Development and Assessment of an Interprofessional Education Simulation to Promote Collaborative Learning and Practice

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Interprofessional collaborative learning is currently an expected outcome of health science programs, as demonstrated by accreditation requirements (Zorek & Raehl, 2013). Academic programs are expected to develop and implement interprofessional education (IPE) learning experiences for students as part of their core curriculums. The Institute of Medicine (IOM, 2015) recently published a report Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes: A Consensus Study. The IOM report identifies the need for rigorous and relevant assessment of interprofessional education and practice. In addition to designing and implementing IPE experiences, academic institutions must also develop assessments that demonstrate that the desired outcomes are being realized.

To meet these curricular goals, we designed a clinical simulation focusing on patient safety, including communication, medication management, and transfer of care (Monaghan et al., 2015). The simulation involved Doctor of Nursing practice (DNP) students from family, adult acute, adult, and pediatric acute care specialties, and Doctor of Pharmacy (PharmD) students. All DNP students who were registered for the advanced practicum course were required to participate and were formatively evaluated; PharmD students participated voluntarily.

The simulated experience took place in the nursing skills and simulation laboratory. The total time allotted for a single simulation was 1 hour. Students were given 25 minutes to complete the scenario in both the outpatient and inpatient setting and an additional 5 minutes for the transfer of care telephone call between providers. The remaining 5 minutes allowed for immediate feedback to the acute care students. Each simulation involved two DNP students and one PharmD student.

Simulated patients presented to the primary care setting potentially requiring transfer to an acute care facility or assistance with medication management using pharmacy consultation. The primary care DNP student evaluated the patient’s condition, collaborated with the outpatient PharmD student, and made recommendations for either discharge home or transfer to an acute care facility. An example of collaboration between the DNP and PharmD student included verifying medication lists, identification of medication interactions, and discussion of cost issues.

The primary care DNP student had to determine mode of transportation and level of acuity of the patient. A telephone was used to contact the inpatient DNP student (adult or pediatric DNP student depending on the scenario). The primary care student provided report in Situation, Background, Assessment, and Recommendation (SBAR) format to the acute care student. The acute care student then had to ask appropriate questions regarding the patient to be ultimately prepared for the admission. While waiting for the patient to arrive, the acute care student collaborated with the inpatient pharmacy student to discuss differentials, diagnostics, and management options. PharmD students calculated emergency medications for the simulated pediatric scenarios. An example of collaboration between the students was discussion regarding pharmacokinetics and potential pharmacologic causes for the patient’s deterioration in a patient with lactic acidosis.

Method

The conceptual framework for the assessment was based on the Interprofessional Education Collaborative (IPEC) core competencies:

  • Values and ethics for interprofessional practice.
  • Roles and responsibilities.
  • Interprofessional communication.
  • Teams and teamwork (IPEC Expert Panel, 2011).

We used a mixed-methods design integrating quantitative and qualitative methods based on data and methodologic triangulation techniques consistent with the recent IOM recommendations for measuring the effect of IPE (Tashakkori & Teddlie, 1998)—specifically, how well the simulation affected student perceptions of the IPEC competencies. The study was reviewed by the institutional review board and was determined to be exempt.

Quantitative Assessment

More than 120 instruments have been identified to assess IPE activities (Kenaszchuk, 2012). The more commonly cited instruments include the Team Skills scale (Hepburn, Tsukuda, & Fasser, 1996), the Readiness for Interprofessional Learning scale (Parsell & Bligh, 1999), the Attitudes Toward Health Care Teams scale (Heinemann, Schmitt, Farrell, & Brallier, 1999), the Interdisciplinary Education Perceptions scale (Luecht, Madsen, Taugher, & Petterson, 1990), and the Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R; Fike et al., 2013). The SPICE-R has been used to assess student perceptions of appropriateness and benefits of interprofessional clinical education. It is a validated 10-question instrument, with each question worth 5 points (1 = strongly disagree to 5 = strongly agree), for a maximum score of 50. For the quantitative assessment portion of this study, postsimulation student perceptions were measured using the SPICE-R instrument. We chose to use the newer SPICE-R because it was recently shown to be superior to the Attitudes Toward Health Care Teams scale-revised instrument (Dominguez, Fike, MacLaughlin, & Zorek, 2015). Statistical analysis included descriptive statistics.

Qualitative Assessment

In addition to quantitative assessment, the IOM report called on academic institutions to include qualitative assessment as a core part of IPE endeavors (IOM, 2015). To meet this need, in addition to the SPICE-R, reflection questions were used to assess student learning. These questions were developed with the intent to capture student perceptions of IPE. The reflective questions assessed the simulation’s effectiveness in requiring team knowledge and experience from each profession, whether the experience improved individual clinical performance, and how this team approach effected patient outcomes.

After the simulation, students were sent an e-mail requesting voluntary completion of the survey. A reminder e-mail was sent 1 week later. The survey consisted of the SPICE-R instrument and qualitative reflection questions about the interprofessional event. The questions were as follows:

  • Did your team integrate the knowledge and experience of other professions to inform care decisions? If so, how?
  • After the interprofessional experience, did you reflect on your performance as an individual, as well as a team, for performance improvement? What did you discern?
  • How do you think the patient outcomes were impacted by your interprofessional collaboration?

These written reflections were collated and analyzed using a modified method delineated by Morse (1994). Responses were initially coded using broad groupings. These broad groupings were then more precisely defined in content to move from open coding to axial coding (Strauss & Corbin, 1990). Axial coding groups data at a subcategory level, refining data reduction during the comprehending stage. The last stage involved synthesizing the grouped responses into themes.

Results

Forty-six students participated and 39 (23 PharmD, 16 Nurse Practitioner) completed the survey, for an 84.8% response rate. The Table demonstrates the results from the SPICE-R instrument. Responses were generally in agreement with the following SPICE-R items: students believed that working with students from another health profession was educationally beneficial to them and should be a requisite educational component, and they thought this collaboration improved health outcomes and patient satisfaction. SPICE-R items that generated disagreement were those that assessed the individual’s role within interprofessional care; understanding of other’s role in interprofessional care; and clinical rotations being the ideal place for interactions with others.

Student Responses to the SPICE-R Instrument Following a Live, Simulated Interprofessional Clinical Patient Management Case (N = 39)

Table:

Student Responses to the SPICE-R Instrument Following a Live, Simulated Interprofessional Clinical Patient Management Case (N = 39)

Qualitative responses indicated that going into the simulation, many were ambiguous about their role but emerged knowing how their individual education and their interaction improved patient outcomes. Four dominant themes emerged from the written responses:

  • Teamwork and discipline-specific contribution.
  • Recognition of one’s own role and respect for other’s role.
  • Enlightenment through experience.
  • Optimization through collaboration.

Teamwork, Discipline-Specific Contribution, Role Recognition, and Respect

Although students expressed some awkwardness in working as a team, most stated that they could use their discipline-specific expertise to aid in the care of the patient, as well as learn and respect the other team member’s knowledge and contributions. This was demonstrated through these example student comments:

  • Our team was able to share the diagnostic information to resolve the clinic scenario. During the hospital scenario, the pharmacy student was able to share treatment guidelines that aided in drug selection.
  • I think we could have made better use of our pharmacy cohorts; we were a little unsure of how to interact in this first experience with an interdisciplinary simulation.
  • I thought this was a pilot type simulation, which I enjoyed very much. I thought both the nurse practitioner and pharmacy students were learning as we progressed through the simulation. At the end, we all had a clearer idea of our roles.
  • As the pharmacy student, I relied on the nursing students to get a detailed history from the patient. As the pharmacy student, it was my responsibility to assess if any of his problems were drug induced.
  • My partner asked if any of the medications could be causing the patient’s symptoms.
  • The nurse practitioner student utilized my knowledge of drug therapies to make an informed decision to admit the patient.
  • We consulted each other about signs and symptoms as well as the guidelines for treatment.

Experiential Enlightenment

Student comments demonstrated the importance that the experience had in recognizing their role in collaborative care:

  • I realized that I could have played my role as a pharmacist better. That is, not only answering the question that was asked of me but also to interpret how they were going to use that information to improve patient care.
  • I was actually worried I overstepped my bounds a little bit, but the nurse practitioner student seemed very grateful for my help and I really enjoyed working with her.

Care Optimization Through Collaboration

Student comments demonstrated their belief that patient care was improved through collaborative practice:

  • I was very thankful that I had a pharmacy student there to help me decide how to treat. It was much easier to focus on other important aspects while pharmacy decided the best drug treatment options.
  • It was beneficial to hear other disciplines perspectives.
  • I think it helps prevent information slipping through the cracks, different health care professionals use different information to reach their conclusions, so putting both strategies together is better.
  • I think patient outcomes are better in interprofessional collaboration. Reaching out to other healthcare professionals can really strengthen a decision or recommendation.
  • I think patients can be treated much more comprehensively with several professions involved.
  • I think that interprofessional collaboration is better for the patient. By discussing the patient with others, we’re more definitively able to make diagnoses and treatment plans.
  • I think the patient outcomes were improved do to double check by the pharmacist of medication doses and regimens. More minds were able to share their knowledge.
  • I think working on interprofessional teams allows for optimal outcomes for patients.

Discussion

This designed experience presented real-life, complex, clinical situations that occur in actual practice. Students were able to practice the technical skills, clinical decision making, and professional teamwork necessary for optimal patient outcomes through the use of standardized patients for competency assessment like previous reports (Jeffries, 2007; Nehring & Lashley, 2010). The use of standardized patients and simulation in interprofessional education activities can improve the understanding of each profession’s role and the importance of communication and team-work (IPEC Expert Panel, 2011). However, despite the required standards to include IPE in both nursing and pharmacy curricula, the use has been limited (Accreditation Council for Pharmacy Education, 2011; Commission on Collegiate Nursing Education, 2013). This innovated IPE activity demonstrated positive outcomes that are reflected in both the quantitative and qualitative data. These results suggest the importance and applicability of educating health professionals in an IPE environment. Both groups overall described the constructive effect of this interaction in the debriefing but stressed how helpful this activity would have been had it been introduced earlier in each discipline’s curriculum. We noted that student responses were consistent with the IPEC core competencies. These core competencies were generated to ensure consistency in the outcomes of IPE experiences created by health science programs. Our data, particularly the qualitative analysis, demonstrated how students can address the core competencies as they prepare to become health care professionals.

In this report, we share our experience with addressing IPE accreditation requirements through the development of a clinical simulation. These data demonstrate a multitude of benefits to students through this simulation to promote collaborative learning and teach collaborative practice skills. We offer our experience to delineate where improvements can be made in all our curricula. Our data indicate that more effort to educate students regarding what roles all health professions should have in interprofessional collaborative care is needed. Further, IPE experiences early in the curriculum, prior to clinical experiences, should be considered and implemented.

References

  • Accreditation Council for Pharmacy Education. (2011). Accreditation standards and guidelines for the professional program in pharmacy leading to the Doctor of Pharmacy degree. Guidelines version 2.0. Retrieved from https://www.acpe-accredit.org/pdf/S2007Guidelines2.0_ChangesIdentifiedInRed.pdf
  • Commission on Collegiate Nursing Education. (2013). Standards of accreditation of baccalaureate and graduate nursing programs. Retrieved from http://www.aacnnursing.org/Portals/42/CCNE/PDF/Standards-Amended-2013.pdf
  • Dominguez, D.G., Fike, D.S., MacLaughlin, E.J. & Zorek, J.A. (2015). A comparison of the validity of two instruments assessing health professional student perceptions of interprofessional education and practice. Journal of Interprofessional Care, 29, 144–149. doi:10.3109/13561820.2014.947360 [CrossRef]
  • Fike, D.S., Zorek, J.A., MacLaughlin, A.A., Samiuddin, M., Young, R.B. & MacLaughlin, E.J. (2013). Development and validation of the student perceptions of physician-pharmacist interprofessional clinical education (SPICE) instrument. American Journal of Pharmaceutical Education, 77, 190. doi:10.5688/ajpe779190 [CrossRef]
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  • Institute of Medicine. (2015). Measuring the impact of interprofessional education on collaborative practice and patient outcomes. Washington, DC: National Academies Press.
  • Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Retrieved from https://nebula.wsimg.com/3ee8a4b5b5f7ab794c742b14601d5f23?AccessKeyId=DC06780E69ED19E2B3A5&disposition=0&alloworigin=1
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  • Monaghan, M.S., Malesker, M., Haddad, R.A., Packard, K., Elsasser, G., Iverson, L.M. & Connelly, S.C.(2015). Development and assessment of an interprofessional education simulation for pharmacy and nurse practitioner students. 2015 AACP Annual Meeting, Washington, DC. American Journal of Pharmaceutical Education, 79(5), 46.
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Student Responses to the SPICE-R Instrument Following a Live, Simulated Interprofessional Clinical Patient Management Case (N = 39)

Item Frequency (%)

Disagree Neutral Agree Strongly Agree
Working with students from another health profession enhances my education. 0 (0) 0 (0) 13 (33.3) 26 (66.7)
My role within an interprofessional health care team is clearly defined. 2 (5.1) 5 (12.8) 24 (61.5) 8 (20.5)
Health outcomes are improved when patients are treated by a team that consists of individuals from two or more health professions. 0 (0) 0 (0) 6 (15.4) 33 (84.6)
Patient satisfaction is improved when patients are treated by a team that consists of individuals from two or more health professions. 0 (0) 2 (5.1) 11 (28.2) 26 (66.7)
Participating in educational experiences with students from another health profession enhances my future ability to work on an interprofessional team. 0 (0) 0 (0) 13 (33.3) 26 (66.7)
All health professional students should be educated to establish collaborative relationships with members of other health professions. 0 (0) 1 (2.6) 6 (15.4) 32 (82.1)
I understand the roles of other health professionals within an interprofessional team. 3 (7.7) 5 (12.8) 21 (53.8) 10 (25.6)
Clinical rotations are the ideal place within their respective curricula for health professional students to interact. 2 (5.1) 3 (7.7) 19 (48.7) 15 (38.5)
Health professionals should collaborate on interprofessional teams. 0 (0) 0 (0) 10 (25.6) 29 (74.4)
During their education, health professional students should be involved in teamwork with students from other health professions in order to understand their respective roles. 0 (0) 0 (0) 13 (33.3) 26 (66.7)

Source

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