Learning by doing: observing an interprofessional process as an interprofessional team

Abstract

New competencies exist for interprofessional education, which are centered on the goal of improving quality of care and patient safety through improved interprofessional collaboration. Interprofessional education and effective interprofessional collaboration are cornerstones of the Veterans Affairs Quality Scholars fellowship program. The purpose of this project was to evaluate an innovative interprofessional education strategy in which teams of physicians and nurses were “learning by doing” as they observed and analyzed the functioning of an interprofessional process, specifically, inpatient discharge. Fellows completed voluntary, anonymous surveys seeking their perspectives about the project. Fellows’ feedback revealed several themes, with both positive and negative characteristics related to team functioning, interprofessional understanding, microsystem knowledge, pooled knowledge and assignment challenges. The strength of this strategy is exemplified by the fact that fellows not only learned from each other’s separate professional observations, but also observed the emergence of a shared interprofessional perspective through working together.

Introduction

Interprofessionalism is the development of a cohesive, integrated practice between different professionals and is considered vital to the delivery of high quality, safe patient care (e.g. D’Amour & Oandasan, 2005). Interprofessional education (IPE) is one way to foster effective interprofessional collaboration (e.g. IPEC Expert Panel, 2011). However, strategies to teach and evaluate interprofessional collaboration are less developed. In this paper we describe the evaluation of an IPE strategy consisting of team-based observation and analysis of an inpatient discharge process. The project was completed by Veterans Affairs Quality Scholars (VAQS) fellows (www.vaqs.org) in a two-year multisite inter-professional program (Estrada et al., 2012; Patrician et al., 2012).

During July 2010, teams of VAQS nurse and physician fellows used a semi-structured guide to: familiarize themselves with inpatient hospital units at five VA Medical Centers in the US; understand the discharge process; obtain perspectives from stakeholders about interprofessional communication; and identify aspects of the process that went well and those that needed improvement. Project goals included gaining a better understanding of the inpatient microsystem and discharge process and, more importantly, working together as an interprofessional team and observing and inquiring about issues of communication, information flow, and interprofessional communication in the microsystem. Together, fellows interviewed stakeholders, observed interprofessional team meetings and patient discharges, and flow-charted the discharge process, paying particular attention to interprofessionalism and communication. Thus, fellows “learned by doing” as they worked in teams to meet the project goals. This experience was enhanced by having time for the teams to reflect on interprofessional issues and obtain feedback during a poster presentation at the VAQS annual meeting.

Methods

Fellows voluntarily completed a survey of eight open-ended questions eliciting information about their experiences with the project. The goal was educational, to improve the project for the next cohort of fellows. Thus, institutional review board approval was not required. We de-identified the data to preserve fellows’ anonymity. Two authors reviewed the responses independently, proposed themes based on participant responses, and discussed the individually-determined themes to build consensus.

Results

Three nurses and four physicians responded to the survey. Based on these data, a number of themes emerged with both positive and negative dimensions. These themes mapped to one or more IPEC competencies (IPEC Expert Panel, 2011).

Team functioning

One theme, team functioning, was reflected in the following statements. Fellows reported that the educational experience was a “good way to get to know each other” (nurse 3) and that they gained a lot of respect for the other profession. Others reported that they would have appreciated, “sit[ting] down at the beginning of the process and stat[ing] our strengths/weaknesses” (physician 1). This theme maps to the IPEC competencies, “forge interdependent relationships with other professions …” (RR7), “engage in continuous … development to enhance team performance” (RR8), and “recognize how one’s own uniqueness … contributes to interprofessional working relationships” (CC7).

Increased understanding of other professions

Some participants reported that the project increased their understanding of other professions, while other participants noted confusion about the education and structure of the other’s profession. This theme of interprofessional understanding corresponds to the competencies “communicate one’s roles and responsibilities …” (RR1), “explain the roles and responsibilities of other care providers …” (RR4), “listen actively and encourage opinions of other team members” (CC4), and “use respectful language …” (CC6). Comments included: “it was a great opportunity to really become educated about the other side … I have much more respect for nursing now … and what it really entailed [research, teaching]” (physician 2); “We each had good interpersonal communication, were respectful, open, flexible, and considerate of one another … I was also intrigued to learn about the social hierarchy in medicine” (nurse 1).

Pooled knowledge

Some fellows reported that being new to their VA site was challenging and that the project increased awareness of the microsystem in which they were working. Knowledge of microsystem functioning relates to the competency “reflect on individual and team performance for … improvement” (TT8). Fellows reported an appreciation of collective learning while also expressing challenges working in a diverse group without clear expectations. The theme of pooled knowledge corresponds to the IPEC competencies “use unique … abilities of team members…” (RR9) and “integrate the knowledge and experience of other professions…” (TT4). Fellows’ ability to pool their knowledge helped them meet the project goals. For example, physician 3 commented that for their team “nursing colleagues understand process mapping, [physician] colleague understands clinical process.” Nurse 2 reported that their group had experience in a variety of clinical specialties in inpatient and outpatient settings and stated, “this range of experience allowed us the potential to assess the microsystem from multiple vantage points.”

Suggestions for enhancement

In addition to providing feedback on their experiences, the fellows offered suggestions to improve this IPE experience.

Plan during the initial phase of project

Fellows highlighted the importance of spending time at the beginning of the project discussing their educational backgrounds, work experience and personal strengths/weaknesses, and introducing differences/sensitivities to promote “cultural competence” (nurse 3) for interprofessionalism. This step is key because fellows stated that there is often confusion about the different professions’ education, roles and responsibilities. Physician 4 stated “I also feel that any preconceived notions need to be checked at the door so that we all start from the bottom to build a foundation based upon current interactions and not entirely on generalizations that we have developed from prior experiences.”

Be mindful throughout the project

Fellows highlighted the importance of discussing assumptions and explicitly planning for on-going reflection time. They encouraged team members to point out when an inappropriate term had been used or assumption made about the other professional group. Using effective meeting skills was another important aspect of being mindful throughout the project.

Embrace multiple perspectives

Fellows stated that promoting interprofessional pairings for observing the discharge process helped to identify and understand biases in observations. They challenged each other to think from a different profession’s perspective and found that, as nurse 2 observed, there is a “tendency of each profession to overvalue their area of practice.” They encouraged equal representation from both professions, but also encouraged the development of a shared interprofessional perspective that is patient-specific or goal-focused.

Teach interprofessional collaboration

Fellows stated that faculty mentors must model interprofessional collaboration. They recommended using activities and projects, such as this one, in nursing and medical schools.

Discussion

IPE often involves learners who are not already working together in a clinical setting, in our case, professionals in a fellowship program. As examples, experiential learning in IPE can be accomplished with simulation (Gough, Hellaby, Jones, & MacKinnon, 2012) or problem-based learning strategies in small groups (Albanese, 2010). In our IPE strategy, fellows learned and reflected interprofessionally in small groups to devise solutions to a clinical problem.

We used fellows’ experiences to modify the project for the following year. For example, project instructions encouraged fellows to start by discussing their backgrounds, strengths and weaknesses. We provided more guidance about the expectations of the project, along with a summary of nursing and medical educational requirements.

We encourage trialing our “learning by doing” education strategy, in which healthcare professionals actively complete a project with a specific and shared goal. This strategy enforces the importance of teamwork and is an alternative to more passive teaching strategies. Implementation may be challenging in traditional educational settings because the infrastructure of regular interaction between the professions does not yet exist. In the clinical setting, regular interaction occurs, but limited time is spent understanding other professions’ backgrounds and roles or on team building. There may be opportunities to think creatively about integrating this type of education strategy into resident and nursing orientation and/or continuing education programs.

Learning by doing allowed fellows to learn from each other’s separate professional observations, to reflect, and to develop a shared perspective. Fellows identified areas in which the other discipline highlighted microsystem issues that may not have been apparent while working in professional silos. The project was the first of its kind for the VAQS fellowship and is an activity VAQS faculty continue to use, evaluate and improve.