Blog Article: Perceptions of Health Sciences Students on anIntroductory Interprofessional Education Course

By | 7th August 2016
Perceptions of Health Sciences Students on an Introductory Interprofessional Education Course

Joe Paul Castillo, Trent Gahl, Liz Torrez, Joua Vang, Jessica Womack, Joy Doll, Ann Ryan Haddad, Anna Maio, Katie Packard, Meghan Potthoff 

Creighton University Center for Interprofessional Practice, Education and Research (CIPER) and Creighton Department of Occupational Therapy

Healthcare is a complicated, critical, and ever changing environment in which health professionals are faced with diverse populations with a variety of conditions (Royeen, Jensen, & Harvan, 2011).  The current healthcare environment requires health professionals to work interprofessionally to promote effective communication to treat and advocate for patients and communities in a team-based matter (Royeen et al., 2011).  IPE requires health professionals to learn and work together to promote beneficence for patients and communities as outlined in the core competencies (Interprofessional Education Collaborative, 2011; Royeen et al., 2011). With healthcare moving towards interprofessional collaboration as a desired approach, higher education institutions need to prepare students on how to work together as an interprofessional team prior to entering the clinical environment (Pardue, 2015).  Making such educational shifts involves changes in accreditation, policy, and implementing IPE core competencies (Pardue, 2015).
Often, universities face the challenge of when interprofessional learning should be offered to students (Sheldon et al., 2012).  Conflicting research exists on whether IPE should be implemented early in the students’ academic career or later, just prior to taking board exams (Sheldon et al., 2012).  One study suggested that IPE could be best experienced once students have a strong identification in their professional identity, claiming that lack of professional identity while experiencing IPE education can lead to role insecurity (Mandy, Milton, & Mandy, 2004). However, Foster and Macleod Clark (2015) suggested that IPE education should be introduced and given to undergraduates before entering their chosen profession.
Therefore, this study addressed students’ perceptions on an introductory IPE course that was given to health science students within their respected disciplines during their first year of study.  The purpose of this study was to identify health sciences students’ perceptions of an introductory IPE course taken at Creighton University in Omaha, Nebraska entitled IPE 400 Introduction to Collaborative Practice. With the emerging importance of IPE, it is important to assess students’ perceptions relating to their own knowledge, attitudes and beliefs.
As the gap between current health professions training and the actual realities of practice have increased, health systems are now seeking graduates who are experienced in teamwork as well as in their own disciplinary knowledge (Pardue, 2015). Working in a healthcare profession, individuals rarely act alone; they are always working within teams or groups. The Interprofessional Education Collaborative Expert Panel (IPEC) (2011) claims that IPE is necessary to inform all healthcare professionals to work collaboratively to produce better patient-centered care. Not only must professionals be able to work with others, but also they must understand the logistics of teams and teamwork, and must be proficient in problem solving, managing conflict, and relaying information in an understanding manner (Doll et al., 2013).
According to the core competencies of interprofessional collaborative practice, IPE accreditation, curriculum, and policy differ in every organization. These aspects of IPE undergo constant development across many healthcare and educational settings (IPEC, 2011). To promote collaborative-based care, core competencies of interprofessional collaborative practice related to IPE must be implemented in order to create a coordinated structure between current education standards and curriculum development (IPEC, 2011). When using the core competencies of interprofessional collaborative practice, results have showed that students understand the values that the competencies represent (IPEC, 2011). From this, students develop the ability to gain knowledge, build skills, and construct relevant ideas related to the core competencies and apply it to interprofessional practice (IPEC, 2011). The core competencies of interprofessional collaborative practice also help identify educational themes that can serve as a plan for educational facilities to implement IPE (Doll et al., 2013).
Experience and perceptions of students is an important factor to consider when trying to implement, evaluate and modify an IPE course. Students may be exposed to many aspects of interprofessional education through prior learning experiences, workshops, courses, and events (Curran, Sharpe, & Forristall, 2008; Mellor, Cottrell, & Moran, 2013). Many students possess positive feelings towards IPE, but feelings can vary based on gender, profession, and year of study (Curran et al., 2008).  Overall, students who have been exposed to IPE better appreciate professional roles in the team approach to patient-centered care and have further developed necessary skills pertaining to communication and teamwork (Sheldon et al., 2012).
After completing an IPE course, students state that they developed a sense of worth and respect for the other team members (Curran et al., 2008; Ruebling et al., 2014; Sheldon et al., 2012). Based on several studies, students exposed to IPE developed a new appreciation and positive attitude towards other professionals, and learned skills pertaining to team oriented care (Curran et al., 2008; Ruebling et al., 2014; Sheldon et al., 2012). It was suggested that learning about other professions through IPE could influence how students feel and contribute to a healthcare team (Mellor et al., 2013). Therefore, it is important to contribute to a student’s knowledge of IPE to help them become collaboration ready practitioners (Ruebling et al., 2014).
Recent studies have suggested that students who lack interprofessional skills training in their university curriculum had to through trial and error in practice (Arenson et al., 2015; Fouche, Kenealy, Mace, & Shaw, 2014). In addition, studies often revealed many students were unsure of their own role when approaching an IPE experience (Arenson et al., 2015; Fouche et al., 2014). Although, Watters et al. (2015) argued through written reflections of an IPE experience students revealed an “awareness of and respect for the scope, practice, and rigor of other programs” (p. 5) and felt more prepared to face the realities of working in the health system. This is supported by another study, which noted that integrating IPE in a university’s curriculum enhanced personal and professional confidence, facilitated a reflective practice, and allowed continued education by providing role models for collaboration (Illingworth & Chelvanayagam, 2007).  
Overall, interprofessional education, even with identified core competencies, still struggles to become part of the mainstream educational core requirements. A host of implementation barriers and challenges has been cited throughout the literature, which include cost, incompatible curriculum, and inadequate faculty engagement (Sheldon et al., 2012). Additional challenges in successfully implementing an IPE program include the logistics of the program and educational setting (Sheldon et al., 2012). According to Cain and Chretien (2013), a lack of strategies may be an impairment when it comes to educating students from different health disciplines. Some impairments include poor grouping of interprofessional professions, time constraints, and lack of effort from facilitators, faculty, and students. Ultimately, if there is no structure for an IPE program, an unsuccessful IPE experience with little interprofessional collaboration is mostly likely the outcome (Cain & Chretien, 2013). Therefore, since IPE and interprofessional practice has yet to be fully recognized, it is important to continue research on this matter. Without continued research, IPE implementation into professional programs cannot be tested and developed, which can cause further delay in producing practitioners that can provide successful collaborative patient-centered care (D’Amour & Oandasan, 2005).
In this study, a qualitative focus group design was used to explore the perceptions of health sciences students regarding their experience in an introductory IPE course. This design was chosen because it allows for open communication and clarification as well as encourages researchers to explore, further develop insight into the specific issues, and to observe how participants interact and discuss the issue amongst themselves (Liamputtong, 2011). Additionally, since there is a lack qualitative research to measure the effectiveness of IPE the Institute of Medicine is currently pushing for more qualitative IPE data collection to use in measuring outcomes. (Institute of Medicine, 2015).  
The target population for this study consisted of approximately 700 students from the following disciplines: medicine, nursing, emergency medical services, occupational therapy, pharmacy, and physical therapy.  To be considered to participate in the study, the health sciences students must have been from one of the five specific health science disciplines, have at least one course on campus and had completed the IPE 400 Introduction to Collaborative Care course at Creighton University by December 1, 2015. Exclusion criteria for the study included students that did not complete a participant disclosure and confidentiality agreement, who were under the age of 19, did not agree to have their comments used for research purposes, and who had not completed the IPE 400 course by December 1. Lastly, participants were not considered if they were not health science students with at least one class on campus.
One researcher handled recruitment for the study. This researcher had access to a list of students who had completed the course. The researcher sent out three emails to the target population of students who met the inclusion criteria to invite them to participate in the study. To increase the number of participants, the first email was sent out three weeks in advance, and one every week after leading up to the focus group date. The email the students received provided them with an opportunity to volunteer to participate in a focus group, along with a participant disclosure, and a confidentiality agreement for the participants to review. The sample for this study consisted of five health sciences students, from a variety of disciplines, who voluntarily participated in one focus group. The final participants were from the disciplines of medicine (n = 3), occupational therapy (n = 1), and emergency medical services (n = 1). 
Data Collection
Eight self-developed focus group questions were used for data collection. The research mentor, also involved in the development and implementation of IPE 400 Introduction to Collaborative Care, helped the researchers create these questions. Questions were given in a consistent order to begin the focus group and to increase dependability of the study by preventing biased question order. Questions were asked from simple to more in-depth, as well as in a neutral form to prevent participants from being influenced to answer a certain way.  The focus group followed a semi-structured interview format. A Creighton employee with previous experience in focus group facilitation, CITI trained and IRB approved who was not a member of the primary research team, led and recorded the focus group using a digital tape recorder.  A professional transcriptionist, outside the research team and found online, transcribed the initial data.
By attending the focus group, students agreed to have their responses anonymously recorded. Each student signed a participant disclosure and confidentiality agreement at the focus group session upon check-in. The CITI trained and IRB approved focus group facilitator used provided pre-scripted, open-ended questions created by the research team to guide the discussion and to encourage conversation and participant involvement. The focus group facilitator utilized probes for further clarification from emerging conversations.
Data Analysis
Before data analysis, three researchers reviewed the transcribed data to ensure accuracy. After that, each researcher independently conducted a content analysis and then collaborated to confer findings (Portney & Watkins, 2015). Researchers began the process by independently reading the transcribed data repetitively to obtain an understanding of the overall perceptions of students, and to determine recurring ideas and themes and/or discrepancies from the focus group. Researchers then read the transcription word-by-word and highlighted words and phrases and created themes. Next, the three researchers collectively categorized repeated words, and created labels that became the initial coding scheme. Triangulation of the multiple reviewers occurred to ensure accuracy of themes (Shenton, 2004). Researchers then separated codes into categories based on content relativity. Lastly, researchers finalized categories and matched corresponding data to create finalized themes. These finalized themes represented overall students’ perceptions; student quotations were selected to exemplify these themes.
The research team was able to identify four common themes from the transcription of the focus group, which were benefits of the course, efficiency of the course, challenges of the course, and recommendations.
Benefits of the course
After completion of the IPE course, the participants reported many benefits of the course such as the importance of teamwork, having a greater understanding and appreciation towards other professionals’ roles and expertise, and how interprofessionalism can benefit the patient or client for best overall care. In regards to the importance of teamwork and related goals of a team:
“Working as part of a team is almost a comfort because you have people that you can    discuss your ideas.”
In addition, many of the participants reported a benefit of the course was learning about what other healthcare professions did and how they contributed differently to the team for continuity of care:
“I think the biggest thing I learned from specifically the IPE course, was just the knowledge of what specifically fit under different healthcare professions.”
Furthermore, participants were also able to gain insight on how IPE along with teamwork and communication can increase quality of care:
“Communication between the different physicians, specialists, and other people is huge because… the patient might get more like duplicate information and that’s always       frustrating for a patient and they think, ‘oh none of these people are communicating.’”  
Efficiency of the Course
Participants reported several different aspects of the course that worked well for them. Many participants agreed on the positives of the course being online, self-paced and modules required to be completed in an established order. As one individual noted, “I appreciated the fact that it was online.” while another added that, “I like doing it at my own pace.”
Both statements were mutually agreed upon by all participants shortly after. In regards to how the course was set up:
“I think it was important that they kind of made you do it in order because you couldn’t  get to the next step without finding a way to complete the previous one, which I thought that was kind of a smart thing to do in setting up this whole course online.”
Challenges of the Course
Even though several benefits came out of the course, several challenges presented themselves through the eyes of the participants. A few participants found challenges in the online experience with technical difficulties arising when navigating the online interface. As one participant stated, “I’m not very technically savvy and I got lost a lot.”  Another challenging aspect to the course is that it was not immediately applicable, and generic:
“I think it’s extremely superficial, you know, ‘this is what my team does, this is how we  can work together. Until you are thrown into the situation or until you see it done as well,      you are not really going to know how it works.”
As the participants in the focus group reflected on their experience, many had suggestions to make the IPE experience better such as timing of the class, meeting other students in the class face to face, and having the leaders in their schools discuss the importance of interprofessional education. Many of the participants stated that they would have enjoyed the class more if it had been given to them prior to school starting:
“I think maybe offering it before you even begin your graduate school would sort of        introduce you to it. This is something Creighton truly believes in and we want to instill it      now,’ so that when you do have that first clinical experience or that first outpatient or    whatever you already know that is something that is expected and something to look out   for.”
Another suggestion that was repeated by participants was to interact with other students in other professions:
“I feel like I don’t get any communication with other schools apart from the volunteer    stuff I do. I mean that’s a huge undertaking for a curriculum,”
Lastly, many of the participants wanted leaders or professors in their department to frame the interprofessional experience:
“During orientation or at some point to have all of the professional schools come together         and have one person from each graduate program, just give a paragraph of why they think     it’s important. I think it would be more meaningful.”
Studies have shown that interprofessional collaborative practice strengthens health systems, is cost efficient, and most importantly, improves outcomes for the patient as determined by the Triple Aim (Berwick, Nolan, & Whittington, 2008; Hoffman, Rosenfield, Gilbert, & Oandasan, 2008; Watters et al., 2015). In this study, students acknowledged how interprofessionalism can benefit the patient or client for best overall care, as well gain a greater understanding and appreciation towards other professionals’ roles and expertise. Suter et al. (2009) believed that understanding and valuing other professionals’ roles is a prerequisite for collaboration and teamwork to occur.  If professionals lack the understanding of roles, it can lead to tension, role blurring, and inability to strike a balance between interdependence and professional autonomy (Suter et al., 2009). With clear roles and communication, working on a team can increase the quality of patient care and outcomes (D’amour & Oandasan, 2005; Suter et al., 2009). When working in a healthcare profession, individuals rarely act alone; they are always working within teams or groups. Some components of successful teamwork include open communication, clear direction, known roles and tasks, acknowledgment and processing of conflict, and the ability to evaluate outcomes and adjust accordingly (O’Daniel & Rosenstein, 2008).  Students in this study acknowledged the roles of different health care professionals, and appreciated the emphasis on teamwork.
From the current study, students reported many positive aspects that worked well for them such as the course being online, self-paced and in module format. Self-paced online learning is an option for implementing IPE because it helps address geographic, time allotment and scheduling barriers frequently faced when coordinating activities across multiple health disciplines (Solomon et al., 2010). According to Casimiro, MacDonald, Thompson, and Stodel (2009), students from different healthcare programs are more than often taught in different locations and having a self-paced format of an online course can help encourage reflection and generate critical thinking.
However, there is little in literature to help determine the optimal length of time required for students to develop online relationships and to learn with, from, and about each other relating to IPE. The main challenges found from the current study were technological difficulties, the generic nature of the developed scenarios, and the lack of availability to apply newly acquired knowledge and skills. Cain and Chretien (2013) identified other possible challenges related to online learning, such as scenario development, technical proficiency of faculty and students, and technology services gaining or providing access to online content. Additionally, Cain and Chretien (2013) states that face-to-face interactions between students provides a much more collaborative and realistic approach to solve realistic problems.Students in this current study recommended having face-to-face interactions for a more meaningful experience.
According to Cain and Chretien (2013), the design of the IPE curriculum and the experience of the facilitator are key factors in determining the breadth and depth of learning. Students in this study suggested facilitators from different professions frame the interprofessional experience. Students said they would like to see their faculty and staff contribute to the lectures, and course content to represent each profession equally. Feedback collected from the students will be used to rearrange course content to allow for equal representations of roles, and will be used to influence when the course will be offered within each discipline’s curriculum.
In this course, the online learning environment will be most students’ first introduction to IPE. It can be assumed that specific disciplines will offer more face-to-face interaction experiences throughout their curriculum. Overall, the Core Competencies of Interprofessional Collaborative Practicesupports the use of educational technologies such as online learning to overcome barriers relating to time and space (IPEC, 2011).
This information of students’ perceptions will add to the discourse of IPE by contributing to the development of a conceptual framework for measuring the impact of IPE, strengthening the evidence for IPE, and ideally effectively link IPE with changes in collaborative practice (Institute of Medicine, 2015). This study has informed students of the benefits of IPE on patient outcomes, preparing them to work more effectively in a healthcare team.  Students reflected on the importance of collaborative practice, effective communication, and their preparedness for team-based care. This information will also help influence professional schools in meeting accreditation standards related to interprofessional practice.
There are various limitations identified in this study. Students’ knowledge base in interprofessionalism was not quantitatively assessed, limiting data collected to only reflect on students’ perceptions of the course. Data of this study were collected through focus groups, which may not be a good representation of a larger population due to small sample size. The focus group used in this study had five participants, vastly smaller than the 700 students enrolled in the course IPE 400 Intro to Collaborative Care. In addition, not all health disciplines were represented in our focus group. Nursing, pharmacy, and physical therapy students did not participate in the focus group. It is also possible for individuals in the focus group to be influenced by other participants, affecting their responses and behaviors. In this study, there was interest from distance students to participate, but this did not fit into the inclusion criteria for participants.  This likely contributed to the small sample size. Lastly, this study is specific to Creighton University; therefore, the results may not be generalized to students in other IPE programs. Although there are limitations to this study, the results are encouraging to those interested in using online learning for IPE. Student examples of sharing professional knowledge demonstrated successful interprofessional learning online.
As interprofessional education courses become part of the accreditation standards for healthcare education, it is important to reflect on student perceptions. Students’ perceptions are necessary to understand the knowledge that they gained taking the course, the structure and format of the course, and their recommendations to improve the course. This study will provide feedback for Creighton University about health science students’ perceptions pertaining to the introductory IPE course.   In addition, quantitative research in the area of IPE is already being collected as an effort to follow the International Institute of Medicine initiative to expand the IPE evidence base. Comparably, there are few studies of IPE that have been explored using a qualitative design to address the important contextual issues and broad consensus of IPE (Institute of Medicine, 2015).  Future research should focus on examining both qualitative and quantitative data to analyze students’ perceptions, and knowledge in the area of IPE. Future studies should attempt to gather data from a bigger and equal sample of different health professions.
For future health professionals, introduction to IPE while in school will allow students to become collaboration-ready practitioners (Ruebling et al., 2014). Experiencing IPE prior to beginning a career will allow students to have experience in teamwork as a part of an interprofessional team, and will allow for higher levels of confidence in their skills (Anderson & Thorpe, 2008; Pardue, 2015).
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