populations, would be ideal. Each session was designed to feature a different topic related to collaboration (Table 2). A key consideration was the disparity of level of students, that is, graduate and undergraduate students, frequently the case in IPE.6 The planning group intentionally wanted to include a variety of learning strategies, such as lectures, high-fidelity simulations, teambuilding projects, facilitated discussions, and group and Volume 40 & Number 5 & September/October 2015

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Table 1. IPE Collaboration Course Outcomes At the conclusion of the course, the student will be able to: 1. 2. 3. 4.

Use knowledge of own and others’ roles appropriately to establish and achieve patient/family/community goals. Apply the principles of teamwork dynamics and group/team processes for effective interprofessional collaboration. Apply leadership principles that support a collaborative practice model. Integrate the value of preventing harm to patients by establishing a culture of safety and providing quality care that is safe, effective, patient centered, timely, efficient, and equitable. 5. Communicate verbally and in writing with each other in a collaborative, responsive, and responsible manner. 6. Engage collaboratively to work out the complexities of ethical challenges as they arise. 7. Seek out, integrate, and value the input and the engagement of the patient/client/family/community as a partner in designing and implementing care/services to decrease disparities in health care in vulnerable populations.

individual reflective exercises.6 To accomplish these goals, identification of expert faculty was key.

IP Faculty The planning group invited 9 dyads of content experts (1 each from medicine and nursing) who were committed to IPE to present each day. The planning committee provided a teaching template for developing each session and asked that dyads connect in teaching teams to develop session learning objectives and content, preparing equal time for didactic and active learning strategies (eg, group discussion, simulation, or role playing). Even at the planning stage, cultural differences between the 2 professions emerged.15 Much of the language used by 1 profession was foreign to the other and required frequent clarification, for example, many of the acronyms. The different levels of expectations regarding planning and details became apparent, as did buy-in to the course. However, the flexibility and commitment of the planning committee served to overcome most of the obstacles. Challenges Faced One of the biggest challenges was timing of the course owing to differing academic calendars, clinical schedules, and available time for electives, described by others.6,16 In the past, the school of medicine had offered 2-week intensive courses of 40 contact hours. To build on this history, the committee considered that a similar format would be attractive for potential students. However, there were fiscal challenges in structuring how the course would be offered across the 2 schools. The medical school required a certain number of electives for no additional charge; the nursing school curriculum did not allow for electives. Therefore, nursing students signing up for this course would generate additional fees. To solve this disparity, it was determined that the course outcomes would mesh with the outcomes of an existing course within the school of nursing. The nursing course director agreed to substitute 40 clinical hours for the IP course contact time. The course was planned for 10 consecutive weekday afternoons, for 4 hours each day. Student recruitment for an elective course near the end of students’ programs of study was the biggest and nearly insurmountable obstacle. The vision for the course was equal numbers of senior medical and nursing students, 10 of each. As the scheduled dates approached, the nursing student quota was reached, but only 2 medical students had registered. Two weeks before the start of the course, both withdrew. The com250

mittee creatively explored every avenue available to enroll a sufficient number of students from the school of medicine. One committee member contacted the course coordinator for the school of medicine’s anesthesiology clerkship elective. The director, an IPE supporter, determined that the IPE course’s outcomes would also meet many of the clerkship’s outcomes. She sent all 8 students enrolled in the clerkship to the IPE course. Therefore, similar to the nursing school, the hours for this IPE course were nested in another course. When the IPE course began, there were 9 nursing students and 8 medical students, a small group and recommended for starting IPE.6

Evaluation Methodology Because this was an initial foray into IPE, the planning group carefully considered how the course would be evaluated. Using standardized quantitative measures would allow comparison with established norms, whereas qualitative strategies were a potentially rich source about the lived experiences of students and faculty. The university’s institutional review board approved the evaluation plan. All student data were collected on the first and last days of the course. Methods for data collection are described in the following paragraphs.

Student Focus Groups Faculty who had not engaged previously in the course convened 3 mixed focus groups of students on the last day. Using previously uninvolved faculty allowed for safe, open conversations.3 Semistructured questions were used as prompts. The focus groups were 45 to 60 minutes long and audio-recorded with subsequent transcription. An acknowledged limitation of this method was it was not possible for students to have reflection time before they offered their insights. Table 2. IPE Course Outline Topics 1. 2. 3. 4. 5. 6. 7. 8. 9.

What is knowledge? Different ways of knowing; data collection Social determinants of health (poverty simulation) Healthy workplace communication Collaborative leadership Interprofessional ethics Crisis resource management Quality and safe patient care Observational field trip to area clinics in teams (project) Team project presentations and wrap up; data collection

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Faculty Survey It is critical to get reflective feedback from participating faculty to learn from the experience as well as students.6 Faculty who were presenters and/or part of the planning committee completed an online survey with 6 open-ended questions, using comment boxes to elicit individual perspectives on what went well, what did not, what they would do differently in planning and/or delivering the presentation, what they thought would have improved student learning, other ideas, and how their commitment to IPE changed as a result of their experience in this course. Faculty received the survey several weeks after the conclusion of the course. Readiness of Healthcare Students for IP Learning Students completed the Readiness of Healthcare Students for Interprofessional Learning (RIPLS), a 15-item survey exploring attitudes of health professional students about IP education. This short form was initially tested with 1179 students from 4 disciplines, yielding a Cronbach’s ! of .91.17 Free to users, the survey was administered as a pretest and posttest. Attitudes Toward Poverty The second measure, Attitudes Toward Poverty (ATP), was used at the beginning and end of the course to assess for change in attitudes about poverty after the students’ experience of participating in the poverty simulation13 and in the collaborative project. The ATP measures 3 attitudinal factors, which are then summed for a total score. They include (1) Personal Deficiency, (2) Perception of Stigma, and (3) Structural Perspective (or explanation for poverty). Also free of charge, the tool was initially tested with 319 students, yielding high internal consistency, measured by a Cronbach’s ! of .87.17

Data Analysis and Findings All students (n = 17) participated in the data collection activities. Although this represents a small number, there were informative findings for future IPE.

Focus Group Findings Three planning group members (2 from nursing and 1 from medicine) read the focus group transcriptions. First, they read individually and then met for several group meetings to identify themes. The qualitative findings from the focus groups offered rich insights for future planning, with 4 themes that emerged: (a) different professional perspectives, (b) appreciation for real-world learning strategies, (c) role ‘‘mysteries,’’ and (d) course timing and logistics. Different Professional Perspectives A range of comments expressed the value of bringing together 2 different groups of professional students. They discussed their ‘‘aha’’ moments about each other, derived from their learning experiences. Medical students indicated that they were familiar with writing or giving verbal orders to nurses. However, during the course, they saw the value of reciprocally sharing information with nurses for critical information exchanges. A medical student participant said, ‘‘In terms of planning my day and getting ready for roundsII need to leave time to talk to the nurse. What are your concerns? What do you think is going on? Not just to go in and demand information that I may or may not get, but to ask, what do Nurse Educator

you think is going on? What are you worried about? What questions do you have for me, or what do you think I’m missing?’’ Appreciation for Real-World Learning Strategies Some faculty dyads did not adhere to the guidelines to balance didactic with active learning. However, the students strongly indicated that they preferred active learning. Even more so, they appreciated real-world learning, such as case studies, simulation, and narrated films. For example, 1 student said this about a physician faculty member who critiqued a film of her team doing an infant resuscitation: ‘‘In the example of the pediatrician who ran the code and replayed the code for everybody on the teamII felt like that was helpful for everybody including her and those who were part of it because they were able to work together, see how they learn together, and see what they needed to work on rather than talk about these theories that are not necessarily put into practice.’’ Role Mysteries Several examples of students’ learning revealed basic role misunderstandings that surprised the committee. For example, nursing students often referred to themselves as patient advocates, implying that advocacy was the exclusive role of the nurse. During the focus groups, some medical students raised the question, ‘‘What are we? We are patient advocates too.’’ The nursing students gained awareness not only of physicians’ roles but also of their own.18 Nursing students indicated that before the course, they were unaware of the graduate medical education system. A medical student commented: ‘‘We still have no idea of what the other person’s role potentially could be. I would have appreciated a day on what nurses learn, what their licenses allow them to do; that is, what does the ‘top of one’s license’ mean?’’ This question highlights new language since the report from the Institute of Medicine19 about the future of nursing and underscores the complexity of entry into the nursing profession with its various levels of practitioners, for example, staff nurses versus advanced practice nurses. Timing of Course and Logistics Students supported the idea of having IP classes; however, they expressed the concern that the timing of this course was far too late in their programs of study. Most of the topics had been addressed at some earlier time in their respective programs, although not interprofessionally, but students in both programs reiterated that the content was needed sooner than their senior year. The planning committee understood that this was the case but, in the early planning phase, determined that these were the only groups who were available to participate in IPE at the time. Because this course was nested in other courses, the intensive approach over 9 consecutive afternoons was most practical. However, students found it limiting and too intense and would have opted for weekly meetings over a longer time.

Student Survey Findings There were no significant differences between pretest and posttest total scores on the RIPLS. However, there was a Volume 40 & Number 5 & September/October 2015

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significant difference between medical students (adjusted mean, 3.23) and nursing students (adjusted mean, 3.67) on posttest Teamwork and Collaboration subscale scores after controlling for pretest scores (F1, 14 = 5.26, P = .04). Nursing students had significantly more favorable attitudes toward teamwork and collaboration at the end of the course than medical students did. Medical students in the focus groups offered comments that may explain the difference. They revealed that they were used to talking with nurses (although not nursing students); conversely, the nursing students stated that they had few opportunities to talk with medical students or physicians. This is consistent with the finding that nursing students have inadequate opportunities to communicate with physicians during their educational programs.20 These findings were an impetus for including simulations to practice IP communication strategies,21 such as crucial conversations and teamwork. After the poverty simulation and other learning activities on poverty, all students had significantly higher ATP Total (pretest mean [SD], 4.00 [0.44]; posttest mean [SD], 4.12 [0.50]; P < .05) and Structural Perspective (pretest mean [SD], 3.81 [0.39]; posttest mean [SD], 4.10 [0.42]; P < .01) scores at posttest, indicating more positive attitudes. There was also a trend for higher Stigma factor posttest scores. In the focus groups, a number of students complained about the poverty simulation. The nursing students had experienced it a year before, so the activity was repetitive, whereas the medical students indicated that they had cared for many patients in poverty. However, as these survey data indicate, the poverty simulation and some of the other learning activities, including discussions and debriefings, had a significant impact on students’ attitudes in 1 of the 3 factors as well as the total scores. The conclusion of the faculty is that sometimes experiences that are uncomfortable or unwelcome may result in more change than learners realize.

Faculty Survey Findings Eleven faculty members responded to the online survey. Four themes emerged: (a) connections were critical (eg, previous relationships, getting together, comparing educational models), (b) the next iteration of IPE should include all professional health care students on campus, (c) creativity and enthusiasm for IPE were stimulated, and (d) faculty development for IPE should be a priority. This last theme was perhaps the most striking, indicating a need for faculty to communicate and work with each other more. Faculty found that differences in teaching styles and challenges in language use, despite working in similar settings for patient goals, need more exploration. These factors may be bigger challenges for IPE faculty than for students. A faculty member expressed: ‘‘We, as IP faculty, could learn a great deal from each other about teaching/learning models and strategies. This course focused on the learning of the students. It would be interesting to take a step back and focus on the learning of the faculty around our commonalities and differences as educators.’’ Another added: ‘‘I want to learn how to change the culture that seems to exist around physician-nurse interactions. We both add equal value to the patient’s health and well-being. I will work to find ways to promote professionalism in the nurses I lead to improve the perception of their value and contribution in the eyes of the providers.’’ 252

The IPE faculty were challenged to teach together because they themselves were educated in isolation.3 Overcoming this reality requires intentional planning to be effective IPE teachers and role models. In fact, it may well be that most of IPE planning time needs to focus on faculty development. As the faculty team learned, IPE also requires institutional commitment including resources for success.16 One faculty participant summed up the need in this way: ‘‘Time is money. I think there needs to be funding to make this sustainable both in terms of committee and faculty time but also in terms of operational costs connected to space and utilization.’’ The level of interest expressed by these faculty is essential as academic communities implement IPE. For IPE success, nurses and physicians need to exhibit professionalism in patient care situations and be willing to talk to each other in transparent ways that both understand.

Conclusion Patient safety demands that health care professional teams collaborate to provide the best patient care. Ideally, students should be exposed to highly functioning IP academic and clinical teams throughout their education. The IPE course described in this article afforded an opportunity for medical and nursing students to learn together to understand each others’ roles and improve communication and collaboration. In the process, faculty also learned they required time and development to learn about each others’ curriculum, pedagogy, and language.

References 1. Blue AV, Mitcham M, Smith T, Raymond J, Greenberg R. Changing the future of health professions: embedding interprofessional education within an academic health center. Acad Med. 2010; 85(8):1290-1295. 2. McPherson K, Headrick L, Moss F. Working and learning together: good quality care depends on it, but how can we achieve it? Qual Health Care. 2001;10((suppl 2)):ii46-ii53. 3. Speakman E, Arenson C. Going back to the future: what is all the buzz about interprofessional education and collaborative practice. Nurse Educ. 2015;40(1):3-4. 4. Gierman-Riblon CM, Salloway S. Teaching interprofessionalism to nursing students: a learning experience based on Allport’s intergroup contact theory. Nurs Educ Perspect. 2013;34(1):59-62. 5. Delunas LR, Rouse S. Nursing and medical student attitudes about communication and collaboration before and after an interprofessional education experience. Nurs Educ Perspect. 2014; 35(2):100-105. 6. Pardue KT. A framework for the design, implementation, and evaluation of interprofessional education. Nurse Educ. 2015; 40(1):10-15. 7. Curtin University of Technology. Interprofessional Capability Framework 2011. Available at http://healthsciences.curtin.edu. au/local/docs/IP_Capability_Framework_booklet.pdf. Accessed October 24, 2014. 8. The Combined Universities Interprofessional Learning Unit. The Interprofessional Capability Framework (CUILU). February 2010. Available at http://www.health.heacademy.ac.uk/doc/ resources/icf2010.pdf/at_download/file.pdf. Accessed October 24, 2014. 9. World Health Organization (WHO). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva, Switzerland: World Health Organisation Press; 2010.

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10. Canadian Interprofessional Health Collaborative. A National Interprofessional Competency Framework. CIHCPIS. February 2010. Available at http://www.cihc.ca/files/CIHC_IPCompetencies_ Feb1210.pdf. Accessed January 29, 2009. 11. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011. 12. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Med Educ Online. 2011;16 Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081249/. Accessed December 20, 2014. 13. Noone J, Sideras S, Gubrud-Howe P, Voss H, Mathews LR. Influence of a poverty simulation on nursing student attitudes toward poverty. J Nurs Educ. 2012;51(11):617-622. 14. Oregon Health & Science University (OHSU). OHSU vision. A look over the horizon. Available at http://www.ohsu.edu/xd/ about/vision/index.cfm. Accessed September 30, 2014.

15. Haddara W, Lingard L. Are we all on the same page? A discourse analysis of interprofessional collaboration. Acad Med. 2013; 88(10):1509-1515. 16. Cranford JS, Bales T. Infusing interprofessional education into the nursing curriculum. Nurse Educ. 2015;40(1):16-20. 17. Curran V, Sharpe D, Forristall J, Flynn K. Attitudes of health sciences students towards interprofessional teamwork and education. Learn Health Soc Care. 2008;7(3):146-156. 18. Hudson CD, Sanders MK, Pepper D. Interprofessional education and prelicensure baccalaureate nursing students: an integrative review. Nurse Educ. 2013;38(2):77-80. 19. Yun S, Weaver R. Development and validation of a short form of the Attitude Toward Poverty Scale. Adv Soc Work. 2010;11(2): 174-187. 20. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. 21. Thomas CM, Bertram E, Johnson D. The SBAR communication technique: teaching nursing students professional communication skills. Nurse Educ. 2009;34(4):176-180.

Nursing Education Journal Resource Nursing education journals are important means of communicating information to help nurse educators keep current and learn about new approaches to teaching. These journals have varying missions and publish different types of articles, and each journal has its own manuscript review process. This lack of uniformity can cause frustration among authors when selecting journals for submission and can result in work having to be redone. A resource is needed that summarizes characteristics of nursing education journals, including the journal’s mission, types of articles published in the journal, manuscript review process, time frame for peer review and publication of papers, and other details important in manuscript preparation. The Table, Supplemental Digital Content 1, http://links.lww.com/NE/A228, provides this resource for nurse educators. The table lists nursing education journals, alphabetically, with subsequent columns defining the journal’s mission, publisher, frequency of publication, review process, time frame for manuscript review and article publication, and several other items. The table will allow nurse educators who are interested in submitting a manuscript to have the appropriate information all in one resource. The table serves as a resource tool to help ease the submission process for nurse educators who are ready to publish their work. Submitted by: Julie A. Pagel, BSN, RN, [email protected]. DOI: 10.1097/NNE.0000000000000189

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Interprofessional Education: Finding a Place to Start.

The Institute of Medicine has recommended interprofessional education (IPE) to improve patient safety and quality outcomes. However, getting started i...
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