Abstract
Objective. The purpose of this study was to evaluate the impact of an interprofessional medical service trip to rural Honduras on pharmacy and medical learners’ attitudes toward interprofessional learning.
Methods. In this mixed-methods research, 19 participating students and residents from medicine and pharmacy completed the Readiness for Interprofessional Learning Scale (RIPLS) before and after the service trip in fall 2017 and spring 2018. Individual semi-structured interviews were conducted with participants following each trip to better understand which aspects of the experience shaped their interprofessional learning.
Results. Following the service trip, a significant improvement was found for the Teamwork & Collaboration subscale and the Negative Professional Identity subscale of the RIPLS. Several themes emerged from interviews, including that face-to-face interaction promotes collaboration; limited resources encourage team-based problem-solving; time together outside of work strengthens interprofessional connections; participating in another profession’s patient care activities fosters appreciation of individual roles; interprofessional care takes time; and participants felt a greater desire to pursue interprofessional practice in the future.
Conclusion. Interprofessional learning during a medical service trip improved participants’ attitudes toward collaboration. This study highlights which aspects of this experience contributed most to interprofessional learning, and our results may guide future efforts to design effective interprofessional education experiences.
INTRODUCTION
As voices across the health sciences call for a greater focus on global health, more and more students in Doctor of Pharmacy (PharmD) programs are choosing to pursue international experiences. 1-3 The potential benefits of these experiences are many and include greater cultural sensitivity, empathy, clinical knowledge, and more appropriate resource utilization. 4-6 Development of interprofessional competencies represents another potential benefit of global health experiences. Among US schools and colleges of pharmacy, two-thirds of international advanced pharmacy practice experiences (APPEs) were classified as interprofessional in 2016. 3
Several studies have highlighted how learners perceive international experiences to be particularly transformative in their personal and professional development. 7-9 Such immersive experiences may also serve as an opportunity for impactful interprofessional learning. At our institution, after more than 10 years of coordinating an interprofessional global health service trip, we observed that learners from both pharmacy and medicine frequently described how this trip was a key factor in their desire to work in an interprofessional setting. Although many examples of interprofessional global health experiences have been described in the literature, only a few studies have specifically examined the impact of these experiences on learners’ interprofessional attitudes. 7, 10, 11 These limited findings have indicated that international experiences have an overall positive impact on interprofessional attitudes, yet it is unclear which aspects of international experiences most contribute to learning and how this can be applied to enhance other interprofessional education experiences. As health science training programs continue to focus on designing effective interprofessional education curricula, we wanted to better understand how and why our institution’s global health experience impacted interprofessional learning. Therefore, the goals of this study were to evaluate the impact of a medical service trip on attitudes toward interprofessional collaboration and to describe which aspects of the experience most contributed to interprofessional learning.
METHODS
The setting for the medical service trip was a primary care clinic in rural Honduras created as a community partnership in 2001 in the aftermath of Hurricane Mitch. Our institution has sent interprofessional teams to this location twice per year since 2005 to provide support to a full-time Honduran physician and nurse. At the time of this study, teams consisted of attending physicians, medical students, medical residents, pharmacy students, and pharmacy residents. Participants attended three required predeparture meetings led by medical faculty, each lasting approximately one hour. These meetings were held in person and included an introduction to trip activities, the community in Honduras, and the principles of community-oriented primary care.
During the two-week service trip, all participants provided direct patient care in the clinic alongside the Honduran medical team. Students and residents also staffed the on-site dispensary where they prepared prescriptions, provided medication counseling to patients, and managed inventory under the supervision of licensed health professionals. Each day, half of the team also traveled to neighborhoods and villages in the catchment area to provide routine well-child care, including basic physical examinations, prophylactic treatments (fluoride dental treatments, hookworm treatment, and vitamin supplementation), and any urgent care needs and referrals. During all patient care activities, medical and pharmacy participants engaged in shared decision-making under preceptor supervision and frequently saw patients together. The medical participants took primary responsibility for the patient interview and physical examination, after which the medical and pharmacy participants discussed the patient case together, and pharmacy participants recommended treatment based on the clinic formulary. Pharmacy participants took primary responsibility for dispensing medications and counseling patients. Throughout the trip, the attending physicians ensured that all medical and pharmacy participants rotated through all areas of the clinic and participated in each patient care role with appropriate supervision, both in the clinic and during well-child visits. Each day, students and residents shared three meals and resided together in quarters adjacent to the clinic. Medical faculty led nightly debriefing sessions to reflect on the day’s activities and discuss patient cases encountered during the day. Outside of clinical activities, learners also had the opportunity to participate in social activities together, including a trip to a local coffee roaster, a group hike, game nights, and a two-night retreat to the beach at the end of the service trip.
In fall 2017 and spring 2018, we administered the Readiness for Interprofessional Learning Scale (RIPLS) 12 before and after each trip to Honduras to assess how the service trip impacted interprofessional attitudes. The RIPLS is a 19-item survey designed to examine the attitudes of health and social care students and professionals toward interprofessional learning. We chose this instrument because its items covered all four of the core competencies for interprofessional collaborative practice set out by the Interprofessional Education Collaborative (IPEC), all of which were aspects of this international experience. 13 Furthermore, the RIPLS was previously validated, has been widely used, was designed to be self-administered, and is appropriate for a studies using pre- and post-assessments. 13, 14 The questions belong to four subscales as proposed by McFadyen and colleagues in 2005; the subscales are teamwork and collaboration (questions 1-9), negative professional identity (questions 10-12), positive professional identity (questions 13-16), and roles and responsibilities (questions 17-19). 15 All items are scored on a five-point Likert scale from one (strongly disagree) to five (strongly agree). Negatively worded RIPLS questions (items 10-12) were reverse scored, so that higher scores indicated more positive attitudes toward interprofessional learning. The questionnaire was distributed at the beginning of each service trip during airline travel to Honduras and again at the conclusion of each trip during the flight back to the United States. These times were selected to ensure the highest response rate. Surveys were anonymous, and pre- and post-trip responses were matched using a unique identifier code known only to the participant. Demographic information collected included discipline (medicine or pharmacy), level of training (student or resident), age, and gender. All students and residents in pharmacy and medicine who participated in the service trip in fall 2017 or spring 2018 were eligible for inclusion.
The RIPLS responses were analyzed using SPSS for Windows, version 26 (IBM Corp). Question scores on the five-point Likert scale were summed for the total RIPLS and for each of the four subscales. The Wilcoxon signed rank test was used to compare paired pre- and post-trip total RIPLS scores as well as summed scores for each subscale. The Mann-Whitney test was used to check for differences in RIPLS scores between pharmacy and medicine participants and between participants with and without prior experience with interprofessional education. In all comparisons, p<.05 was considered statistically significant.
In addition to understanding how the service trip impacted attitudes toward collaboration through the RIPLS, we wanted to gain a deeper understanding of which unique aspects of this trip most contributed to interprofessional learning and how this could be applied to enhance other interprofessional learning experiences. To investigate this, we invited students and residents to participate in one-on-one semi-structured interviews following each service trip. Key guiding questions (Table 1) were developed using elements of the RIPLS and the Interprofessional Collaborative Competency Attainment Survey (ICCAS). 16 Following verbal consent, interviews were carried out by two pharmacy student research assistants (KM or AT) who did not participate in the trip as well as one pharmacy resident (HR) who did participate in both trips. Most participants were interviewed face-to-face or via phone following their return to the United States, while some interviews were conducted face-to-face during travel back from Honduras. Interviewers were trained to ensure common interviewing techniques, and the guiding questions were used to promote consistency among interviewers. Demographics collected included discipline (medicine or pharmacy) and level of training (student or resident). Each interview was audio recorded and transcribed verbatim using Microsoft Word (Microsoft Corporation), omitting any identifying information.
Interview Guide Used in Semi-Structured Interviews Conducted Following an International Service Trip
Interview transcripts were analyzed qualitatively using an inductive approach in which codes and themes were derived from the data. First, members of the study team reviewed each transcript individually and performed open coding. After reviewing transcripts independently, all investigators met to develop the initial codebook. Once a consensus definition of each code was reached by the study team, each interview was coded by two reviewers independently using Microsoft Word. An iterative coding process was used to ensure that the codes and themes represented the range of responses as new interviews were coded. As coders encountered data that did not fit a preexisting code, the study team made edits and additions to the codebook after discussion and consensus. A third and fourth reviewer determined the final coding where discrepancies existed. Coded text was grouped by code to help distinguish emerging patterns and themes. The research team met to identify overarching themes through discussion and consensus, and the authors verified and agreed that the themes represented participant responses and that saturation of themes was achieved. To better understand results in relation to current interprofessional education standards, emergent themes were mapped to IPEC’s current core competencies for interprofessional collaborative practice. 17 The University of Pittsburgh Institutional Review Board reviewed this study and deemed it to be exempt.
RESULTS
During fall 2017 and spring 2018, 20 learners participated in the service trip to Honduras. Of these, 19 participants (95%) completed both a pre- and post-trip RIPLS questionnaire, and these included medical students (n=6), pharmacy students (n=6), medical residents (n=5), and pharmacy residents (n=2). One medical resident did not complete a post-trip RIPLS questionnaire during travel back to the United States and was unreachable after return and was therefore excluded. Respondents were majority female (16/19, 84%).
The RIPLS questionnaire results are summarized in Table 2. The RIPLS scores were high for participants at baseline (median of 84 out of 95 total points). The RIPLS scores showed significant improvement following the service trip for the teamwork and collaboration subscale (median 44 vs 45, p=.03) and the negative professional identity subscale (median 13 vs 15, p=.01), though absolute increases were small. There were no significant differences in RIPLS scores between pharmacy and medical participants either before or after the trip. Of the 19 participants who completed the RIPLS, 11 reported having previous experience with interprofessional teaching. There were no significant differences in RIPLS scores among students with or without previous experience in interprofessional teaching.
Pharmacy and Medical Learners’ Scores on the Readiness for Interprofessional Learning Scale Before and After Completing an International Service Trip
Interviews were completed and analyzed for 17 out of 20 trip participants (85%). One medical student and one medical resident were unreachable. An additional interview with a medical student was completed but failed to record, so responses were not included. Interview participants included in the analysis were medical students (n=4), pharmacy students (n=6), medical residents (n=5), and pharmacy residents (n=2). Six common themes emerged during analysis, which are described below and listed in Appendix 1 along with corresponding IPEC core competencies and representative quotations.
The first theme that emerged from the interviews was that participants identified face-to-face interaction with other professions as key to promoting collaboration. Almost every participant from medicine and pharmacy remarked that working together in the same space positively impacted their teamwork. Several learners described how precepting discussions would typically take place in the medication dispensary, which allowed pharmacy participants to be integral to decision-making. Medical participants described the benefits of close and constant communication with the pharmacy team members, including more effective problem-solving and better understanding the rationale behind medication recommendations. Pharmacy participants, likewise, described how being present throughout the patient encounter informed their treatment recommendations to optimize care.
Most participants contrasted these face-to-face interactions with their past clinical experiences in the United States, where disciplines worked physically apart, and communication was brief and often by electronic means only. Several medical participants described how at home they only communicated with pharmacists in response to a problem, and how the lack of face-to-face communication had led them to feel, as one participant said, like pharmacists were “less of a resource and more of a gatekeeper.” One medical resident likened the face-to-face collaboration in Honduras and patient care rounds in the United States but noted that having separate workspaces for the remainder of the day limited collaboration beyond rounds. Pharmacy participants also contrasted collaboration in Honduras with experiences at home, where providers were difficult or impossible to reach by electronic means. In relation to these experiences, participants tended to describe face-to-face team communication on the trip as more integrated, more effective, healthier, and refreshing.
The second theme identified was that limited resources encouraged team-based problem-solving. Participants from both professions discussed how having limited medication options available in Honduras encouraged collaborative problem-solving, and how pharmacy participants’ medication knowledge was necessary to determine the best available treatment. Participants also noted that limited access to information resources caused them to work together more closely to make decisions. One medical student described how, due to a limited internet connection to his usual medical references, he instead consulted pharmacy students to identify appropriate medication treatments and recommend dosing. Pharmacy participants also reported feeling more trusted by medical students and residents due to reduced access to information resources, with one student noting, “they have to rely more on our pharmacy expertise about a medication.”
The third theme that emerged from the interviews was that time together outside of work strengthened interprofessional connections. Participants in pharmacy and medicine described the trip as unique from other interprofessional experiences because it allowed for time to get to know one another, both as individuals and as professionals. Some discussed how downtime together along with continuous exposure in the clinic allowed them to build relationships beyond work and recognize similar interests and goals. Pharmacy participants described how this nonstop exposure helped them to develop “a lot of trust between the team, and respect,” which made them more likely to ask one another for assistance. Likewise, medical participants described how time spent together helped them to feel more cohesive with pharmacy participants and to feel that everyone was working toward common goals.
The fourth theme identified was that participating in another profession’s patient care activities fostered appreciation of individual roles. One participant described how on the trip “everyone did everyone else’s job,” and another mentioned that “anything that could be shared would be.” Both medical and pharmacy participants discussed how the flexibility to join in one another’s tasks led to a deeper understanding of each profession’s abilities and contribution. A comparison of responses from pharmacy and medical participants revealed which traits each profession appreciated most in the other following the service trip. Medical participants described a greater appreciation for pharmacy participants’ medication knowledge, ability to counsel patients, and consideration for patients’ clinical pictures. On the other hand, pharmacy participants gained a greater appreciation for medical participants’ communication skills, decision-making, knowledge of diagnosis, and desire to help patients. Pharmacy participants also frequently described gaining a greater appreciation for their own education, clinical contributions, and value to the medical team, which led to increased confidence.
The fifth theme was that interprofessional care takes time. When asked about disadvantages of interprofessional work, the most common response was that coordinating among multiple team members requires more time and effort. Most described this in terms of an increase in their own individual time rather than an overall increase in time of care for the patient or medical team. Several participants also discussed how facilitating communication and having a clear understanding of team roles can improve the efficiency of interprofessional care. Even with increased time of care, many participants noted that the impact of interprofessional practice on patient care was worth the investment of time.
The sixth and final theme identified was that participants felt a greater desire to pursue interprofessional practice in the future. Interestingly, pharmacy and medical participants tended to respond differently when asked how the international experience would affect their future practice. While some pharmacy participants described how the trip had intensified their desire to work in interprofessional teams, most pharmacy participants focused more on the setting and nature of their future interprofessional interactions. Some commented on their desire to work with other professions in low-resource settings because of the trip. Others discussed how the trip increased their confidence in approaching physicians and their desire to form relationships with team members. Medical participants, on the other hand, tended to focus mostly on their intention to seek input from pharmacists in the future. Every medical student and resident commented on this in some form, with most connecting their desire for collaboration to having a better understanding of pharmacists’ knowledge and roles.
DISCUSSION
While results of the RIPLS indicated only modest improvements in the teamwork and collaboration subscale and the negative professional identity subscale, qualitative analysis of participant interviews highlighted unique aspects of this global health experience that fostered interprofessional learning. Several factors may have contributed to the modest changes observed in the RIPLS following this service trip. Participants had high median RIPLS scores at baseline (84/95), which was not surprising since this was a voluntary interprofessional experience. As others have noted, there is no comprehensive quantitative tool to assess interprofessional learning. 13 Despite several strengths of the RIPLS, it has also received criticism including its possible poor sensitivity, psychometric invalidity, and for the multiple changes proposed to its subscales over the years. 18-21 Furthermore, although the four-subscale RIPLS version used in this study has been validated and widely used, concerns have been raised about the weak internal consistency of subscale four (roles and responsibilities). 15, 22-24 This may have contributed to our lack of significant findings in the roles and responsibilities subscale despite this being a prominent theme in participant interviews. As students are exposed to more interprofessional education throughout their didactic curricula, further research is needed to guide which interprofessional education assessment tools are best for which contexts, and the development of new and more comprehensive tools may be needed. Shrader and colleagues have highlighted the benefits of using both quantitative and qualitative approaches when assessing interprofessional education outcomes to examine “both what and why.” 13 Qualitative analysis of interview data allowed us to gain further insight into why the trip influenced the attitudes assessed in the RIPLS, including those about teamwork, collaboration, and professional identity, which surfaced repeatedly in participant interviews.
We identified four key elements of the service trip that contributed to interprofessional learning for students and residents in both pharmacy and medicine: face-to-face interaction, working in a low-resource setting, spending time together outside of work, and participating in other professions’ responsibilities. Although these elements may be present to varying extents in local interprofessional education experiences, participants identified these as key differentiating factors that made this international experience impactful. Each of these themes corresponded to at least one IPEC core competency, indicating that elements of this trip strengthened essential knowledge and skills for interprofessional practice. Other studies of short-term experiences in global health provide further support for these elements of meaningful interprofessional learning. For example, Johnson and colleagues studied an interprofessional service trip to Ecuador and identified the importance of “unstructured, informal communication” outside of clinic hours as well as “seeing each profession in action,” similar to our findings. 7 Bentley and colleagues examined interprofessional education competencies developed during an international medical mission to Bolivia and identified the importance of immersion to intensify interprofessional learning. 25 Like our study, they also highlighted how team problem-solving occurred when deciding how to best use a limited supply of medications. Steeb and colleagues also noted that pharmacy students completing APPEs in low- and middle-income countries were more likely to experience growth in interprofessional collaboration competencies compared with students completing APPEs in high-income countries. 11 Other schools and colleges of pharmacy can consider intentionally incorporating these elements into their interprofessional education programs to enhance learning.
Our results also revealed some ways in which this immersive interprofessional learning experience affected physician and pharmacist trainees differently. While both medical and pharmacy participants described gaining a greater appreciation for one another’s roles, pharmacy participants were unique in describing how they also gained a greater appreciation for their own distinct role and value on the medical team. This appreciation for pharmacists’ uniqueness is integral to professional identity formation. 26 Previous studies have highlighted the difficulty of developing professional identity in the classroom, due to limited opportunities to experience how pharmacists relate to other health care professionals, and due to the challenges that students face in understanding what distinguishes pharmacists from other health professionals. 27, 28 Pharmacy students and residents in this study noted that sharing responsibilities, participating in the roles of their medical colleagues, and having their medical colleagues participate in medication-related tasks were key to appreciating their own unique role. Future research should focus on how different types of interprofessional education activities influence professional identity formation, and how this is developed differently in different professions.
Currently, barriers such as cost and travel logistics make international experiences inaccessible for many learners. Emergent themes identified from participant interviews contain lessons that can be applied to enhance interprofessional education experiences at home as well as abroad. The importance of face-to-face interactions was a prominent theme in our participant interviews. To promote face-to-face interaction, institutions should identify ways to create shared workspaces among different health professions during academic and clinical experiences to promote communication and collaboration. Future research could examine whether face-to-face collaboration during training helps to facilitate non–face-to-face collaboration later in one’s career. To expose learners to team-based problem-solving in limited-resource settings, institutions can consider ways to use interprofessional service learning to help meet local community needs. For example, studies of interprofessional student-run free clinics have reported positive effects on interprofessional attitudes and competencies. 29, 30 To facilitate time together in nonwork environments, pharmacy programs can consider creating shared extracurricular experiences or common housing options to promote personal connections with other health sciences students. Finally, programs should look for ways to allow learners to participate in another profession’s patient care activities. For example, interprofessional shadowing experiences have been developed, with positive outcomes reported. 31, 32
This study had some limitations. As mentioned above, the RIPLS tool has several disadvantages in this context and may be more appropriate for learners newer to interprofessional education. 13 Qualitative research has inherent limitations, including the biases of both researchers and participants. Although identified themes were grounded in the data, pharmacists and pharmacy students collected and analyzed data, possibly introducing bias based on professional identity and differences in interviewing style. The primary investigator participated in both service trips, and this preexisting relationship may have influenced participants’ responses. To minimize this influence, each interviewer spoke with both medical and pharmacy participants.
Our results represent a unique international setting, and variability in experiences such as practice model, professions represented, differences in international partners, and participants’ prior interprofessional experiences would likely affect results. Sample size was limited to trip participants during one academic year. Future studies could include participants from multiple international service-learning programs to ensure generalizability of concepts, and they could also integrate perspectives of other participants beyond learners.
CONCLUSION
Results from this study shed light onto the value of medical service trips for learners. Changes in RIPLS scores following the trip demonstrate some measurable value of interprofessional work, although more comprehensive quantitative tools to assess interprofessional education outcomes are needed. Interviews provide insight into specific aspects of international medical service that contribute most to interprofessional learning, including face-to-face interaction, collaborating in a limited-resource setting, spending time together outside of work, and participating in another profession’s activities. These results may help educators develop effective interprofessional experiences both at home and abroad.
Appendix
Themes, Core Competencies, and Representative Quotes Identified from Interviews With Pharmacy and Medical Learners Who Completed International Medical Service Trips
- Received May 26, 2021.
- Accepted November 5, 2021.
- © 2022 American Association of Colleges of Pharmacy
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