Evaluation of an Interprofessional Education Communication Skills

ORIGINAL RESEARCH PAPER

Evaluation of an Interprofessional Education Communication Skills Initiative P Solomon, J Salfi McMaster University, Hamilton, Ontario, Canada Published: August 2011 Solomon P, Salfi J Evaluation of an Interprofessional Education Communication Skills Initiative Education for Health, Volume 24, Issue 2, 2011 Available from: http://www.educationforhealth.net/

ABSTRACT

Context: Interprofessional education of pre-licensure students is viewed as an important precursor to developing healthcare professionals who are able to work collaboratively. Objectives: This study conducted a program evaluation of an innovative interprofessional communication skills initiative which incorporated problem-based learning, cooperative learning and standardized patients. Methods: The communication skills session consisted of a three-hour, faculty facilitated, interactive format in which teams of five to eight students met to conduct an interview with a standardized patient and develop an interprofessional care plan. The program evaluation included measures of satisfaction, the Interprofessional Education Perception Scale (IEPS), the Readiness for Interprofessional Learning Scale (RIPLS), focus groups and individual interviews. Findings: A total of 96 students from medical, nursing, physiotherapy, occupational therapy, midwifery, physician assistant and pharmacy programs self-selected to participate in the evaluation. Students rated their satisfaction with the communications skills sessions highly. There were small but statistically significant changes pre- and post-session in the IEPS. Qualitative analyses revealed that students perceived that they had learned about each others’ scope of practice and built confidence in their communication skills. The skill of the facilitator and preparation for the experience were perceived to promote the success. Discussion and Conclusion: The demand for experiential events which provide students with the skills required to interact effectively in healthcare teams is likely to continue with the growing awareness of the need for interprofessional education. A learning experience which incorporates standardized patients and feedback from faculty facilitators can promote authentic interprofessional learning, and develop students’ confidence to communicate in a team environment. Keywords: Communication skills, interprofessional, interprofessional education, program evaluation © P Solomon, J Salfi, 2011. A licence to publish this material has been given to Education for Health: http://www.educationforhealth.net/ 1

Context There has been increasing emphasis on the importance of interprofessional collaborative practice as it improves the quality of patient care and safety, enhances the accessibility and continuity of care, and helps to decrease conflict, redundancy and staff turnover1. Interprofessional education (IPE) is defined as occurring when two or more professions learn with, from and about each other to improve collaboration and the quality of care2. Advocates suggest that IPE is important to cultivate mutual trust and respect, and to confront misconceptions and stereotypes, dispelling prejudice and rivalry between professionals2. The ability to communicate in a respectful manner facilitates connectedness between members of a team, as it allows for an awareness of equal power, and fosters shared decision-making, responsibility and authority3. Recent reports outlining the essential interprofessional competencies reinforce the centrality of communication skills. For example one of the domains of the interprofessional competency framework developed by the Canadian Interprofessional Health Collaborative (CIHC) is interprofessional communication. Descriptors of relevant behaviors include active listening, communicating to ensure common understanding of care decisions, setting shared goals and sharing responsibilities for care among others4. In a review of interprofessional communication courses in undergraduate health education programs in the United Kingdom, Priest et al5. noted a number of benefits and suggested that shorter learning opportunities may be preferable to longer, more laborintensive initiatives, and that these opportunities need to be interactive. Fidelity and authenticity of the educational experience were also important, as students must perceive the context as meaningful to their future clinical roles in order to be fully engaged. Some have reported using standardized patients as a way to promote realistic encounters. Westberg et al6. described an experience in which medical, pharmacy and nursing students participated in standardized patient interviews. Students performed individual interviews, while fellow students and faculty observed behind a one-way mirror. Following the separate interviews, the students met as a group to develop care plans. Students were provided with general group feedback, and each individual was also provided with one-on-one feedback from a faculty member from their own profession. Of the 26 (out of 48) pharmacy students who completed the experience, self-designed pre- and post-surveys revealed that students developed a better understanding of both nursing and physician roles. Another example of an interactive and engaging IPE learning opportunity can be found in an article by Dobson et al7., which described an osteoporosis assessment lab, where pharmacy, nutrition and physiotherapy students interviewed standardized patients and developed care plans. Of the 25 teams of three, only one consisted of all three professions; four teams consisted of two pharmacy and one physiotherapy student, and the remaining 19 teams consisted solely of pharmacy students. The authors compared the quality of the care plans based on the team type. Not surprisingly, the interprofessional teams produced more comprehensive care plans. We were interested in developing a communication skills initiative that would require students to negotiate their own roles within a team environment, and learn about team communication skills and strategies as they worked through an identified healthcare scenario. The purpose of this article is to present a program evaluation of an interprofessional communication skills initiative which incorporates aspects of problem-based learning and cooperative learning, and uses standardized patients to provide a realistic and engaging learning experience for pre-licensure students.

© P Solomon, J Salfi, 2011. A licence to publish this material has been given to Education for Health: http://www.educationforhealth.net/ 2

Program Description A brief description of the interprofessional program at McMaster University will provide a context to the communication skills initiative. All students in the Faculty of Health Science are required to participate in mandatory IPE activities. In keeping with the small group, student-centered, adult learning philosophy within the faculty, students are able to choose from a variety of activities to meet the requirements for their program. Activities vary in length and complexity, and are labeled as exposure, immersion or mastery levels to reflect this. The communication skills sessions are considered to be immersion events designed to address four global competencies. Students shall: 1.

describe their own professional roles and responsibilities, and the general scope of practice of other health professionals to colleagues and patients/clients;

2. 3.

know how to involve other professions in patient care appropriate to their roles, responsibilities and competence; collaborate with other professions to establish common goals, provide care for individuals and caregivers, and facilitate shared decision-making, problem-solving and conflict resolution;

4.

contribute to team effectiveness by sharing information, listening attentively, respecting others’ opinions, demonstrating flexibility, using a common language, providing feedback to others, and responding to feedback from others.

The communication skills sessions are three hours in duration. The format consists of an introduction and orientation to the session, followed by a team meeting in which the students review a patient scenario and plan the initial interview of a standardized patient who has been specially trained to portray the scenario. An example of a scenario can be found in Figure 1. Typically there are between five and eight students on each team. The initial interview with a standardized patient is 20 to 30 minutes in duration. When the interview is over, the patient leaves the room and the student team meets to discuss their findings and their treatment and/or discharge plan. Once this task has been completed, the patient returns to the room and a follow-up meeting is conducted to discuss the interprofessional plan of care. A faculty facilitator observes all the interactions behind a one-way mirror. At the completion of the interaction with the patient, there is a 60-minute debriefing and feedback session where the faculty facilitator provides individual and team feedback to the student group.

This scenario involves two standardized patients—a mother and daughter dyad, so that students can practice assessment and communication with both individuals, as well as observation of the dynamics of the relationship and communication patterns between an elderly women with impaired cognitive function, and her daughter. The students receive a request for an assessment from the case manager.

Scenario – The Case Manager’s Home Visit Mrs. Cooke is a seventy-four year old woman who lives with her small dog in a one bedroom apartment. Recently widowed, her community case manager came to reassess her ability to function on her own. Prior to this visit, Mrs. Cooke was receiving one hour of personal care per week to assist with her bath. Upon the case manager’s arrival, the door to the apartment was wide open, Mrs. Cooke was wandering around without stockings, and her blouse was half-open. Bruises were visible on her legs. Her wallet sat open on the kitchen table, next to an empty medication dossette.

Figure 1: Communication skills scenario


Students from medical (MD), nursing, physiotherapy (PT), occupational therapy (OT), midwifery (MW) and physician assistant (PA) programs, and pharmacy residents are eligible to participate in the communication skills sessions. Students sign up for this interprofessional event on a first-come, first-served basis, but there are limits on the numbers of students from each professional program in order to ensure an interprofessional mix.

Program Evaluation Methods The program evaluation incorporated both qualitative and quantitative measures.

Measure of Satisfaction Students answered five questions related to their satisfaction with various components of the communication skills sessions. The self-designed questionnaire asked students to rate the components on a seven-point Likert scale ranging from very dissatisfied to very satisfied immediately following the communication skills event. One of the items asked the students to rank their overall satisfaction with the experience.

The Interdisciplinary Education Perception Scale The Interdisciplinary Education Perception Scale (IEPS) is an 18-item scale designed to measure student perception and attitudinal change following IPE8. With six-point Likert scale responses, there are four factors: competence and autonomy, perceived need for cooperation, perceptions of actual cooperation and understanding others’ values. Internal consistency has been reported from r = .51-.87. The factors have a range in maximal possible scores from 72-96 and the maximum total score is 330. Students in our evaluation completed the IEPS immediately prior and following the communication skills sessions.

Interprofessional Focus Groups and Interviews Students were also asked if they would participate in either an interprofessional focus group or an individual interview. The purpose of these sessions was to gather in-depth information of the students’ views on the strengths and challenges of the communication skills session and of the learning that occurred within the session. All focus groups and interviews were audiotaped and the transcripts were analyzed using a qualitative content analysis9. This consisted of a line-by-line review of the transcripts to identify a key word or phrase that represented the participants’ words. The coding scheme was developed by a research assistant and verified by one of the study investigators. Codes similar in focus were grouped to form themes that emerged from the data. This project received ethical approval from the Research Ethics Board at McMaster University.

Results We recruited 96 volunteer students for this program evaluation. The greatest number of students were from the medical program, followed by students from occupational therapy, physiotherapy, midwifery, nursing, physician assistant and pharmacy programs. The mean age for the students was 25.2 years, with a range from 19 to 60. A breakdown of participants by gender and program can be found in Table 1. © P Solomon, J Salfi, 2011. A licence to publish this material has been given to Education for Health: http://www.educationforhealth.net/ 4

Table 1: Participants in the communication skills sessions by gender and discipline* Discipline

Gender Females Males 22 7 13 0 10 0 9 0 3 1 6 1 20 3 83 12

Medicine Midwifery Nursing Occupational therapy Pharmacy Physician assistant Physiotherapist Total

Total 29 13 10 9 4 7 23 95

missing data n=1

Quantitative Findings There were 96 students who completed the satisfaction questionnaire; 92 students completed the IEPS. Table 2 provides a summary of the students’ satisfaction scores. For ease of interpretation, responses that indicated very satisfied or satisfied have been combined to form a satisfaction score while those responses that indicated very dissatisfied or dissatisfied have been combined to form a dissatisfaction score. Overall satisfaction was high with only 1% (n=1) of the students indicating being 'dissatisfied,' and 4.2 % (n=4) indicating 'neutral.' Students were satisfied with the clinical relevance of the experience, the contributions of the faculty facilitator, and the opportunities to collaborate with students from other programs. While 85.4% (n=82) were satisfied with the opportunity to learn about the roles of other professions, 12.5% (n=12) indicated they were neutral and 2.1% (n=2) were dissatisfied with this item. Table 2: Student satisfaction scores post communication skills sessions (n=96)* Indicate your level of satisfaction with the: 1. Clinical relevance of module materials* 2. Contribution of the faculty facilitator to my learning 3. Opportunities to collaborate with students from other professions 4. Opportunities to learn about the roles of students from other health professions 5. Rate your overall satisfaction with the clinical component

N 85 93

Satisfied % 91.4 96.9

N 6 3

Neutral % 6.5 3.1

N 2 0

Dissatisfied % 2.1 0

89

92.7

6

6.3

1

1.0

82

85.4

12

12.5

2

2.1

91

94.8

4

4.2

1

1.0

*missing data n=3

Table 3 presents the pre- and post-scores of the IEPS. Mean scores were calculated for both subscales and for the total score. Student t-tests were used to test significance between scores. While there was a statistically significant difference between the overall score following the communication skills session (p=.034) only one of the subscales, Perception of Actual Cooperation, reached a statistically significant level (p=.009).


Table 3: Interprofessional education perception scale scores pre and post communication skills sessions (n=92) IEPS Subscales Competency and autonomy Perceived need for cooperation Perception of actual cooperation Understanding of other’s values Overall IEPS score

Mean total preevent (s.d.) 79.39 (7.83) 65.93 (8.27) 74.02 (9.21)

Mean total post-event (s.d.) 79.96 (8.43) 66.46 (8.16) 75.88 (9.30)

T value

df

Sig.

-.814 -.623 -2.685

91 91 91

.418 .535 .009

49.13 (8.22)

49.78 (9.57)

-.875

91

.384

266.56 (23.31)

270.92 (25.46)

-2.157

91

.034

Qualitative Findings Twenty students volunteered to participate in one of five focus group sessions. An additional two students were unable to attend the focus groups and chose to participate in individual interviews leaving a total of 22 students who provided qualitative feedback. There were eight occupational therapy students, six students from medicine, three nursing students, two midwifery students, two physiotherapy students and one student from the physician assistant program. Seven themes emerged from the focus groups and interviews. The themes are illustrated below with representative quotes. Planning for Success The students reflected on the importance of the planning session for setting the tone of the experience and allowing it to unfold in an organized manner. As one student said, 'It was good too, because we asked everybody like, ‘okay, well you as a nurse, what is your primary concern? What are the physicians’ primary concerns? The PAs? The OTs? The PTs?’ So then we had an idea really of what everybody was more focused on. That way we could kind of organize it and how we would go through.' Importance of Facilitator The students recognized that the facilitator was an important part of the learning experience. The facilitator intervened if students felt 'stuck,' ensured that there was a balance between learning about teamwork, collaboration and communication skills, reinforced positive communication and teamwork, and provided extensive feedback. One student described how the facilitator intervened, 'We got off to a bit of a rocky start and went sort of in the wrong direction and [the facilitator] sort of came in and said, ‘I think you should go over what went wrong here' and as we were talking about it, she said, 'okay, you as a physio or you as an OT or you as a doctor -- what could you have done to put this on the right track?’ So she kind of made us reflect back on where we fit into the picture.' Building Confidence Although students stated they occasionally felt some stress with having to make decisions with students they had not met previously, they recognized that the communication skills sessions allowed them to make mistakes and learn techniques in a © P Solomon, J Salfi, 2011. A licence to publish this material has been given to Education for Health: http://www.educationforhealth.net/ 6

situation without risk. This allowed them to build confidence not only in communication techniques, but also in their professional roles. 'We are all going to be out there in the real world, why not practise this when you're not in the real world, where you can make mistakes, where you can challenge yourself to step out and totally screw up?'

Balancing Communication Skills with Interprofessional Learning The communication skills sessions were complex and required students to think beyond their personal communication style and relationships with other team members. The sessions also challenged them to advocate for their own professional role, and were intended to help them learn about the scope of practice of others. Often students were unaware of the extent of their learning until it had been identified and made explicit by the facilitator. This quote illustrates how the students learned about others' scope of practice through the types of questions they asked. 'But I think I did most of my learning of the other professions within the actual scenario in terms of what sorts of things they would be asking the patient about and what sorts of things they would be informing the patient about.'

Feeling Discomfort Not surprisingly, students felt some initial discomfort as they had to interact with others whom they had not met previously. Although the introduction and orientation sessions were designed to ease the students into the experience, it was not possible to totally alleviate this anxiety. One student saw this as a learning opportunity. 'It was a bit awkward at first but I mean like realistically, it's going to be a little awkward too. So it's good training to see who's going to start and how the interview is going to go or how are you going to work about it.'

Learning about Others' Scope of Practice Students identified that learning about others' roles and scope of practice was an integral part of the experience. Often stereotypes and misconceptions about a profession’s responsibilities were dispelled. Some students expressed surprise at the extent of the roles of others, as with this student, 'I never thought that [pharmacists] really had to communicate with patients at all because my perception was pharmacists were more collaborating with the team as a whole, they don't really get to see patients unless it's more education wise or drug wise. But it was very fascinating to see the good skills those pharmacy students have.'


Positive Experience In keeping with the high rates of satisfaction, learning communication skills in a experiential format with colleagues from other professions was valued. Students enjoyed the opportunity to interact with each other in a less stressful, yet realistic environment and valued the feedback from the facilitators. 'It was really great to see how all the professions did overlap; like you were saying, with a holistic view and that you're not just focused on one thing, you're kind of looking at the whole person.'

Discussion Our evaluation revealed that pre-licensure students enjoyed the opportunity to interact with colleagues from other professions in an intensive, yet realistic educational event. Students built confidence through their interactions and learned about others' scope of practice. Standardized patients provided an authentic alternative to onsite clinical education, yet allowed students to feel 'safe' in their clinical interactions. While the IEPS showed statistically significant changes, whether these are clinically meaningful or significant is unclear. There are few well-validated measures of IPE and interprofessional collaboration. While IEPS is generally recognized as having undergone more rigorous psychometric testing, it is not without problems. In a recent review, Thannhauser et al10. noted that the lack of consistent vocabulary and consensus of important elements to be measured in IPE have hampered the development of more robust tools. A key strength of our study is the mixed methods approach which enabled a more comprehensive evaluation of our initiative. The student feedback suggests the facilitator role is important for making interprofessional learning explicit, and for balancing interprofessional and subject-related learning. Our facilitators were social workers who had expertise and skills in communication and group process. They were required to observe the interactions, provide feedback and suggestions, promote group problemsolving and self-evaluation around communication issues, and role model respectful team interactions. Recognizing the importance of immediate feedback, we devoted a full hour of each three-hour session to debriefing with the facilitator. We view the reflection and insight gained from the experience as a critical element of student learning. This opportunity for developing and refining communication strategies seldom happens in the midst of a busy clinical education experience. The findings reinforce our view that the skills of the facilitators contribute to the success of this initiative. Standardized patients are also an important contributor to success. However, standardized patients require training, are expensive, and not all educational programs have access to this resource. Other communication initiatives have used faculty to role-play patients. Morison and Stewart11 used senior health officers to role-play parents in a scenario in which students from both medicine and nursing programs had to explain aspects of care for their child. This model might address the issue of access; however it is likely a more expensive use of resources. An emerging and related area incorporates patient educators as trained facilitators, and may be an alternative that is less costly and more accessible to some programs12,13. Another potential alternative is for students to role-play the patients. However this is unlikely to be as authentic and engaging for the students. In their communication sessions with medical, pharmacy and nursing students, Westberg et al6. noted the challenges associated with case development, in particular ensuring that the complexity of the case is suitable for each program and in keeping with the © P Solomon, J Salfi, 2011. A licence to publish this material has been given to Education for Health: http://www.educationforhealth.net/ 8

limited time available to students. They also worried about the cost and time associated with training standardized patients when developing new cases. We have found that the cases are highly reusable. Although the case simulation is standardized, there is considerable variation depending on the students’ previous experiences, the group dynamics that evolve, and their prior level of communication skills. Therefore each scenario unfolds differently and it is impossible to predict the outcome. Although students may be aware of the possible scenario through discussions with their colleagues prior to their experiences, we found that this has not had an impact on the outcome and learning that occurs. Due to the emphasis on small-group, problem-based learning at McMaster University, students have experience in collaborative small-group learning, albeit in intraprofessional courses, prior to their communication skills experiences. This could enable the students to more efficiently participate in the communication sessions, and could contribute to the positive feedback that we received. In spite of their previous experiences, students were still uncomfortable during the initial stage of the session. Those wishing to develop similar experiences with students who are new to group learning may need to allow for additional time for the introduction and group formation and to be more directive with their instructions and expectations. This study is limited in that we evaluated student perceptions immediately following the interprofessional event. The communication skills sessions are just one component of a comprehensive curricular approach in which the goal is to graduate health professionals who can collaborate effectively in clinical practice. The complexity of evaluating the long term effectiveness of IPE and whether there are long term behavioral changes that impact on patient care, has been widely acknowledged. It is even more difficult to evaluate the behavioral change resulting from a single IPE event. Nonetheless, positive perceptions and high levels of satisfaction are foundational to behavioral changes and need to be evaluated. In addition, students have some choice in their selection of IPE events; thus students who chose to participate in the communication skills sessions and evaluations may have been predisposed to evaluate them positively.

Conclusions The demand for experiential events which provide students with the skills required to interact effectively in healthcare teams is likely to continue with the growing awareness of the need for IPE. Given the centrality of communication skills in fostering teamwork and collaboration, it will be important for educators to develop innovative, experiential events that are suited to cultural, financial and personal resources of their institution. A learning experience which incorporates standardized patients and feedback from faculty facilitators can promote authentic interprofessional learning, and develop students’ confidence to communicate in team environments.

Acknowledgements The authors would like to acknowledge the valuable contributions of Carl Delottinville, Susanne King and Nicole Gervais. This research was supported by a grant from the Interprofessional Health Education Innovation Fund, Ministry of Health and Long Term Care and Ministry of Training, Colleges and Universities for the Province of Ontario, Canada.

References 1. Canadian Health Services Research Foundation (CHSRF). Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada. Ottawa, ON: Author; 2006.


2. Centre for the Advancement of Interprofessional Education (CAIPE). Defining IPE [Internet]. Retrieved September 18, 2010 from www.caipe. org.uk/about-us/defining-ipe/ 3. Selle KM, Salamon K, Boarman R, Sauer J. Providing interprofessional learning through interdisciplinary collaboration: The role of modelling. Journal of Interprofessional Care. 2008; 22(1):85–92. 4. Canadian Interprofessional Health Collaborative. A national interprofessional competency framework. Vancouver, BC: Her Majesty the Queen in Right of Canada; 2010. 5. Priest H, Sawyer A, Roberts P, Rhodes S. A survey of interprofessional education and communication skills in healthcare programmes in the UK. Journal of Interprofessional Care. 2005; 19(3):236-250. 6. Westberg S, Adams J, Thiede K, Stratton T, Bumgardner M. An interprofessional activity using standardized patients. American Journal of Pharmaceutical Education. 2006; 70(2):1-5. 7. Dobson R, Taylor J, Cassidy J, Walker D, Proctor P, Perepelkin J. Interprofessional and intraprofessional teams in a standardized patient assessment lab. Pharmacy Education. 2007; 7(2):159-166. 8. Luecht R, Madsen M, Taugher M, Patterson B. Assessing professional perceptions: design and validation of an interdisciplinary education perception scale. Journal of Allied Health. 1990; 19(2):181-191. 9. Hseih H, Shannon S. Three approaches to qualitative content analysis. Qualitative Research. 2005; 15(9):1277-1288. 10. Thannhauser J, Russell-Mayhew S, Scott C. Measures of interprofessional education and collaboration. Journal of Interprofessional Care. 2010; 24(4):336-339. 11. Morison S, Stewart C. Developing interprofessional assessment. Learning in Health and Social Care. 2005; 4(4):192-202. 12. Towle A, Bainbridge L, Godolphin W, Katz A, Kline C, Lown B, Madular I, Solomon P, Thistlethwaite J. Active patient involvement in the education of health professionals. Medical Education. 2010; 44:64-74. 13. Solomon P. Student perspectives on patient educators as facilitators of iInterprofessional education. Medical Teacher. In press.
