Interprofessional Service Learning in Medical Education: a Year-Over-Year Assessment of Student Feedback

Abstract

Community service learning has been extolled as an effective vehicle for interprofessional education based upon studies assessing the short-term impact of these experiences on positive team behaviors and communication skills. Through this study, the authors explore year-over-year student impressions of an interprofessional service learning program to determine whether the short-term successes detailed in prior studies are sustainable over time. Course evaluations were collected from 168 first-year medical students (M1) at Virginia Tech Carilion School of Medicine (VTCSOM) over a 4-year period beginning in 2013 and ending in 2017. All 238 current and former VTCSOM students were also prospectively surveyed and 87 (37%) responses were received. Study results indicate that first-year medical students consistently find interprofessional service learning opportunities to be valuable with regard to improving understanding of the roles of other health professionals, as well as helping to generate positive team behaviors. However, as students progress through their medical education and beyond, they may perceive the skills learned and obstacles encountered through these opportunities to be less generalizable to a clinical setting. These findings add to a growing body of evidence supporting the efficacy of service learning in interprofessional education. However, they also suggest that a potential divide may exist between the intended goals of these experiences at an administrative level and the team-based behaviors and communication skills that clinical students and practicing physicians use to navigate interprofessional conflict in the workplace.

Electronic supplementary material

The online version of this article (10.1007/s40670-020-00948-7) contains supplementary material, which is available to authorized users.

Introduction

Although caring for patients used to fall almost exclusively under the purview of the solo practitioner, the increasing complexity of our society’s health problems and our rapidly evolving body of scientific knowledge regarding disease processes and prevention have served as major catalysts for the transition to our current team-based approach to the delivery of medical care [1]. As a result, communication and collaboration amongst members of different healthcare professions has taken on critical importance in an effort to both optimize the patient experience and deliver the safest and most effective patient care [2].

In 2009, six national educational associations representing many of the healthcare professions formed the Interprofessional Education Collaborative (IPEC), which has worked to champion the importance of early and continued interprofessional education and exposure between students from different health professions programs. Using the IPEC Core Competencies as a guide, health professions schools around the nation have begun to incorporate interprofessional experiences into the traditional model of health education to help students begin to develop the necessary skills to function as effective members of our future healthcare teams [3, 4]. Many of these institutions have chosen to deploy their interprofessional curriculum through service learning in an effort to provide a practical context for the implementation of topics covered and skills learned through these courses [5, 6].

Established in 2007, the School of Medicine (SOM) has been a leader in interprofessional health education since its inception. As one of its four foundational “value domains,” the interprofessionalism (IPL) program at SOM is longitudinally integrated into the curriculum beginning with a specially designed interprofessional leadership course that places first-year medical students in the same classroom as students from the allied health professions. As part of this program, students participate in year-long Service Learning Projects (SLP), which involves interprofessional groups partnering with local organizations to address areas of need within the community [7].

While several studies have extolled community service learning as an effective vehicle for interprofessional health education, these conclusions are largely based upon data assessing the short-term outcomes of these experiences on positive team behaviors and communication skills [8]. In an effort to better understand year-over-year perceptions of interprofessional service learning amongst medical students, we investigated data from our program to determine whether student perceptions of the SLP differ between academic years (AY), whether these perceptions change as students progress through their undergraduate medical education and enter clinical practice, and whether interprofessional service learning might prompt future community engagement.

Methods

Curricular Description

SOM is one of the smallest medical schools in the country matriculating an average of 42 medical students per class year. Similar to most medical schools in the USA, coursework is broken up into two distinct phases: phase one consists of 2 years of pre-clinical education centered around learning the fundamental basic science principles and clinical skills necessary to practice medicine, while phase two consists of 2 years of clinical education and the application of these concepts in direct patient care. As part of the pre-clinical curriculum for first-year medical students at SOM, students engage in a Longitudinal Ambulatory Care Experience (LACE) in order to develop their clinical skills through direct patient care as well as engagement with interprofessional faculty in a variety of standardized activities. Furthermore, first-year students also participate in a unique, yearlong, interprofessional leadership course, which brings together physician’s assistant, nursing, and allied health students each week to work with and learn from one another. Throughout the year, students from the various health professions work in Team Action Groups (TAGs) guided by a faculty facilitator to learn about interprofessional teamwork and effective communication, different team member roles and scopes of practice, and collaborative leadership in the healthcare environment. This course culminates with a required SLP, the goals of which are to promote the development of positive team behaviors and communication skills amongst members of different health professions, as well as provide a practical context for the implementation of these skills in a dedicated activity that must be accomplished as an interprofessional team [7].

Study Design

The current study was conducted as a hybrid retrospective analysis and cross-sectional study. In order to conduct the study, two different data instruments were employed.

Retrospective Data Collection

First-year medical student (M1) responses (n = 168) from four academic years were obtained from a retrospective review of End-of-Block evaluations that are required for course completion. These evaluations contained a series of statements pertaining to various aspects of the IPL curriculum that took place during that period. The majority of items are scored on a Likert scale ranging from one to five, with a score of five signifying that a student strongly agrees with the statement and a score of one signifying that a student strongly disagrees with the statement. A final item contained a textbox that open-endedly asks students for qualitative feedback regarding the various activities and topics covered during the block. Only items queried across multiple years were included in the study and not all included items were queried across all academic years.

Survey Design and Delivery

A survey instrument was designed to sample cross-sectional data from medical students and alumni. Survey design took place in four phases: initial development, pre-testing, redesign, and deployment. First, key administrators, faculty, and staff involved in the development and deployment of the IPL curriculum at SOM met with researchers several times over a 6-month time period to develop survey items based upon the goals of the investigation. Items that were ultimately selected for inclusion in the survey received unanimous multi-disciplinary support. Next, the preliminary survey was trialed in a small group of medical students and feedback on the instrument was solicited through focus groups. This feedback was incorporated as appropriate. Revised items were then placed into one of three broad groups based upon the overarching theme being explored by each question (Table 1). The items and their groupings were then submitted for final approval from the survey development team prior to deployment.

Table 1.

Overarching themes investigated by example survey items

Interprofessional skills

– Participating in the Service Learning Project helped me to become more comfortable with students from other health professions

– Working to develop Team Contracts prior to beginning my team’s Service Learning Project helped to facilitate group communication and accountability.

– Discussing similarities and differences between group member values helped to facilitate easier selection of a Service Learning Project

–Discussing similarities and differences between group member values helped me to learn more about other health professions students in my group

– Executing the Service Learning Project helped to improve my communication skills and interactions with other health professions students

– Navigating obstacles as a part of the Service Learning Project helped me to improve my conflict resolution skills

– Participating in the Service Learning Project was an effective means by which to develop and practice teamwork and leadership skills

Community engagement

– I felt like I contributed to the betterment of my community through my group’s Service Learning Project

– Working with an organization whose mission aligned with my group’s values deepened my sense of community involvement and impact

– Participating in the Service Learning Project helped me discover other opportunities that are available to give back to my community

Clinical applicability

– Participating in the Service Learning Project helped me to identify some of the potential obstacles that interprofessional health teams may face in a clinical setting

– I have witnessed interprofessional conflicts during LACE that are similar to obstacles that I dealt with during the Service Learning Project.

– I have used some of the skills and/or strategies I developed through my participation in the Service Learning Project during LACE/clinical clerkships.

The survey instrument was administered electronically to all currently enrolled second- through fourth-year medical students (M2–M4s) at SOM, as well as all alumni (n = 238). Responses were collected from May to November 2017. Each item contained a statement scored on a Likert scale with a score of four signifying that a student strongly agrees with the statement, and a score of one signifying that a student strongly disagrees with the statement. For one item, a score of four denoted that a student had a very positive experience, while a score of one denoted that a student had a very negative experience. A final item contained a textbox that open-endedly asked respondents for qualitative feedback regarding their experiences with the SLP.

Data Analysis

M1 data from End-of-Block evaluations was analyzed for statement items and qualitative feedback that specifically related to the SLP. These were further stratified to examine just those items and feedback that directly related to our areas of study. Initial analysis of M2–M4 and alumni responses involved stratifying items into two different categories based upon their mean response values. Any items with a mean of > 3.0 were classified as “strengths” while any items with a mean of < 2.5 were classified as an “opportunity.” Raw data was also examined for correlations between responses on items related to community involvement as a part of the SLP, overall experience with the SLP, and current involvement in community service.

Statistical analysis was conducted using R software. The main statistical methods used were Kruskal-Wallis one-way ANOVAs with post hoc testing. M1 responses on End-of-Block Evaluations were compared across different academic calendar years and within each sample group. M2–4 and alumni responses were compared against one another and within each sample group. Qualitative feedback was included to provide context for student responses.

Ethical Considerations

This study was sent to the Institutional Review Board and was found to be exempt of continued oversight. All response data was collected anonymously. Participation in the study was voluntary and respondents retained the option to forgo answering any items that they wished.

Results

Overall, 168 M1 student responses were collected from End-of-Block evaluations over a 4-year period beginning in AY 2013–2014 and ending in AY 2016–2017. After stratifying items by relation to the SLP and then again by relevance to study goals, five items were selected for inclusion in the study.

Raw data for items 1–5 is summarized in Table 2. For item 2, we found a statistically significant difference (p = 0.02) between the M1 Class of 2020 mean of 3.2 (1.21) and the M1 class 2018 mean of 4.0 (0.96). Hence, the class of 2018 perceived that the SLP was a more effective method for learning teamwork and leadership skills than the class of 2020. Qualitative data was also collected from M1 students and is included in the discussion section to help explain quantitative findings or provide contrasting opinions from some students.

Table 2.

Summary statistics for selected M1 course evaluation measures

Item	M1 cohort	Collection	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree	Mean (SD)	N
1	Class of 2020	AY 16–17	12%	60%	17%	7%	5%	3.6 (0.95)	42
	Class of 2019	AY 15–16	25%	30%	23%	18%	5%	3.5 (1.19)	40
	Class of 2018	AY 14–15	14%	64%	19%	2%	0%	3.9 (0.66)	42
2	Class of 2020	AY 16–17	12%	37%	24%	15%	12%	3.2 (1.21)*	41
	Class of 2019	AY 15–16	17%	41%	22%	12%	7%	3.5 (1.14)	41
	Class of 2018	AY 14–15	29%	50%	12%	7%	2%	4.0 (0.96)*	42
	Class of 2017	AY 13–14	12%	57%	17%	12%	2%	3.6 (0.93)	42
3	Class of 2020	AY 16–17	10%	43%	33%	7%	7%	3.4 (1.00)	41
4	Class of 2019	AY 15–16	17%	21%	29%	21%	12%	3.1 (1.27)	41
5	Class of 2018	AY 14–15	14%	55%	24%	7%	0%	3.8 (0.78)	42

Items included the following: 1: Working on the development of the Service Learning Project Team Contract helped my TAG group begin to communicate about accountability to each other and to the group. 2: The Service Learning Project was an effective method for learning teamwork and leadership skills. 3: The process of selecting my group’s Service Learning Project helped me negotiate and collaborate with others from different backgrounds and pursuing other careers and goals. 4: The process of selecting my group’s Service Learning Project helped me appreciate the roles, scopes of practice, and contributions of the other healthcare professions. 5: Beginning the process of selecting my group’s Service Learning Project allowed me to apply relationship-building skills and the principles of team dynamics

*p < 0.05

With regard to M2–M4 students and alumni, we surveyed 238 current and former SOM students. We received 87 responses, which represented a 37% overall response rate with each class approximately equally represented. As summarized in Table 3, both the M4 Class of 2018 and alumni respondents found group-specific organization selection and community involvement to be strengths of the SLP component of the IPL curriculum, with > 87% (n = 56) of them indicating that they agreed or strongly agreed with those items. In contrast, the M2 Class of 2020 respondents actually rated these items as opportunities for improvement (i.e., mean < 2.5) within the curriculum. Both the M3 Class of 2019 and alumni respondents rated items that described the relationship between the SLP and their clinical experiences as opportunities for improvement within the curriculum. Again, although not reflected in the figure, the M2 Class of 2020 respondents actually rated these items as strengths (i.e., mean > 3.0).

Table 3.

Items classified as strengths (mean > 3.0) and opportunities (mean < 2.5) by academic class

Item	Academic class	4: Strongly agree	3: Agree	2: Disagree	1: Strongly disagree	Mean (SD)	N
2A	M2 Class of 2020	20%	60%	13%	7%	2.1 (0.80)	15
	M4 Class of 2018	25%	55%	8%	0%	3.2 (0.58)	12
	Alumni	32%	67%	10%	3%	3.2 (0.71)	40
2B	M2 Class of 2020	20%	47%	20%	13%	2.3 (0.96)	15
	M4 Class of 2018	25%	67%	8%	0%	3.2 (0.58)	13
	Alumni	23%	65%	5%	8%	3.0 (0.77)	40
2C	M2 Class of 2020	13%	7%	47%	33%	3.0 (1.00)	15
	M3 Class of 2019	8%	17%	67%	8%	2.3 (0.75)	12
	Alumni	5%	43%	40%	13%	2.4 (0.78)	40
2D	M2 Class of 2020	7%	13%	47%	33%	3.1 (0.88)	15
	M3 Class of 2019	8%	17%	67%	8%	2.3 (0.75)	12
	Alumni	7%	46%	41%	5%	2.4 (0.71)	41

Items included the following: 2A: I felt like I contributed to the betterment of my community through my group’s SLP. 2B: Working with an organization whose mission aligned with my group’s values deepened my sense of community involvement and impact. 2C: I have witnessed interprofessional conflicts during my (clinical clerkships/LACE) that are similar to the obstacles that I dealt with during my SLP. 2D: I have used some of the skills and/or strategies I developed through my participation in the SLP while on my (clinical clerkships/LACE)

We continued by examining each academic class’ responses to the two items addressing overall experience with the SLP and current involvement in community service. The majority of respondents from both the M4 Class of 2018 and alumni groups indicated that they had positive or very positive experiences with the SLP, with 100% (n = 13) of M4 and 65% (n = 43) of alumni respondents selecting one of these responses. In contrast, only 41% (n = 12) of respondents from the M3 Class of 2019 and 34% (n = 15) of respondents from the M2 Class of 2020 selected one of these options. Moreover, we found that current involvement in community service ranges from 38 to 53% across different groups, with the M2 Class of 2020 having the highest percentage (n = 15) of respondents indicating that they are currently engaged in service work or volunteering.

To investigate our preliminary findings further, we conducted a statistical analysis on all survey items to determine whether significant differences existed between academic classes. The M2 Class of 2020 perceived to a significantly lesser extent than other groups that that they had “…contributed to the betterment of their community through their group’s SLP.” This class also indicated to significantly lesser extent than other groups that “…working with an organization whose mission aligned with their group’s values deepened their sense of community involvement and impact.” Moreover, the M2 Class of 2020 indicated to significantly higher extent (p < 0.05) than other groups that they had “…witnessed interprofessional conflicts during clinical clerkships/LACE that were similar to the obstacles they dealt with during the SLP” and that they had utilized “…some of the skills and/or strategies they developed through my participation in the SLP while on clinical clerkships/LACE.” Finally, the M2 Class of 2020 overall experience rating mean was found to be significantly lower than both the M4 Class of 2018 and alumni rating means (p < 0.05, 0.05). The remainder of survey items assessing interprofessional skills were not found to have statistically significant differences between different classes.

Lastly, we conducted an investigation into the statistical relationships between student perceptions of their overall experience with the SLP and (1) their current involvement in community; (2) their motivation to get more involved; (3) the extent to which the SLP helped them discover other opportunities to serve; (4) the extent to which working with an organization whose mission aligned with their group values deepened their sense of community involvement and impact. Since the data was ordinal, these relationships were explored using Spearman’s rho ordinal correlation coefficients. For this analysis, we anticipated observing that overall student experience with the SLP was not independent from each of these other important factors. The results, as shown in Table 4, indicate that statistically significant correlations between item 5 and items 2–4 do exist. Qualitative data was also collected from M2–M4 students and alumni and is included in the discussion section to help explain quantitative findings or provide contrasting opinions from some respondents.

Table 4.

Spearman correlations between student perceptions

	1	2	3	4	5a
1: I am involved in community service activities and/or volunteering in my current community	1.000
2: Participating in the Service Learning Project has motivated me to get more involved in my community	0.040	1.000
3: Participating in the Service Learning Project helped me discover other opportunities that are available to give back to my community	0.019	0.548*	1.000
4: Working with an organization whose mission aligned with my group’s values deepened my sense of community involvement and impact	0.051	0.593*	0.750*	1.000
5: Overall, my experience with the IPL Service Learning Project was	0.002	0.479*	0.545*	0.561*	1.000

n = 65

*Indicated estimate was statistically significant p < 0.05

^aNumbers 1–5 refer to survey questions 1–5 contained within the Table 3

Discussion

The M1 retrospective analysis suggests that students who have just begun their medical education consistently find value in a small group approach to interprofessional service learning, which mirrors interprofessional education at other institutions [9]. Students were consistently supportive of opportunities that allowed them to engage with and learn from individuals from different health professions programs, both inside and outside of the classroom. M1 students also consistently indicated general approval for a structured, systematic approach to service learning opportunities as evidenced by high performance ratings on items related to both the planning and development portions of the SLP. The vast majority of constructive feedback from M1s revolved around dissatisfaction with some of the obstacles encountered during the organization phase of the SLP. One student summarized by saying, “Students were frustrated that the projects were tricky to set up/organizations weren’t responding to us.”

With regard to other classes, survey data helped identify several important trends that vary distinctively between medical students in the pre-clinical phase of their education (M2) and medical students in the clinical phase of their education (M3–M4) and/or physicians currently in practice (alumni). M2s responded favorably to items related to similarities between skills learned and obstacles encountered during the SLP and their LACE experiences. Conversely, M3–M4s and alumni responded poorly to these items. One plausible explanation for this finding is that medical students on their clinical rotations, as more passive members of the healthcare team, are less likely to be exposed to or directly involved in interprofessional conflict [10]. However, it is also possible that interprofessional service learning opportunities might benefit from additional efforts to more directly parallel interprofessional collaboration in the clinical environment [11]. Despite mean response scores for these items defining them as opportunities for improvement within this cohort, qualitative feedback from some students in this group is very encouraging. One M3 wrote, “The Service Learning Project was an excellent opportunity for me to gain experience working in an interprofessional environment with members of different healthcare teams. As a third-year student, I find myself frequently using the skills I learned to navigate obstacles in the hospital and in the clinic.” Another alumnus stated, “I have gained more appreciation for IPL since graduation seeing graduates of other medical schools interact with other members of the healthcare team.”

With regard to queried items addressing community involvement and perceived community impact, M2 students did not respond favorably. Qualitative feedback from several students echoed sentiments from the M1 End-of-Block evaluations, in particular regarding frustrations over poor communication from partner organizations. One student said, “The SLP had a lot of potential; however, this potential was severely diminished by unresponsive organizations.” Unlike medical students in the pre-clinical phase of their education, M3 and alumni responded very positively to these items. One factor that almost certainly contributes to this finding is that many of the community organizations that partnered with interprofessional student groups upon initial development of the SLP program gradually became less responsive and willing to engage in these opportunities with each subsequent academic year. This was likely due to several different factors including a recognition of the resources required to coordinate such a project. Although not investigated in the current study, changes in community partner investment in interprofessional service learning opportunities might plausibly impact program quality and thus influence student perceptions of these experiences. Another potential explanation for this trend is that logistical issues may become less memorable over time and, as a result, respondents focus more on their overall learning experience and their community impact as part of their interprofessional team. Supporting this latter presumption, one alumnus remarked, “One of my many nice memories from my time at SOM. Enjoyed the chance to get more involved in the extra-academic community that makes up patients, staff, etc. at the school.”

Overall experience with the SLP varied inversely with academic year, with students in the later parts of their medical education demonstrating the most positive responses. This might suggest that, aside the aforementioned logistical hassles, students better appreciate the general utility of interprofessional collaborative skills the further they are in their medical education. Furthermore, despite their class’ low rating of this item, some pre-clinical students still perceive the SLP to be an overall positive experience. A prominent example comes from an M2 who said, “This project was an awesome experience. We were able to become closer to students at different schools in Roanoke and make new friends. We were also able to become closer with the community. I felt like I made a lasting contribution.”

With regard to current involvement in community service, M2s unsurprisingly demonstrated the highest rates of current involvement in community service. This is likely due to the fact that M2 students simply have more free time due to less academic and clinical requirements. Other academic classes also indicated that they were currently involved in community service, with an inverse relationship being seen as students progress through their medical education.

In an effort to further explore the relationship between the items listed above, we ran a correlational analysis as shown in Table 4. Although this analysis revealed statistically significant relationships between several items, no statistically significant relationship was found between overall experience with the SLP and current involvement in community service. Furthermore, the strength of these relationships is only moderate suggesting that other factors likely play a role in influencing community involvement in students still currently in medical school as well as physicians out in clinical practice.

Limitations

One important limitation of the current study is the inability to compare M1 responses with those of other queried academic classes. This is due to the fact that the M1 data was acquired retrospectively and thus comes from the same group of students that responded to our survey instrument, albeit at a different point in their education. As a result, any attempt at comparing these groups from a statistical standpoint would be inherently flawed. A possible work around to this might involve a statistical comparison of differences in each individual student’s perceptions across multiple years. However, because our survey distribution was designed to maximize anonymity, individual responder identification is not impossible. While this limitation does not directly impact the findings of our study, the inclusion of M1s in future cross-sectional studies might provide additional pre-clinical perspectives on interprofessional service learning.

Another important limitation in the current study is our inability to conclusively determine whether interprofessional service learning independently prompts future community engagement in medical students and physicians. Future studies assessing this content area might include distinct questions aimed at identifying which specific factors are likely to play a role in medical student and/or physician engagement in volunteerism within their community.

Lastly, as is the case in any study conducted at a single institution, the findings of our specific program may not be generalizable to all students at all medical schools across the country. In the interest of helping educators determine the potential applicability of our findings to their institutions, we have provided a description of our curricular structure as well as the goals and objectives of our interprofessional service learning opportunities in the above methods. Future studies assessing medical student attitudes towards interprofessional service learning might consider a multi-center sampling approach in an effort to capture a larger student population.

Conclusion

Historically, health professions students have had minimal contact with one another throughout their education and yet are expected to perform as an ideal team upon first contact in a clinical setting to render safe and effective patient care [ 12]. As a result, early-career health professionals may encounter difficulties attempting to navigate interprofessional conflict, which can result in medical errors that have significant impacts on patient outcomes [13]. In order to help address this problem, many health professions schools across the country have begun to integrate interprofessional experiences into their curriculum. Interprofessional service learning has been identified in the research literature as a collaborative and effective means by which to engage students from different health professions in interprofessional education [6, 14, 15]. Through this study, we sought to explore year-over-year student impressions of a required interprofessional service learning opportunity at our institution to determine whether the short-term successes detailed in prior studies are sustainable over time.

Our study adds to a growing body of evidence supporting the effectiveness of service learning in interprofessional health education [8]. Furthermore, our investigation expounds on these findings by providing evidence that M1s consistently find value in interprofessional service learning opportunities even across multiple academic years. Moreover, we also provide novel data suggesting that medical student perceptions regarding the applicability of skills learned and obstacles encountered through interprofessional service learning opportunities may diminish as students progress through their medical education and once they enter clinical practice. These findings lead us to consider that a potential divide may exist between the intended goals of these experiences at an administrative level and the team-based behaviors and communication skills that clinical students and practicing physicians use to navigate interprofessional conflict in the workplace. Finally, we determined that students further along in their medical education and physicians in clinical practice look back more favorably on interprofessional service learning experiences suggesting they may have greater appreciation for the general utility of interprofessional collaborative skills the further they are in their medical careers.

Compliance with Ethical Standards

This study was sent to the Institutional Review Board and was found to be exempt of continued oversight. All response data was collected anonymously.

Conflict of Interest

The authors declare that they have no conflict of interest.