Interprofessional Education in Neurology Intensive Care Unit: Learning Activity for Students Completing Clerkships and Field Experiences

Abstract

Introduction

Teaching learners the benefits and challenges of interprofessional collaborative practice (IPCP) in acute care is best done in the context of authentic patient care rather than classroom settings. Yet differing clinical schedules of students and faculty as well as structured, controlled environments of intensive care units are not conducive to bringing multiple interprofessional learners to the bedside.

Methods

We developed a 2.5-hour interprofessional education (IPE) activity based around neurology intensive care unit patients that was implemented using team-based learning (TBL) methodologies, including individual/team readiness assessments (iRAT/tRAT) and application activities comprising interprofessional student-led care conferences in which authentic patients and their unique, deidentified clinical parameters were discussed. Students represented medicine, nursing, chaplain, physician assistant, social work, respiratory therapy, pharmacy, physical therapy, and law programs.

Results

Two hundred ninety-three students participated online during the first year. Mean tRAT scores were 14.9 points higher than iRAT scores (39.5 vs. 24.6 of 44 possible). There was strong agreement from students that the session met educational objectives (all >4.0 on a 5-point Likert scale). Individualized feedback was provided to learners using a rubric; 276 students shared personal reflections of knowledge learned through interactions with other health professional students/faculty.

Discussion

IPE activities that use authentic patient chart data as the basis for student application exercises are useful learning tools since students must teach and learn from each other, interpret data, and propose care plans based upon their collaborations. This enables students to experience acute care IPCP in a low-stakes environment.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Communicate as a member of an interprofessional team in the care of an acutely ill patient.
• 2.Use skills and knowledge of all team members to develop an interprofessional care plan for an acutely ill patient.
• 3.Integrate knowledge and experiences of health care team members to inform care discussions across the continuum from patient admission to postdischarge.

Introduction

Interprofessional education (IPE), when students from two or more professions learn with, from, and about each other for the purposes of improving patient outcomes, is believed to promote development of a collaborative, practice-ready workforce that is capable of improving patient outcomes.¹ IPE emphasizes the shared values and ethics that are held by all health care professionals, different roles and responsibilities that each profession brings, effective communication strategies, and teamwork.² As of the 2018–2019 academic year, 146 of 151 allopathic medical schools in the USA included IPE in their curricula.³ However, meaningful IPE activities can be difficult to execute on account of challenges with academic and curricular scheduling necessary to secure participation from faculty and students across a variety of professions and the need to maintain workflow in clinical environments.⁴

Due to challenges with implementing IPE, most reports in the literature focus on students participating in classroom-based discussions during their preclinical years of training.^5,6 Recently, a neurology-related IPE event described by Kung and colleagues involved medical and physical therapy students working together in a neurology clinic to improve communication skills.⁷ Our initiative builds on the concept of interprofessional learners interacting in the context of authentic patient care by exposing nine different types of professional learners to the realities of patient care in an ICU. Learners in our educational experience interpret actual chart information, teach each other, and make decisions about their professions’ next steps, while collaborating in a safe environment where mistakes are acceptable and teaching/learning from each other is expected.

At our academic medical center, a concerted effort was made to embed IPE within all required medical student clerkships. For the neurology clerkship, student-led care conferences were created for acutely ill patients hospitalized in the neurology intensive care unit. In addition to third-year medical students, other participating learners were in their final years of education (e.g., completing clerkships, field experiences). All medical students and nearly all nonmedical learners had participated in classroom and simulation-based IPE activities prior to this endeavor. However, prior to this activity, very few of them had experienced intentional IPE activities based around authentic patients who were currently receiving care. Prior to the pandemic, neurology student care conferences occurred in a conference room at the academic medical center. However, the COVID-19 pandemic created challenges for hospital-based educational experiences due to the necessity of social distancing. Thus, the neurology IPE case conferences swiftly converted to an online format with additional components such as team-based learning (TBL), readiness assessment tests (RATs), and peer feedback added to encourage learner engagement.

This IPE activity is based on the framework of social constructivism; that is, students were engaged in problem-solving based on preexisting knowledge that each individual brought to the activity, and interprofessional peer-to-peer teaching was essential. Students constructed their own meaning as new information was learned and applied it to the clinical context.⁸ We hypothesized that student-led care conferences would be an effective learning tool, even in a virtual environment. Herein, we describe the structure and processes of the events and provide a sample patient case (admission notes and chart notes) and facilitator guide. We have also included a rubric used for faculty and peer evaluations for completeness, but full qualitative analysis of the effectiveness and impact of the session, including data related to students’ learning and behavior changes, will be the focus of another manuscript.

Methods

The IPE activities took place in the context of a mandatory neurology clerkship for third-year medical students. We invited learners from nursing, pharmacy, physical therapy, occupational therapy, respiratory therapy, social work, and physician assistant programs, as well as chaplain residents to join. Law students heard about this experience, and one individual contacted us to participate. Per their course faculty, all health profession students had prior knowledge of managing acute care patients and/or patients with neurological findings prior to participation. The activity took place entirely online using Canvas as a learning management system and Zoom. Students were divided into small groups (about seven students per group; every group had medical and nursing students; students from the other professions were distributed across groups such that all groups had at least one of these other professional students and/or a faculty facilitator from a different profession) that met in Zoom breakout rooms.

Each month, 1 week before the scheduled session, a neurologist would review charts to identify a patient hospitalized in the neurology ICU, who was diagnosed with a medical condition that had widespread applicability and implications for interprofessional learning (stroke, Guillain-Barré syndrome, etc.). The neurologist would identify admission data, pertinent information related to the course of hospitalization, and prepare related talking points for facilitator guides.

Prior to the session, students received presession readings that included excerpts from Moon and colleagues pertaining to nursing diagnoses as well as patient safety, patient quality, and teamwork in ICUs.^9–11 Prereadings set the stage for individual/team RATs (iRAT/tRAT; Appendix A) that occurred at the beginning of the synchronous Zoom session. iRATs were submitted individually via the learning management system, Canvas. Immediately thereafter, students moved to breakout rooms and completed a tRAT as a group using Qualtrics that was configured to (a) respond to correct/incorrect responses using branching logic that depicted incorrectly answered questions repeatedly until correct answers were selected and (b) award points for correct answers in a descending manner based upon the number of tries submitted; this model mimicked the immediate feedback assessment (scratch-off) cards that are frequently associated with TBL exercises.

In addition to presession readings, students were expected to have downloaded and read the deidentified patient admission notes (Appendix B) from Canvas prior to the synchronous online session. These notes detailed a patient's admission record (complaint, past medical history, medications, vital signs, imaging, physical/neurological examination, etc.) to the neurology ICU. This document formed the foundation of the TBL application exercise. Students were also expected to select a team-specific role (different from their professional roles) and respond to an ice-breaker question posed in a team-specific Google document (Appendix C). The same Google document also served as a graphic organizer during the application exercise.

On the day of the IPE event, we allotted 30 minutes for completion of the iRAT/tRAT questions, followed by another 30 minutes for the initial discussion/review of the admission notes (Appendix C). Students then returned to the large Zoom group for a 15-minute report-out/debrief led by a clinician (nurse, physician, pharmacist), followed by a 15-minute break during which students received additional chart notes (Appendix D) in Canvas for them to read on their own. The instructions students received then were as follows: “You are just returning to the wards after having been off for a few days. The team will begin rounds soon and you only have a few minutes to review new information in the patient's chart to prepare for morning report. What information do you review? What new information did you learn that needs to be shared with the team? How does this align with the team's initial thoughts after the discussion of the admission notes” (Appendix B)? Notably, the chart notes document contains information relevant to all professions and encompasses too much information for any one individual to comprehend (mimicking actual patient care). After students familiarized themselves with the additional things that transpired with the patient over days following admission, students were placed back into breakout groups to discuss further questions posed in the Google document (Appendix C) for 30 additional minutes. Faculty, present in each breakout room, had facilitator guides (Appendix E) to ask probing questions or explain/emphasize clinical or interprofessional information related to the case. Finally, students returned to the large-group Zoom room debriefing and received an update on the patient's current status/disposition. In total, we allotted 2.5 hours for this activity. This event occurred almost monthly to capture all medical students completing required neurology clerkships (e.g., nine sessions per year).

Immediately following each session, students submitted an evaluation indicating the extent that educational objectives were accomplished, explained what they had learned, and identified a behavior they could change to improve collaborative care on the wards. Follow-up at the end of the students’ clerkships/field experiences captured information regarding whether students made that behavior change and the associated outcomes (improved quality of care/patient safety),¹² as we wished to know the extent that this activity had on transferring knowledge from classroom to wards and attaining higher levels on the Kirkpatrick's pyramid model of training evaluation.¹³ The learning and behavior change data is the focus of another manuscript.

Students received individualized feedback from their facilitators and two peers about their performance using a rubric based on interprofessional competencies that took into account the online nature of the activity (Appendix F). The Canvas learning management system included a table that listed student names/professions/colleges according to each TBL group number. Students were instructed to provide feedback via Canvas to the two students whose names immediately followed their own name in their TBL group list. The list was arranged such that two students from the same profession were never listed sequentially; this assured that each student received feedback from at least one profession other than their own. (If student names were at the bottom of the list, they provided feedback to the students whose names were at the top of the list.) Facilitators provided electronic feedback to each student in their group by completing individualized rubrics in Qualtrics. Following the event, a staff member collated all feedback (from faculty and peers) and distributed it to students and their program faculty.

The Penn State Health Milton S. Hershey Medical Center and Penn State College of Medicine Institutional Review Boards deemed further review of this project not necessary (No. 15528; July 1, 2020).

Results

In 2021, a total of 293 students representing medicine (n = 146), nursing (n = 114), chaplain (n = 7), physician assistant (n = 7), social work (n = 6), respiratory therapy (n = 5), pharmacy (n = 4), physical therapy (n = 3), and law (n = 1) professions participated in nine educational sessions that were held monthly between March and December. During any given month, between 25 and 46 learners attended and were split into smaller teams, with each team containing six or seven students. Readiness assessment scores were available for 282 of these students (11 students arrived late or had difficulty with technology, thus no readiness assessments were available for them; Table 1). The tRAT contained 11 questions that were worth 4 points each if answered correctly the first time; however, students lost points each time they chose an incorrect answer; thus, the number of potential points available on the tRAT was 44. To maintain a comparable scale, the iRAT column in Table 1 represents the mean number of questions individuals answered correctly (iRAT) multiplied by four. As expected, tRAT scores exceed iRAT scores by 13 to 22 points, depending upon the profession.

Table 1. Individual and Team Readiness Assessment Test Performance^a.

Learners (270 respondents, 92%) rated the activity highly (mean ratings from all professions exceeded 3.7 out of 5 on a Likert scale) when assessing the extent to which the educational objectives were accomplished (Table 2).

Table 2. Student Agreement Regarding Whether the Session Objectives Were Accomplished^a.

A total of 276 students (94%) shared examples of knowledge that they learned from the session. A full thematic analysis is the focus of another manuscript, but a few representative comments pertaining to what was learned from another profession are illustrated below:

• •“During this session I learned more about what nursing can do in an acute brain injury event and the information that they can give. Getting a practical experience with members of the other profession visualizes everything and gives some exposure before experiencing a similar scenario in real life. From all this, I have learned how to better work with the other professions.” (medical student)
• •“I learned the role of a chaplain is complex. I did not know that the chaplain is not only a spiritual leader but also a patient advocate.” (nursing student)
• •“Nursing colleagues complete a very thorough neuro assessment as often as once per hour for NCCU [neurology critical care unit] patients. I learned about the different options for rehab following stroke including acute, subacute, home-based.” (medical student)
• •“I learned from the medical students about how to read or interpret results of different tests and procedures. I learned from respiratory therapists more about what their role looks like in an acute setting. I also learned a lot about chaplains and their purpose in helping patients and their families talk through their diagnoses, no matter their religion. I would not have thought about these things if I was only working with people from my own profession.” (nursing student)

Discussion

In this study we present a novel interprofessional curriculum to advance collaborative practice in acute care settings. Our objective was to demonstrate feasibility and acceptability for learners participating in this initiative delivered via online TBL methodologies. The effectiveness and impact of the curriculum will be assessed in future manuscripts. Herein, we have described a mechanism for engaging students in student-led care conferences where they learn with, from, and about each other in the context of how each profession provides care to acutely ill patients hospitalized with neurological concerns.¹² The value of this activity is that it is authentic; it uses real (deidentified) chart notes, with abbreviations, multisyllabic words, medical jargon, and even poor grammar/punctuation, mimicking real life.¹² Students must be able to collaborate with others, interpret data, and develop a plan, while simultaneously being humble enough to recognize their own limitations, look up information when necessary, and ask questions. No one person (neither students nor the faculty facilitators) knows all the information/answers. In this activity, it is imperative that learners rely on other professions. In health care, we encounter complex patients with multiple comorbidities and unclear differential diagnoses. Thus, this educational activity mimics reality. Given the complex content covered by this activity, it is only appropriate for more advanced learners who are doing clerkships/field experiences in acute care settings. By using authentic chart data, students learned where to look in a patient's chart for specific items (e.g., speech language pathology notes for swallow tests), and they learned the importance of checking interdisciplinary narrative updates (the medical students were unaware of this section of the chart since physicians do not contribute to it) from various health care personnel.

Prior to COVID, we met in a conference room outside the neurology ICU for student-led care conferences. After the onset of COVID, we needed to pivot to online learning modalities. Despite the online nature of this activity, students indicated strong agreement with questions that queried whether the activity had met stated educational objectives. We believe that the addition of the iRAT/tRAT, Google Docs, and rubrics completed by peers helped learners focus and stay engaged in the online learning environment. As anticipated with TBL pedagogies, team scores far exceeded individual performance. The addition of the iRAT/tRAT component was an ideal opportunity to set the stage for the application exercise—by reinforcing the notion that we all perform better in a team than we do as individuals. This reality is true not only in TBL, but also in health care. The rubric that we used is unique and modified from an example described by Cottrell and colleagues.¹⁴ Most students demonstrate appropriate interprofessional behaviors, but some outliers tend to display too much or too little of a behavior (e.g., too shy/quiet or too domineering of the group). Thus, we created a rubric that we affectionately termed the Goldilocks rubric, where appropriate behaviors were represented in the middle (indicative of being “just right”). Since this type of rubric was new to students and faculty, we needed to orient all participants to the scale.

We have found it beneficial to change the case monthly so that the patient under discussion is someone that is currently admitted to the hospital. This means that typically, one or more of the students participating in the student-led care conferences have been involved in that patient's care. This connection seems to increase the clinical relevance of the case for the learners (e.g., this is real rather than just a paper case) when individual learners can share their personal experiences and knowledge related to care of the patient. Since these student-led care conferences have occurred approximately nine times per year since 2016, we have amassed quite a library of cases and corresponding facilitator guides. The Appendices B, D, and E contained herein are examples from one specific session. While we believe there are benefits in having a clinician identify a new patient each month for events such as this, it is time-consuming to update the materials, and thus it would not be sustainable without an individual who has dedicated time/effort for IPE.

This initiative was implemented at a college of medicine that is not part of an academic health science center. As a result, the number of medical student participants exceeded the number of other professional students at each event. The teams we created were as balanced as possible with medical students (and/or faculty facilitators) distributed across teams. The nonmedical students were recruited from other colleges/universities whose program directors assigned them to participate; we used the imbalance as a learning opportunity to explicitly encourage nonmedical students to ego-up by explaining to them that in actual patient care there will likely be only one chaplain or one social worker or one clinical pharmacist assigned to a patient, but the patient may have multiple physicians (intern, resident, attending, specialty consultants, hospitalist, etc.). Since there was variability in the number and type of nonmedical students available to participate each month, one limitation we encountered was the inability to ensure that all students teams had uniform compositions. The predominance of medical students may affect the generalizability of these results; other outcomes might result if interprofessional team members were able to be more equally distributed across small groups.

Another limitation may involve the format in which the RAT questions were written. The NBME has stringent guidelines regarding the type and structure of multiple-choice questions that are used for licensure examinations; however, other disciplines such as nursing and pharmacy use a variety of question types, including question structures that are disallowed by the NBME. Since the RAT questions were crafted by interprofessional faculty, NMBE best practices were not followed. This may have impacted student performance on the RATs.

We occasionally encountered challenges with the accuracy of the numeric ratings selected on peer evaluations since the numeric indicator of highest student performance was in the middle of the rubric rather than on an end. On occasion, a peer evaluator would give high numeric marks (indicative of too much of a competency) to a colleague, while at the same time providing positive written feedback that was not in alignment with the numeric rating. When this occurred, we would cross-check the ratings with facilitators and the other peer evaluator (and reach out to facilitators if necessary) to be sure that we addressed any IPE competency concerns if warranted. However, in each case, it was determined that the student evaluator had simply not read/listened to the rubric instructions. If we had not caught these situations in which the rubric was misapplied, a student could have received inappropriate feedback suggesting that they were domineering, selfish, or behaving in an obstructionist manner.

Finally, we were fortunate to have a neurologist with protected time dedicated to IPE efforts to identify new patients and prepare materials each month, but we recognize that this may be challenging for other medical schools.

An unexpected benefit of pivoting the student-led care conferences to an online format on account of COVID was that it became possible to invite learners from outside our local geographic area. This had not been possible when events were held in person. Thus, we were able to establish new, collaborative relationships with more students across a broader range of universities. As a result, the sessions were continued online even postpandemic, enabling continued IPE collaborations with multiple schools and a variety of interprofessional students.

In the future, it will be of interest to perform statistical analysis (e.g., discrimination index, point biserial) on the RAT questions to determine if correlations exist between student performance and question formats/types that are inconsistent with NBME best practices and rewrite the questions if that is determined to be the case. It may be of interest to determine if this type of methodology (using authentic, deidentified patient chart data) has applicability to other clerkships (e.g., internal medicine inpatient services) with other interprofessional learners. Additionally, it may be of interest to collaborate with an IPE program at a large academic health science center where there are larger numbers of nonmedical students available to participate each month to create more balanced teams.