Effectiveness of interprofessional education in renal physiology curricula for health sciences graduate students

Abstract

The primary purpose of conducting an interprofessional education (IPE) experience during the renal physiology block of a graduate-level course was to provide basic science, physical therapy, and physician assistant graduate students with an opportunity to work as a team in the diagnosis, treatment, and collaborative care of a patient with acute kidney injury. The secondary purpose was to enhance the understanding of basic renal physiology principles with a patient case presentation of renal pathophysiology. The overall purpose was to assess the value of IPE integration within a basic science course by examining student perceptions and program evaluation. Graduate-level students operated in interprofessional teams while working through an acute kidney injury patient case. The following Interprofessional Education Collaborative subcompetencies were targeted: Roles/Responsibilities (RR) Behavioral Expectations (RR1, RR4) and Interprofessional Communication (CC) Behavioral Expectations (CC4). Clinical and IPE stimulus questions were discussed both within and between teams with assistance provided by faculty facilitators. Students were given a pre- and postsurvey to determine their knowledge of IPE. There were statistically significant increases from pre- to postsurvey scores for all six IPE questions for all students. Physical therapy and physician assistant students had a statistically significant increase in pre- to postsurvey scores, indicating a more favorable perception of their interprofessional competence for RR1, RR4, and CC4. No changes were noted in pre- to postsurvey scores for basic science graduate students. Incorporating planned IPE experiences into multidisciplinary health science courses represents an appropriate venue to have students learn and apply interprofessional competencies.

INTRODUCTION

Healthcare education faculty and programs are continuously implementing new methods to improve student learning outcomes. In addition to improving student learning outcomes, the United States (U.S.) healthcare industry is seeking the assistance of academic institutions to promote student behavioral change that can support improvement in healthcare outcomes. Specifically, training students in team-based behaviors or interprofessional collaborative practice skills is a developing evidence-based practice in health education.

In 2003, an Institute of Medicine report, Health Professions Education: A Bridge to Quality (6), indicated the current U.S. health education system was not adequately preparing students or health professionals to meet the demands of the diverse population being served. For example, students are trained in silos, even though teams of various health professionals are needed to support those who are diagnosed with chronic diseases (6).

In response to numerous national and international health education and healthcare delivery reports, many health educational accreditation organizations have required the integration of interprofessional education (IPE) in accreditation standards. IPE is defined as “when students from two or more professions learn about, from and with each other” (15). IPE experiences differ within institutions and among institutions. However, paper case-based studies, standardized patients, high-fidelity simulation, community engagement, and clinical rotations are commonly utilized to incorporate IPE.

A recommendation from the Health Professions Education: A Bridge to Quality report was to develop a common core set of team-based competencies. In 2011, the Interprofessional Education Collaborative (IPEC) identified 4 competencies and 38 subcompetencies in the domains of Values/Ethics, Roles/Responsibilities (RR), Interprofessional Communication (CC), and Teams and Teamwork (7). In July 2016, IPEC updated the competencies to be more inclusive of population health and added one new subcompetency in the RR domain (8). Louisiana State University Health -New Orleans (LSUH-NO) uses the 39 subcompetencies to guide student IPE learning.

In 2015, LSUH-NO established a centralized office, the Center for Interprofessional Education and Collaborative Practice (CIPECP), to support faculty training and student learning in IPE. A goal of the CIPECP was to increase interprofessional learning for all students enrolled in all six schools (Allied Health Professions, Dentistry, Graduate Studies, Medicine, Nursing, and Public Health) by assisting faculty in the development and implementation of meaningful IPE experiences. A centralized IPE office supporting faculty is a foundational component of IPE success (9).

During the 2016 summer semester, a faculty member in the physiology department approached the CIPECP with interest in creating an IPE experience within the renal block of a graduate-level physiology course scheduled during the 2017 spring semester. The physiology course included basic science graduate students enrolled in the School of Graduate Studies, and physical therapy and physician assistant students from the School of Allied Health Professions. The physiology faculty member collaborated with a nephrologist, physical therapist, and the CIPECP director to create an acute kidney injury patient case, facilitator’s notes, stimulus questions, and surveys for a 2-h session, which included clinical and IPE applications.

A common barrier in implementing IPE experiences is the difficulty in finding common time for scheduling students from various professions to interact. Multidisciplinary basic science courses, such as physiology, are prime opportunities to engage students in interprofessional learning early in their academic careers (12) and should be seen as enablers for developing IPE experiences. Specific to this experience, which focused on the renal system, students were able to work together to answer case-based application questions, as renal physiology, in particular, is difficult for students to comprehend (2). An acute kidney injury patient case was developed as a pilot project to reinforce basic renal physiology principles and offer the students an IPE experience. In 2016, the LSUH-NO Physiology department implemented its first IPE experience embedded within the endocrine block of the same physiology course. Edwards et al. (3) reported positive changes in student perceptions of their IPE competency after a case-based endocrine physiology IPE session.

The purpose of the learning activity was twofold. The students were asked to apply foundational renal physiology knowledge to a patient case and then engage in interprofessional discussions focused on the following IPEC subcompetencies:

• • RR Behavioral Expectations (RR1): Students should be able to communicate their roles and responsibilities clearly to other healthcare professional students.
• • RR Behavioral Expectations (RR4): Students should be able to explain the roles and responsibilities of other care providers and how the team works together to provide care.
• • CC Behavioral Expectations (CC4): Students should be able to listen actively and encourage ideas and opinions of other team members.

The Kirkpatrick Model is commonly used to evaluate the effectiveness of student IPE training (13). The Kirkpatrick Model includes four levels: 1) reaction, 2) learning, 3) behavior, and 4) results. For use in IPE, Barr et al. (1) expanded the four-level model to include six categories. The learning level was subdivided into 2a, modification of perceptions and attitudes, and 2b, acquisition of knowledge and skills (1). The reaction and learning levels are most commonly assessed in educational environments, as behavior and results require assessment in practice, which occurs after student graduation (13). Specific to the pilot project, the authors focused on assessing level 1, reaction, and level 2a, learning: modification of perceptions and attitudes (1). An assessment tool was developed to measure student changes in perceptions related to IPEC subcompetencies (level 2a) and evaluate student satisfaction of the IPE experience (level 1).

The outcomes that were quantitatively assessed in the present study included a comparison of the students’ ability to communicate their roles and responsibilities clearly to other healthcare professional students; explain the roles and responsibilities of a science researcher, physical therapist, and physician assistant; and their ability to explain how a team works together to provide care as related to acute kidney injury, both before and after the IPE experience. Students evaluated the IPE activity and responded to three open-ended questions regarding their reason for promoting team-based healthcare, how they might promote team-based care in their future clinical practice, and suggestions for improving the IPE experience.

METHODS

Study design.

Doctoral (n = 3) and master’s (n = 3) degree students from the School of Graduate Studies, doctoral students in Physical Therapy (n = 33), and master’s students in Physician Assistant (n = 28) programs in the School of Allied Health Professions participated in the learning experience. One week before the experience, faculty posted two documents to the university’s electronic educational platform: 1) evaluation of acute kidney injury among hospitalized patients (modified from UpToDate; Ref. 11), and 2) items to complete Prior To Class. Students were instructed to read the overview article and the items to complete Prior To Class document. The Prior To Class document contained the four learning expectations, three concepts to keep in mind during the case, initial presentation of the patient, and three basic renal physiology questions to answer.

The initial patient presentation is as follows. Mr. Jerome Richards is a 62-yr-old African American male with a history of hypertension, who presents to the emergency room with fever, chills, and a cough for the last 4 days. He reports that he has had a productive cough with greenish/white sputum, as well as chills and a home recorded temperature of 102°F. He reports that he’s been taking his medications, but he’s had some nausea and vomiting, and he hasn’t been able to eat or drink much for the last day. He reports some shortness of breath, but denies any orthopnea, melena, or hematochezia. He states that he’s had dark urine for the last day and thinks he hasn’t urinated very much over the previous 12 h.

Students were organized into 10 groups of 7–9 members; including all three professions (one group lacked a basic science graduate student). One student from each professional program was randomly selected to serve as a leader for each group. The group leader was responsible for ensuring all students had an opportunity to contribute to the discussion as facilitators rotated between groups. The learning experience was 120 min in length. The duration of each event was as follows:

• Presurvey (5 min).

• Teams assemble for clinical case assessment (55 min).

• Teams assemble for IPE questionnaire (15 min).

• Team leaders provide clinical report to class (25 min).

• Team leaders provide IPE report to class (15 min).

• Postsurvey (5 min).

Students were asked to complete an IPE pre- and postsurvey using a personal laptop computer during class time. The presurvey included five demographic questions (anonymous identifier, sex identification, program of study, year of study, and number of previous IPE experiences), and six questions related to the IPE student learning outcomes (RR1, RR4, and CC4). The postsurvey included a total of 12 questions: 2 demographic questions, 6 IPE questions, 3 activity evaluation questions, and 3 open-ended questions. Table 1 provides a list of pre- and postsurvey questions. Three open-ended questions were included on the postsurvey:

Table 1.

Pre- and post-IPE survey and evaluation questions

Questions	PreSurvey	PostSurvey
IPEC subcompetency questions
Q1. I am able to communicate my roles and responsibilities clearly to other healthcare professional students, as related to acute kidney disease (RR1)	√	√
Q2. I am able to explain the roles and responsibilities of a science researcher as related to acute kidney disease (RR4).	√	√
Q3. I am able to explain the roles and responsibilities of a physical therapist as related to acute kidney disease (RR4).	√	√
Q4. I am able to explain the roles and responsibilities of a physician assistant as related to acute kidney disease (RR4).	√	√
Q5. I am able to explain how a team works together to provide care, promote health, and prevent disease as related to acute kidney disease (RR4).	√	√
Q6. I am able to listen actively and encourage ideas and opinions of other team members (CC4).	√	√
IPE activity evaluation questions
Q7. Everyone on the team contributed to the discussion.	X	√
Q8. Conversations on my team were respectful.	X	√
Q9. Because of my interprofessional education (IPE) experiences, my appreciation for a team-based approach to healthcare has improved.	X	√

Q1–Q9, questions 1–9.

• 1. What would be your reason to promote team-based healthcare?
• 2. How might you promote team-based care within your future clinical practice?
• 3. Do you have any suggestions for improving this IPE experience?

The clinical and IPE stimulus questions were prepared in the format of short-answer quizzes. The quiz was not graded, but was assessed by the renal block director (LMH-B) for student learning. The quizzes were password protected, so the students could only access the material during a predetermined time during class. The patient case unfolded over the 55-min time session in the course of 15 pages in which Mr. Richards enters the emergency room, is admitted to the hospital, and moved to the intensive care unit. Patient case information given during the patient case presentation included the following: history and physical, including assessment of mobility, blood and urinary laboratory, urine microscopy, renal ultrasound, and chest X-ray results. The student group could only move to the subsequent page after answering the stimulus questions on the previous page. The students were unable to view previous pages in the patient case. The clinical quiz contained 31 questions, and the IPE quiz contained 6 stimulus questions, which were submitted online during class time by one member of each team.

Examples of clinical stimulus questions include the following:

• Question 4: What other information would you like to ask Mr. Richards based upon your professional perspective? Why?

• Question 7: What is your first step in assessing Mr. Richards’ health in the emergency room?

• Question 11: How does your profession assess a patient’s alert and oriented status?

• Question 14: Upon completion of the physical exam, would you like to run any tests? What type of tests? What irregularities in the history and physical might you focus your attention on?

• Question 16: What do the abnormal serum laboratory values tell you about body fluid volume and organ function?

• Question 20: Since he has not urinated very much in the previous 12 h, what additional information might you obtain?

• Question 29: What do the changes in plasma creatinine and blood urea nitrogen suggest?

• Question 31: Based upon Mr. Richards’ current status, are there any other health professionals you might consult and why?

IPE stimulus questions included all the following:

• 1. What is the role of the basic science researcher in regards to this patient case?
• 2. What is the role of the physical therapist in regards to this patient case?
• 3. What is the role of the physician assistant in regards to this patient case?
• 4. What is your professional perspective of health?
• 5. Referring to the Up To Date Overview of acute kidney disease in adults, Mr. Richards has an increased risk for the development of chronic kidney injury in the future. What recommendations would your team suggest to reduce the incidence of future chronic kidney injury and how will your team work together to provide and coordinate care to promote health and prevent disease?
• 6. What were the benefits of working through Mr. Richards’ care as a team?

Faculty facilitators were available in the classroom throughout the entire session and moved freely among the 10 student groups. Facilitators were provided with a supporting document, which provided explanations for the clinical stimulus questions and possible discussion topics for the IPE stimulus questions. The final diagnosis for Mr. Richards is as follows. Sepsis developed as a result of community acquired pneumonia and was complicated by acute kidney injury. The low blood pressure resulted from prescribed medications (lisinopril, angiotensin converting enzyme inhibitor; hydrochlorothiazide, diuretic; and ibuprofen, nonsteroidal antinflammatory drugs) and community acquired pneumonia induced sepsis (vasodilation), which led to hypoperfusion of the organs, renal ischemia, and acute kidney injury.

After that time, each group was asked to participate in a large group discussion, providing insight to a stimulus question from their group’s perspective. The large group discussions were allocated 25 and 15 minutes for the clinical and IPE stimulus questions, respectively. The discussion of the clinical stimulus questions was led by the nephrologist (MVN) and a discussion of the IPE stimulus questions was led by the CIPECP director (TPG).

Data collection and analysis.

The educational pilot project was developed as a quality improvement initiative within the physiology course for graduate studies and physical therapy and physician assistant programs. Institutional Review Board approval was not required for a quality improvement project. A Likert scale ranging from strongly disagree to strongly agree (1–5) was used to measure the responses from the IPE subcompetencies and activity evaluation questions. Quantitative analyses were performed using the Statistical Analysis System (version 9.4). The pre/postpaired comparisons were carried out using the Wilcoxon signed-rank test. P value of <0.05 indicates statistical significance.

RESULTS

Seventy-two and sixty-seven students participated in the pre- and postsurvey, respectively. After the data were cleaned for missing responses, 67 student paired data were analyzed.

Table 2 provides a summary of the IPEC subcompetencies data analysis. There was a statistically significant (P < 0.05) increase from pre- to postsurvey scores for all six IPE questions for all students. Physical therapy and physician assistant students had a statistically significant increase in pre- to postsurvey scores. The presurvey and postsurvey scores were not different for the students enrolled in the School of Graduate Studies.

Table 2.

Assessment of IPEC subcompetencies across student groups

Questions	Student Group	Presurvey	Postsurvey	Post/Presurvey	P Value
Q1	All students	3.80 (0.76)	4.43 (0.65)	0.62 (0.69)	<0.0001*
	Graduate studies	3.5 (1.04)	4.16 (1.16)	0.66 (1.03)	0.50
	Physical therapy	3.72 (0.83)	4.45 (0.56)	0.72 (0.67)	<0.0001*
	Physician assistant	3.96 (0.57)	4.46 (0.63)	0.50 (0.63)	0.0009*
Q2	All students	3.22 (0.86)	4.08 (0.79)	0.86 (0.099)	<0.0001*
	Graduate studies	4.16 (0.40)	4.33 (0.81)	0.16 (0.98)	1.00
	Physical therapy	2.93 (0.78)	3.93 (0.89)	1.00 (1.03)	<0.0001*
	Physician assistant	3.35 (0.86)	4.21 (0.62)	0.85 (0.93)	0.0002*
Q3	All students	3.11 (1.08)	4.35 (0.68)	1.23 (1.00)	<0.0001*
	Graduate studies	2.16 (0.40)	4.00 (1.26)	1.83 (1.16)	0.06
	Physical therapy	3.75 (0.86)	4.45 (0.61)	0.69 (0.63)	<0.0001*
	Physician assistant	2.57 (0.95)	4.32 (0.61)	1.75 (1.00)	<0.0001*
Q4	All students	3.44 (0.90)	4.34 (0.75)	0.92 (0.79)	<0.0001*
	Graduate studies	2.83 (0.98)	4.00 (1.26)	1.16 (1.16)	0.12
	Physical therapy	3.09 (0.94)	4.21 (0.78)	1.21 (0.81)	<0.0001*
	Physician assistant	4.00 (0.47)	4.59 (0.50)	0.62 (0.56)	<0.0001*
Q5	All students	3.86 (0.81)	4.49 (0.58)	0.62 (0.73)	<0.0001*
	Graduate studies	3.33 (1.21)	4.33 (0.81)	1.00 (1.09)	0.12
	Physical therapy	3.84 (0.79)	4.48 (0.61)	0.63 (0.65)	<0.0001*
	Physician assistant	4.00 (0.72)	4.53 (0.50)	0.53 (0.74)	0.0009*
Q6	All students	4.42 (0.60)	4.71 (0.45)	0.30 (0.49)	<0.0001*
	Graduate studies	4.50 (0.54)	4.66 (0.51)	0.16 (0.40)	1.00
	Physical therapy	4.50 (0.50)	4.78 (0.41)	0.31 (0.47)	0.002*
	Physician assistant	4.32 (0.72)	4.64 (0.48)	0.32 (0.54)	0.011*

Values are means (SD).

^*Statistical significance.

Table 3 provides the student evaluation of the IPE experience. The survey means (scale 1–5) for questions 7, 8, and 9 were 4.65, 4.74, and 4.65, respectively. There were no student responses of strongly disagree or disagree regarding the student participation in the discussion (question 7), respectful conversations (question 8), and improvement in appreciation of team-based approach to healthcare (question 9).

Table 3.

Student evaluation of the IPE activity

Questions	Strongly Disagree (Score 1)	Disagree (Score 2)	Neutral (Score 3)	Agree (Score 4)	Strongly Agree (Score 5)	Survey Mean
Q7	0	0	3.0 (2)	28.8 (19)	68.2 (45)	4.65
Q8	0	0	0	25.8 (17)	74.2 (49)	4.74
Q9	0	0	6.1 (4)	34.9 (23)	59.1 (39)	4.65

Values are in percent (with no. of students responding in parentheses).

Open-ended questions.

On the postsurvey, students were asked three open-ended questions. Student responses were one to two sentences in length. The two questions related to team-based care were analyzed for themes. The course director reviewed the data and identified predominant themes. Fifty-four students provided a response to “What would be your reason to promote team-based healthcare?” Thirty-seven students indicated team-based healthcare would provide the highest quality and comprehensive care of the patient. Fifty-two students responded to “How might you promote team-based care within your future clinical practice?” The following two themes were noted: suggest consultation with different healthcare professionals based on the patient’s needs (31 responses), and encourage professions to communicate with each other (21 responses). Forty-four students responded to “Do you have any suggestions for improving this interprofessional experience?” When asked for suggestions to improve the experience, nine students responded positively to the experience. Three common suggestions were noted: decreasing the number of clinical questions (7 responses), increasing the amount of time provided for the experience (6 responses), and having the ability to view all information about the clinical case throughout the class session (7 responses).

DISCUSSION

After the publication of Thistlewaite (12) in Anatomical Sciences Education, which promoted multidisciplinary basic science courses as prime opportunities for IPE, anatomy faculty engaged in developing multidisciplinary IPE experiences and publishing outcomes related to these activities (4, 5, 10). For example, anatomists, orthopedists, and physical therapists team-taught anatomy of the knee joint to small groups of medical and physical therapy students (10). Evaluation results demonstrated that the students appreciated this approach and performed better on exams. Nursing topics and anatomy lectures were combined for interprofessional learning of medical and nursing students (5). The students were highly satisfied with the collaborative training and believed IPE to be an important experience for their future profession and understanding of other health professionals. In reviewing the research for IPE integration into other basic science courses, such as physiology, we have yet to see the level of engagement compared with anatomy. In the current IPE experience, there was a statistically significant increase from pre- to postsurvey scores for all six IPEC subcompetency questions for all students, physical therapy students, and physician assistant students. These data indicated students perceived an increased ability to communicate their respective roles, explain the roles of fellow students’ professions as related to acute kidney injury, and engage in active listening. Physical therapy and physician assistant students had a statistically significant increase in pre- to post-IPE survey scores.

The pre- to post-IPE survey question scores were not different for the students enrolled in the School of Graduate Studies. It is possible that the small number (n = 6) and large standard deviation for the students enrolled in the School of Graduate Studies precluded the ability to demonstrate a statistically significant difference between pre- and post-IPE survey scores. Previously, Edwards et al. (3) found no significant difference in IPEC subcompetency scores for students enrolled in the School of Graduate Studies (n = 9) for an endocrine physiology IPE experience. Additionally, the physical therapy and physician assistant programs are clinically based, while graduate studies is not, and so those differences between the training in those programs may have contributed to the results of the survey. Additional research and/or program evaluation specific to students in basic science graduate programs should be conducted to determine why there was a lack of significant change in IPE perceptions after participation in an IPE experience.

Faculty will incorporate student suggestions in preparation of the renal IPE for the next graduate-level physiology course. The class period of 120 min cannot be extended. Therefore, the number of clinical questions will be decreased from 31 to 20. In addition, students will be provided objective information related to the case, such as the normal range of values for all of the laboratory tests. Providing additional clinical information instead of students spending time researching the results will decrease the total time needed to complete the clinical case questions. Students will also have the ability to freely navigate throughout the case to review the previous case information, questions, and answers.

There are increasing numbers of IPE research studies from various health professions indicating positive changes in student attitudes and perceptions regarding team-based care. In addition, there are known barriers to IPE, such as scheduling and incorporating additional content into already full curricula (14). Multidisciplinary physiology courses can be utilized as opportunities to integrate IPE experiences for early learners, helping to address common barriers to IPE implementation and program-level accreditation standards.

The experiential learning is an educational orientation that aims at integrating theoretical and practical elements of learning, emphasizing the significance of experience for learning. We want students to get into the habit of linking and constructing meaning from their experiences; such work requires reflection. Learning through reflection is an attempt to promote behavioral change of students. Reflecting on work enhances its meaning and reflecting on experiences encourages insight and complex learning. To reflect, students must act upon and process the information, synthesizing and evaluating the data. In the end, reflecting also means applying what we have learned to contexts beyond the original situations in which we learned something. For the IPE experience, students must apply basic renal physiology concepts for the understanding of the mechanisms responsible for the symptoms presented by Mr. Richards throughout the case. The experiences of working as a team on the case should contribute to their learning of renal physiology. Our overall goal is to provide beginning graduate students with an IPE experience so that their skills and appreciation of working as a team will flourish throughout their education and careers.

GRANTS

This study was supported in part by 1 U54 GM104940 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds the Louisiana Clinical and Translational Science Center.

DISCLAIMERS

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

DISCLOSURES

No conflicts of interest, financial or otherwise, are declared by the authors.

AUTHOR CONTRIBUTIONS

L.M.H.-B., M.V.N., J.M.E., and T.P.G. conceived and designed research; L.M.H.-B., M.V.N., J.M.E., and T.P.G. performed experiments; L.M.H.-B., D.E.M., and T.P.G. analyzed data; L.M.H.-B., M.V.N., D.E.M., and T.P.G. interpreted results of experiments; L.M.H.-B. and T.P.G. drafted manuscript; L.M.H.-B., M.V.N., J.M.E., and T.P.G. edited and revised manuscript; L.M.H.-B., M.V.N., J.M.E., D.E.M., and T.P.G. approved final version of manuscript.