Transformation of an Online Multidisciplinary Course into a Live Interprofessional Experience

INTRODUCTION

In May 2011, a report representing collaboration among six health professional education organizations (ie, Association of American Medical Colleges, American Association of Colleges of Nursing, American Association of Colleges of Pharmacy, American Dental Education Association, Association of Schools of Public Health, and the American Association of Colleges of Osteopathic Medicine) was publicly released. The document, Core Competencies for Interprofessional Collaborative Practice, serves as a foundational document from which interprofessional education (IPE) and practice experiences may be designed.¹ The expert panel identified four general competency domains to guide preparation for interprofessional collaboration: values and ethics for interprofessional practice, roles and responsibilities, interprofessional communication, and teams and teamwork.

In addition, The National Academy of Medicine conducted a workshop on Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice. This workshop highlighted the need for enhanced collaboration among health care disciplines to improve patient care, improve patient outcomes, and achieve more efficiency and affordability within health care systems.²

The emphasis of the aforementioned competencies and increasing promotion of patient-centered care with improved outcomes has made IPE a requirement in the accreditation standards for many health profession colleges such as pharmacy, osteopathic medicine, dental medicine, occupational therapy, physical therapy, and physician assistant programs.^3-8 The standards require programs to build opportunities for students to “learn with, from, and about each other to improve collaboration and the quality of care.” Programs have developed different approaches to introduce IPE within their curricula.^9-15 Practice models vary significantly, including service learning opportunities with home visitation programs,^9,14,15 combination courses with classroom and clinical site experiences,¹³ and clinical site experiences as part of advanced training opportunities.¹⁰ Despite different curricular design, all programs include active learning utilizing an interprofessional team as part of their experience regardless if it is part of a clinical site experience^10,13 or part of simulation exercises within a classroom.¹¹ Curricular IPE programs also vary significantly in size from small cohorts of 29 students¹³ to large programs including more than 500 students.⁹ Variation in the published literature is beneficial because health professions colleges seeking to incorporate IPE differ, and their resources and ability to foster this curricular endeavor vary.

Midwestern University developed an interprofessional committee of faculty to develop and implement interprofessional content and learning activities across the different colleges to prepare health professions students to provide integrated, high-quality patient care within the evolving health care system. This committee included representatives from all of the colleges on campus. In this manuscript, we will describe how we transformed an online interdisciplinary course into an interprofessional experience, and highlight activities such as video sessions and standardized patient encounters that were used to deliver teamwork training. Students were then assessed for knowledge, skills, attitudes, and self-perceived behaviors regarding interprofessional collaboration.

DESIGN

Midwestern University Downers Grove campus is a private academic institution with four colleges: osteopathic medicine, pharmacy, dental medicine, and the health sciences. Within the College of Health Sciences, we have programs that include physician assistant studies, physical therapy, occupational therapy, biomedical sciences, clinical psychology, and speech-language pathology. Approximately 3,000 students are enrolled in the four colleges.

In 2012, the deans of all of the colleges supported an interprofessional faculty committee to attend the Interprofessional Education Collaborative (IPEC) Institute in Herndon, Virginia, with the goal of creating a plan to implement an IPE course on our campus. The institute provided our team with a framework to discuss our IPE goals, strengths that existed on our campus, and the barriers to implementing IPE at our institution. IPE goals, surrounding the ideas of teamwork, collaboration, and communication were created to guide the development of IPE at Midwestern University. The involvement of the IPE committee to develop and implement such a large and substantial course was extensive. The planning for this course began in 2012 after the committee returned from the IPEC Institute. Implementation of the new course began fall quarter 2014 after monthly meetings and discussions surrounding the creation and implementation of the course, and then receiving course approval from all college curriculum committees.

EVALUATION AND ASSESSMENT

The primary aim of the revision of this course was to make it a truly interprofessional collaboration among students to learn about their respective professions and to begin to communicate with one another as professionals. A secondary aim was to gather quantitative and qualitative feedback about the course. As the course was developed, we prospectively planned to examine the impact of this course on the knowledge, skills, attitudes, and self-perceived behaviors of first professional year students. Items were generated in an attempt to assess four distinct but related aspects of education tied to interprofessionalism (ie, self-perceived knowledge, skills, importance, and frequency of action). Reliability was established using Cronbach’s alpha, with all items producing a value of .95. Alpha levels for the individual subscales (eg, roles and responsibilities of various health care professionals, interaction with other health care professionals, etc.) ranged from .67 to .93. This quantitative data was collected via a paper-based survey (Appendix 2) administered to all consenting first-year professional students at three specific points in time: immediately pre-course (Time 1), immediately post-course (Time 2), and at the end of the first professional year (Time 3). Qualitative data was assessed using video session and standardized patient encounter assignments (Appendix 3). Approval was obtained from the university’s Institutional Review Board. Students were informed about the study verbally and via a cover letter when paper surveys were distributed. Students who completed the survey were viewed as having given consent.

Of the 783 students enrolled in the course, 130 students completed all three time points of the survey. The proportion of students from each program is represented in Table 2. Quantitatively, students were neutral about the course and found it moderately valuable (M = 6.23 [on a scale from 1 to 10], s = 2.4), interesting (M = 5.61, s = 2.6), and enjoyable (M = 5.57, s = 2.6). Written feedback from the course indicated that the majority of students thoroughly enjoyed the standardized patient encounter and thought the course provided a valuable opportunity to interact with other students in other colleges. They also valued learning about the roles and responsibilities of the other disciplines.

Assessments from the video session and standardized patient assignments were obtained. In addition to assessment criteria for each specific assignment, student groups also were evaluated by the standardized patient on items such as communication, nonverbal skills, discussion content, roles of their respective profession, and group dynamics. Qualitative observation from the assignments revealed a strong interprofessional team collaboration, communication, and patient advocacy. Participants were asked to report their perceptions of: interprofessional education, providing high-quality patient care, roles and responsibilities of various health care professionals, effectively interacting with other health care professionals, interprofessional communication, interprofessional team-based approach in assessing patient care issues, interprofessional team-based approach in treatment planning of patient care issues, and ethics for interprofessional practice. Specifically, they were asked to indicate how knowledgeable they were about these practices, how skillful they were in demonstrating these practices, how important these practices were to them, and how often they demonstrated these practices. Participants also were asked to indicate the likelihood that they would engage in future interprofessional practice, initiate future interprofessional practice, facilitate their collaborative practice with other health care providers, and that interprofessional practice would improve their patients’ health care outcomes. An initial Repeated Measures MANOVA was used to determine whether there were any overall significant changes in these factors across the duration of the study. For any significant findings, univariate post hoc tests were used to clarify the specific patterns of these changes. Specifically, individual comparisons between all three assessment periods were performed to determine exactly in what way scores were changing over time. These analyses revealed five specific patterns of findings, each one corresponding to a unique pattern of change.

Pattern 1 (Table 3) was observed when scores showed an initial significant increase between Time 1 and Time 2, with no subsequent significant change between Time 2 and Time 3. This suggests that, for variables demonstrating this pattern such as engaging in interprofessional education and understanding the roles and responsibilities of various health care professionals, the course was effective at producing a gain that was observed in the short term, and maintained over the longer term (ie, scores increased and “leveled off”).

Pattern 2 (Table 4) was observed when scores showed an initial significant increase between Time 1 and Time 2, followed by a significant decrease to baseline between Time 2 and Time 3. This suggests that for the variable, frequently interacting with other health care professionals, the course was effective at producing a gain that was observed in the short term, but not maintained over the longer term (ie, scores increased and then decreased by the same amount).

Pattern 3 (Table 5) was observed when scores showed no significant change between Time 1 and Time 2, but a significant decrease between Time 2 and Time 3. The means for these variables, such as the likelihood of engaging in future interprofessional practice and the likelihood that it would improve patient outcomes, were higher at Time 1 and Time 2, and despite showing a significant decrease from Time 2 to Time 3 were still rather high at Time 3 and not significantly different from Time 1.

Pattern 4 (Table 6) was observed when scores showed no significant change over time at all. One interpretation of this finding is that for variables such as the importance of providing high-quality patient care or effective interprofessional communication, the course was not effective at producing any change whatsoever. Alternatively, an examination of these means suggest that scores were already rather high at Time 1, and that no change was observed because of a ceiling effect.

Pattern 5 (Table 7) was observed when scores showed an initial significant increase between Time 1 and Time 2, followed by a significant decrease between Time 2 and Time 3 which was still significantly higher than scores at Time 1. This suggests that for variables such as the knowledge, skills, and frequency of engaging in interprofessional education, the course was effective at producing a gain that was observed in the short term, and maintained to a lesser degree over the longer term. For these variables, booster sessions or additional IPE courses may assist in maintaining the magnitude of the change initially observed.

DISCUSSION

This course allowed students, who are very early in their professional endeavors, to gain an appreciation for the importance of various roles in health care and how they can all significantly contribute to patient care when working collaboratively. The activities throughout this course gave students the foundation to begin conversations with each other and with a standardized patient, contributing to significant changes in their attitudes toward IPE and patient care. Consistent with the results of this study, some of these changes were maintained over time in areas that the course emphasized, such as identifying the roles and responsibilities of different health professionals. These experiences are similar to other universities that have demonstrated best practice models of interprofessional education for health care students.⁹ Rosalind Franklin University of Medicine and Science offers a course with a didactic component similar to ours with approximately 500 students who are divided into 16-member interprofessional teams. Similar to our results, students valued a team-based approach to quality patient care and appreciated the focus on learning about each other’s disciplines and beginning to develop interprofessional communication skills.⁹

However, in our study where students reported a decrease in the frequency of interacting with other health care professionals (ie, Pattern 2, Table 4), this may be a result of minimal curricular activities after the course where students have the opportunity to engage in IPE. This same logic could be applied to those variables that showed a significant increase between Time 1 and Time 2, but a significant decrease between Time 2 and Time 3 (ie, Pattern 5, Table 7). For example, between Time 2 and Time 3, students reported a decrease in how skillful they were in engaging in IPE. This could be secondary again to a lack of exposure or opportunity to engage in IPE learning activities after completion of the course.

Furthermore, in Pattern 3, where results did not identify a significant change between Time 1 and Time 2, but instead, a significant decrease between Time 2 and Time 3, an examination of the means for these variables indicate a possible explanation for this otherwise counterintuitive pattern. Specifically, there might have been a ceiling effect that potentially masked significant increases from Time 1 to Time 2 in this area. Further, as academic and clinical demands placed on students generally increase between Time 1 and Time 3, it may be that students perceive that they have less time to participate in interprofessional activities, and thus are less likely to seek out additional opportunities for increased interprofessional interaction (both as students in academic and clinical settings, as well as professional settings). Similar changes also have been identified in other studies, where students reported negative shifts toward interprofessional learning and interactions after longitudinal IPE curricula.^16,17 As McFadyen and colleagues indicate, this negative shift may be a result of attitudes that were initially more “idealistic” rather than “realistic.”¹⁶

Our course offered different types of teaching methods that included lectures, breakout sessions, and a standardized patient encounter. In a study that measured the knowledge, skills, and attitudes of interprofessional teamwork of 438 medical students and nursing students, there was no difference in the educational method used to teach IPE.¹⁸ However, feedback from our students indicated breakout sessions and standardized patient encounters were preferred over didactic lectures.

Based on student feedback from course evaluations, students valued interprofessional education. The most positive feedback was the ability to meet students from other disciplines and learn more about what each profession can contribute to patient care. The biggest criticism about the newly revised course was the time that the course was offered. Because it was held in the late afternoon after all other courses had taken place, the timing caused long hours on campus and heavy traffic delays when all students were exiting campus at once. Students also requested more breakout sessions for discussions and the creation of more complex patient scenarios.

There were hurdles to the design and implementation of this IPE course. The first to mention was the time intensity and faculty workload necessary to develop and implement such a large course. It took more than a year to schedule meetings, create the course, gain curricular approval for all colleges, and then implement the course. Scheduling common course time across the colleges was a challenge resulting in an evening time that was not well-received by students.

Because the course was offered to first-year students in the first quarter of their professional career, the topics discussed during class could not be applied to patient disease states, so applicability was limited. Also, because of the large class size, the number of standardized patient encounters also was restricted. These limitations also were noted by students in their course feedback.

Survey response rates were small. We only reviewed results from students who completed all three time points of the survey. The limited response was most likely due to the surveys being distributed over the course of their entire first professional year.

Based on the limitations noted above and student feedback, some proposed changes were implemented, and this course was offered for the second time in the fall quarter of 2015. The course was moved to the middle of the day, and some activities were reformatted to increase opportunities for teams to collaborate. A second standardized patient encounter was added, and the video sessions were replaced with breakout sessions. Additionally, the number of large class lectures decreased with one topic reformatted as a breakout session that covered the topic of ethics. One Health,¹⁹ an initiative that links human, animal, and environmental health in an interprofessional approach, also was added to this course as an introductory lecture and breakout discussion session. Aspects of One Health also were added to the second standardized patient encounter.

Our institution is focused on IPE and better care for the patients these students serve and will continue to serve beyond graduation. As a result, our committee is working on a second interprofessional course to be delivered later in the curriculum. It is in the planning stages of development to include therapeutic disease state management while continuing to emphasize collaboration and communication skills. By expanding this IPE curriculum, students will have additional opportunities to engage with students enrolled in other health professions programs. These additional IPE interactions potentially could reinforce and maintain certain attitudes that were seen in this study to have had a negative shift over time (eg, skillfulness in engaging in IPE).

SUMMARY

Interprofessional education is an integral part of many health sciences professions’ accreditation standards and curricula. Understanding the role of each discipline in the health care team is the initial step in creating a dynamic team that values shared decision-making. This course provided health professional students an opportunity in which they were able to accomplish this initial step. However, to ensure students grow in their ability to engage in future interprofessional collaborative practice, additional IPE interactions throughout the curriculum are necessary.