Interprofessional Education and Collaboration around Stockholm: A Study Trip Report
Heike Penner & Rita Hofheinz
Department of Staff Development, University Hospital Munich, Germany
As a result of demographic changes in Germany, the growing proportion of elderly people with chronic, multiple diseases is making increasingly complex demands on health care professionals. A trend analysis at the University Hospital of Munich (Klinikum der Universität München, KUM) has shown that, in recent years, the proportion of patients 65 years or older has risen, especially in intensive care. The growing number of cases with a significant reduction in the average length of stay and the increase in complex treatment and care needs (Bartholomeyczik 2007) makes it necessary to reallocate tasks as well as rethink the cooperation between health professionals in acute patient care (Kuhlmey 2011; Renz et al. 2014).
To meet these new challenges, it takes trusting collaboration within the therapeutic team (Reeves et al. 2012; Renz et al. 2014). However, professional practice and public health care assessments show that the structural conditions and the professional skills of health professionals in Germany are not promoting interprofessional cooperation (World Health Organization [WHO] 2010; Sieger et al. 2010). Doctors and nurses, the main health care professionals treating patients in the hospital, aiming to prevent errors and improve patient care (common team goal), often have difficulty working in teams: nurses sometimes blame doctors for communication deficiencies while physicians want their workload to be acknowledged by other health care professions (Hibbeler 2011). Communication problems within the health care team in turn may lead to poor patient outcome (Sachverständigenrat für Gesundheit 2007; Okuyama et al. 2011; Boev & Yinglin 2015).
From 1999 to 2002, a pilot project entitled Interprofessional Communication in the Hospital was initiated and implemented by the Federal Chamber of Physicians and the German Council of Nursing. It involved doctors, nurses and patients who focused on their communication and collaboration style(s), exploring different hospital tasks, such as patient admission and discharge and ward rounds. The results of the project showed major communication and collaboration deficiencies and a clear need for improving team cooperation (Lecher et al. 2002). In 2007, the Expert Council on Health Care also referred to these problems, noting that the current division of tasks and lack of cooperation between the health professions is not suited to meeting the demographic, structural and innovative demands (Sachverständigenrat für Gesundheit 2007).
SiHaKo Project: An Overview
In 2015, the project, Strengthening Interprofessional Collaboration through Shared Learning Seminars (Stärkung der interprofessionellen Handlungskompetenz, SiHaKo), was launched by the authors with financial support from the Robert Bosch Foundation. This project is directed at medical residents and nurses participating in the post-graduate course in intensive care. Residents and nurses examine, discuss and reflect on the treatment strategy of chronically ill patients with multiple illnesses. The overall objective of the project is to improve collaborative practice and quality of care.
The project includes 68 education units, divided into an orientation and development phase and consisting of, among others, communication seminars, demand-driven theoretical classes, and simulated interprofessional case discussions. The main focus of the seminars is on team communication and patient safety. By learning how to use various interprofessional communication tools (e.g. SBAR) and quality tools (e.g. CAM-ICU) during simulated interprofessional case discussions, the participants develop an awareness of their respective perspectives, their similarities and differences. The simulated interprofessional case discussions are held in a “protected classroom” environment where the students learn about others’roles, learn to solve problems together and thus overcome their limitations and fears within an interprofessional team. The objectives of the simulations allow students to practice and demonstrate team-based skills including communication, mutual support, leadership and “knowledge circulation” which aims to make all participants (nurses/doctors/supervisors) equal partners (DeJong 2012). Over the course of the project, an interprofessional group of lecturers/supervisors is available for all students for professional support and dialogue. The intensive project experience aims to facilitate trust and create a team that continuously reflects on and optimises its actions and communication processes and is able to design its workflows effectively and efficiently.
Study Trip to Stockholm (Sweden)
During the project planning phase, the authors searched for interprofessional education (IPE) and interprofessional practice (IPP) programmes in health care, both nationally and internationally. In Stockholm, we found a project that we thought could serve as an example for the SiHaKo project. Active networking between the education departments in Munich and Stockholm began in 2014. As a result, a speaker from Stockholm was invited to Munich to give a presentation on IPE at the 19th Munich Intensive Care Day in March 2015. Our study trip to Stockholm took place in October 2016. We planned the trip in cooperation with one supervisor of the IPE Södersjukhuset Utbildningscenter and one supervisor of the IPEICU at Karolinska University Hospital Stockholm. A representative of the Robert Bosch Foundation joined us on our study trip. We visited six different IPE locations in and around Stockholm, which are connected to each other through the Södersjukhuset Utbildningscenter.
Days 1 to 3. We began our tour at the Education Centre of the Stockholm South General Hospital (Södersjukhuset). Here, we were introduced to the Utbildningscenter, receiving information about the history and concept of IPE and IPP in Sweden and the larger Stockholm area.
During our stay in Stockholm, we were able to observe the employment of the SBAR communication tool with different training teams on different interprofessional training wards. We were given the information that all health care professionals involved in the IPE training (students/supervisors/facilitators) were taught the SBAR concept. According to the IPE learning objectives of the Karolinska Institutet and depending on the level of (interprofessional) education (undergraduate/postgraduate courses), we noted differences in supervising styles: If undergraduate students required professional assistance, supervisors tended to be pro-active, while for students in the postgraduate education programme supervisors were waiting patiently in the background until the students asked for their assistance. On the interprofessional training ward, supervisors (doctors/nurses with pedagogical training) and interprofessional students form a team within each shift’s health care team, meeting for reflection at midday. Clinical assessments of patients take place at the patient’s bedside. The student teams perform the clinical assessment and discuss their findings among themselves before they present them and the therapy goal to the supervisors in the so-called “protected classroom”. After each shift a reflection unit takes place, using, for example, Gibbs’ Model of reflection. This cyclic generic framework is a general approach to reflection and novices may find it too vague requiring further guidance (Thompson & Pascal 2012).
Day 4: To find out how IPE works in an intensive care unit, we visited the Utbildnings Unit ICU at Karolinska Huddinge (IPEICU) because of its similarities to our own project. This IPEICU is open 18 weeks per year for one to two IPE teams per week. We were able to join the IPE teams for one shift on 6 October 2016. Each team is responsible for the care of one patient and coordinates its work with other health care professions. An important part of the IPE training is the joint clinical assessment of the patient followed by the IPE team’s reflection on the therapy plan. The IPE training team consists of students (nurses and residents in ICU training), supervisors (specialist nurses/doctors ICU with pedagogical training) and head supervisors (specialist nurses) facilitating the interprofessional activities and encouraging the participants to remain faithful to the IPE learning concept (Conte et al. 2015).
At the beginning of the shift, we observed the clinical assessment of the patient at the bedside by the IPE student team. The supervisors were quietly standing in the background, observing the students and taking notes. Later, the entire IPE training team retired to the seminar room where the students presented their observations and findings on the patient in accordance with the SBAR concept to reflect collaboratively on the therapy plan. The supervisors used a hermeneutic approach and did not respond directly to the students’ questions, but asked further specific questions that prompted the students to reflect on and, if necessary, rethink their decisions (V= Vorverständnis, or prior understanding, T= text or context understanding; V¹= enlarged understanding, T¹= enlarged context understanding, etc.).
This approach gave the students the space and time to think about and discuss the therapy plan, giving them a feeling of ownership. The learners had enough time to present and re-evaluate their own professional perspectives. In the seminar room, students found a stress-free and safe atmosphere where they could learn from each other in order to arrive at a collaborative therapy decision. Conte et al. (2015) found that students in the IPE programme in Stockholm indicated that being provided this space and time was a major motivating factor for them. If health care students, from the beginning, are (made) aware of their own professional roles and the roles and perspectives of other health care groups, they may find it much easier to contribute to and focus on collaboration between health care professionals. However, interprofessional communication and collaboration in health care does not happen on its own, it should be offered early and practiced as a lifelong process. The need for life-long learning in IPE is also shown by the WHO (2010).
We were able to experience and observe IPE in several training centres in the Stockholm area. In all centres, we met highly committed and enthusiastic Swedish colleagues who welcomed us warmly and work hard to promote an interprofessional spirit in health care. It takes people like them to bring the idea of IPE to (practice) life. Without their hard work and the government’s decision to include IPE in the curricula, the journey would not have been this successful. However, it has taken the Swedish health care system more than twenty years to come this far.
While we can learn a lot from the Swedish model, it will be necessary to adapt it to the German context. Our project is one of a few IPE projects in Germany. The health care system is undergoing constant reforms, and many projects have never gone beyond pilot project level. The Swedish IPE model, however, gives us hope that our vision will become a reality. How to design healthcare education as to meet the needs of the future remains a crucial question. Whether IPE and teamwork are one answer to this question will have to be the subject of further studies.
Special thanks to Rene Ballnus, Helen Conte, Sara Fouraux, Anna Magdsjö, Erika Thorwaldsdotter, Linda Arundson, Eva Barkestad, Anders Nilsson and other Swedish colleagues for their warm welcomes and insights into their professional worlds.
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