Assessing dental student perceptions after engaging in a longitudinal interprofessional education curriculum: A preliminary study

Abstract

Purpose/Objectives:

Baseline IPE perceptions for dental students were gathered prior to the implementation of a two-year formalized IPE curriculum at a U.S. institution. The goal was to establish a baseline of student perceptions and, in the future, continue to track student IPE perception data with IPE engagement as one measure of outcomes. The purpose of this paper is to analyze two dental student cohort perceptions of IPE after engaging in a two-year longitudinal curriculum.

Methods:

First and second year students were required to participate in a two-year IPE curriculum. As a requirement of the curriculum, students were asked to complete a validated IPE assessment, the Student Perceptions of Interprofessional Clinical Education-Revised instrument, version 2 (SPICE-R2). Students completed the SPICE-R2 survey, using a retrospective pretest/posttest design, after engaging in the two-year curriculum.

Results:

Sixty-four students in cohort 2017 and 70 students in cohort 2018 completed the entire SPICE-R2. Statistically significant positive changes (p<0.05) were found in both dental student cohorts after engagement in the 2-year longitudinal IPE curriculum.

Conclusion(s):

A longitudinal IPE curriculum has the potential to impact student IPE perceptions. Additional longitudinal multi-institutional research is needed to determine best practices in delivery and learning.

INTRODUCTION

As more publications have focused on interprofessional education (IPE) in the current health education literature, there has been a consistent call to improve the rigor of the accompanying research.^1-3 IPE is defined as “students from two or more professions learning about, from, and with each other to enable effective collaboration and improve health outcomes.”⁴ Measuring IPE outcomes longitudinally following a series of interprofessional learning experiences during an academic journey provides an opportunity to understand impact in this specialized area of education. If the purpose of IPE is to develop collaborative-practice ready health professionals,⁴ continuous exposure to interprofessional learning experiences throughout the curricula would be supportive of the goal.

The dental education community, including the American Dental Education Association (ADEA) and the Commission on Dental Accreditation (CODA), support IPE through advocacy and the establishment of education standards, including the core principle of “collaboration with other healthcare professionals⁵,” respectively. CODA Standard 2-20 requires educational programs to demonstrate student engagement with other health professions.⁵ Additionally, ADEA was an inaugural member of the Interprofessional Education Collaborative (IPEC), which established what has since become the leading competency framework for interprofessional collaboration in the United States.⁶ Furthermore, CODA supported the Health Professions Accreditors Collaborative (HPAC) guidance report for IPE development.⁷

HPAC is a 25 member organization of health profession accreditors focused on preparing students for interprofessional practice.⁸ The HPAC report, Guidance on Developing Quality Interprofessional Education for the Health Professions, provided support for creating a framework for developing, assessing and evaluating IPE that results in quality IPE experiences.⁷ HPAC advocated for the development of integrated interprofessional experiences throughout the length of the program, offering didactic, clinical and extracurricular experiences targeting IPEC competencies.⁷

Prior to the HPAC publication, Louisiana State University Health Science Center at New Orleans (LSUHSCNO) developed and implemented a formalized didactic two-year IPE curriculum required for all first and second year students across a spectrum of schools and programs, which included criteria proposed by HPAC. With two dental student cohorts completing the longitudinal experience known as Team Up™,⁹ the assessment and evaluation of the IPE experience warrants analysis. Analysis of Team Up™ student learning outcomes is a critical step in evaluating the quality of this longitudinal IPE experience.

Prior to Team Up™ in 2017, IPE opportunities for dental students included a 2-hour IPE event and an elective course. First year dental students were required to participate in the 2-hour IPE event and 4^th year dental students had the opportunity to enroll in the elective course. Beginning in 2015, dental student perceptions about IPE were collected annually for a period of three academic years. Results were analyzed and published by Townsend et al. in 2018, indicating that with “minimal to no IPE intervention, dental student perception scores remained the same regardless of year of study and over a period of three years.”¹⁰ The goal of the study by Townsend et al. was to establish a baseline of students’ IPE perceptions and to continue tracking students’ IPE perceptions following engagement in Team Up™.¹⁰ The purpose of this paper is to assess the impact of Team Up™ on dental student perceptions of IPE after engaging in a two-year longitudinal curriculum.

Literature Review

Most IPE literature has focused on measuring student attitudes and perceptions as a means to assess and evaluate outcomes.³ While some argue educational researchers must move past measuring perceptions, there remain large gaps in this area. A search of the National Center for Biomedical Information (NCBI) database, PubMed¹¹, using the keywords dental, longitudinal, and IPE revealed ten articles. Of the ten articles, only one met the criteria of all three keywords. ¹² A further review of the literature found four additional articles evaluating first- or second-year dental students engaging in longitudinal classroom-based IPE experiences.^13,15-17 Four of the five articles included research occurring within the U.S.^{13, 15-17}, two articles analyzed data at the program level^16,17, two articles used the same assessment tool^{15, 16} and two articles included research occurring at the same institution.^16,17 The following literature review occurs in chronological order and details the five articles which evaluated first- or second-year dental students.

Coster et al. conducted a multi-institutional study measuring student perceptions using the Readiness for Interprofessional Learning Scale (RIPLS).^13,14 Students from eight professional programs (dentistry, dietetics, medicine, midwifery, nursing, occupational therapy, pharmacy, and physiotherapy) attending three institutions in the United Kingdom participated in the research.¹³ Only one of the institutions included an IPE course during the first year.¹³ The authors noted a negative change in RIPLS score for all students, but did not report on program or institutional differences.¹³

Fitzsimmons et al. evaluated a year-long interprofessional curriculum for first year learners at an U.S. institution.¹⁵ The authors used the Readiness for Interprofessional Learning Scale (RIPLS) and the Interdisciplinary Education Perception Scale (IEPS) to measure student perceptions from medicine, physical therapy, dentistry, nursing, and pharmacy programs.¹⁵ Results indicated a statistically significant decline in the professional identity RIPLS subscale, the competency/autonomy IEPS subscale and the perception of actual cooperation subscale.¹⁵ The results included 65 paired data sets, but there was no indication of program representation.¹⁵

Lockeman et al. used the Student Perceptions of Interprofessional Clinical Education-Revised instrument, version 2 (SPICE-R2) to evaluate early learner perceptions at a U.S institution.¹⁶ Students from the programs in dentistry, dental hygiene, nursing, occupational therapy, physical therapy and pharmacy participated in a series of four IPE experiences occurring over a period of two months.¹⁶ Each session was scheduled for 90 minutes.¹⁶ The authors found no statistical significant change in the total score or factor scores in dental student perceptions when using a retrospective pretest-posttest design.¹⁶

McGregor et al.¹⁷ also used the SPICE-R2 to evaluate early learner perceptions of IPE after a one-hour credit course at the same U.S. institution as Lockeman et al.¹⁶ Programs represented in the course included dental hygiene, dentistry, nursing, occupational therapy, pharmacy and physical therapy.¹⁷ Students attended 13 sessions.¹⁷ Using a retrospective pretest-posttest design, the authors noted a statistically significant positive change in the roles/responsibilities for collaborative practice factor for the dental students.^16,17

Sabato et al. engaged medical, nursing, nutrition and first-year dental students in a three-day case-based IPE experience.¹² Second year dental students also engaged in a case-based IPE experience, but with social work, medicine and nursing student participation.¹² The authors measured student reactions, not perceptions, to the IPE activity using a non-validated instrument.¹²

The literature review includes two articles, which can be used for comparison and demonstrates a lack of research occurring within early learner dental students engaged in longitudinal IPE experiences. This, coupled with HPAC’s recommendation to develop integrated IPE experiences throughout the length of a curriculum, highlights the need to evaluate outcomes over time as a component to defining quality IPE. This study will evaluate the research question “What are dental student perceptions of IPE after engaging in a longitudinal curriculum?”

MATERIALS AND METHODS

Beginning in August 2017, first year students entering LSUHSCNO were required to participate in the Team Up™ curriculum. Each academic program was tasked with finding coordinating times, and this two-year IPE curriculum was integrated within both the fall and spring schedules within existing courses as selected by the individual schools. As a requirement of the curriculum, students were provided an electronic link to complete the Student Perceptions of Interprofessional Clinical Education-Revised instrument, version 2 (SPICE-R2), a validated IPE perceptions instrument. Each Team Up™ cohort completed the SPICE-R2 in April after the two-year period. Students rated their perception using a retrospective pretest/posttest design.

A retrospective pretest/post-test design asks the participant to simultaneously rate a statement based upon the present moment and a defined period of time from the past.^18,19 For example, in this study, at the end of the two-year experience, students were asked to rate their level of understanding of other students’ educational training prior to beginning Team Up™ (previous time frame) and at the end of Team Up™ (present moment). A retrospective pretest/posttest design is recommended to address emerging patterns indicative of response-shift bias.¹⁸ The bias can be attributed to novices elevating self-appraisals due to poor metacognitive skills¹⁹ and/or a change in the participant’s understanding of the content. This approach, therefore, changes the participant’s standard of measurement.¹⁸

This phenomenon describes a situation in which there is an initial inflation of students’ perceptions in understanding of a topic.²⁰ However, as learning progresses, the student’s standard of measurement also changes.¹⁸ Asking students to synchronously rate their perceptions at two different points in time provides an opportunity to use the same standard of measurement.¹⁸ This study was approved by the Institutional Review Board at LSUHSCNO (#10106).

IPE Curriculum

In 2015, LSUHSCNO established a centralized office, the Center for Interprofessional Education and Collaborative Practice (CIPECP). The CIPECP assists in the development, implementation and assessment of LSUHSCNO-related IPE activities. More specifically, the CIPECP coordinates student education in IPE across all LSUHSCNO schools and programs using a team-based, patient-centered lens and promotes faculty development in IPE. One of the initial goals of the CIPECP was to develop a foundational IPE curriculum for all LSUHSCNO students. The realization of that goal is Team Up™, a two-year required IPE curriculum for first and second year LSUHSCNO students. Team Up™ is predominantly classroom-based and engages students in small group discussion, with the exception of presenting culminating projects at the end of Year 1 and Year 2. Through small group discussions and projects, students applied interprofessional behavioral competencies as defined by the Interprofessional Education Collaborative.⁶

The inaugural year of Team Up™, 2017-2018, included only first year students from the Schools of Allied Health Professions, Dentistry, Medicine, Nursing and Public Health. Students were organized into 65 teams, with 9-11 students per team. Student teams remained together for the two-year period. IPE learning experiences occurred on a monthly basis from 4-6pm during the months of September, October, November, January, February, March and April for a total of 14 two-hour sessions. Class sessions were held at both campuses, LSUHSCNO main campus and the School of Dentistry campus, approximately five miles from main campus. Eleven teams met on the School of Dentistry campus and 54 teams met on the main campus. During the second year of the curriculum, the 11 student teams that met on the School of Dentistry campus met on the main campus, and 11 student teams that met on the main campus during year 1 met on the School of Dentistry campus. Alternating campuses provided students the opportunity to experience both environments. Student teams used small and large traditional classroom spaces on both campuses.

The number of faculty facilitators varied for each session. Some student teams had a consistent faculty facilitator for the entire first year and other student teams shared variable faculty facilitators with 2-3 student teams. Faculty facilitators represented all six Schools. All faculty facilitators were required to attend at least three training sessions: 1) an overview of IPE, 2) an overview of the Team Up™ curriculum and 3) a review and discussion of the monthly topic. A faculty training session was provided for each topic in Year 1 and 2 of the curriculum.

The focus of the first year of the Team Up™ curriculum is for students to build interprofessional teams developing effective communication and collaboration skills. In addition to monthly small group discussions, students apply their teamwork and communication skills through the Health Partner Project. The Health Partner Project provides an opportunity for student teams to interact with a community member over a series of three planned visits. Students learn about the Health Partner’s health, health goals and health care lived experiences. Based upon this information, student teams develop a community resource list to support the community member’s health goals. With the exception of the final presentation of the Health Partner Project in April, all activities related to the project occurred outside of monthly Team Up™ sessions.

The focus of the second year of the Team Up™ curriculum is to enhance student knowledge about professional roles while applying collaborative skills through case-based learning. Cases cover a wide spectrum of patient/client conditions with a focus on primary and secondary prevention. The culminating project is the development of an interprofessional primary or secondary annual wellness visit specific to an age or medical condition and is presented through a poster.

For the 2018-2019 academic year, the CIPECP decreased the number of student teams to 60, based upon classroom and faculty facilitator resources and availability. In addition, the students from the School of Graduate Studies joined Team Up™ Year 1. With this addition, Team Up™ was officially a required component of the curriculum for each of the six LSUHSCNO schools. The months of engagement, number of campuses and the number classroom spaces utilized remained the same. As a result of these changes, the average number of students per team increased to 10-13.

Participants

The Program in Dentistry at LSUHSCNO is a four-year program and accepted 65 students in 2017 and 75 students in 2018. Students entering in 2017 were known as the Team Up™ 2017 Cohort for the two-year period (2017-2019). Students entering in 2018 were known as the Team Up™ 2018 Cohort for the two-year period (2018-2020). Dental students in the Team Up™ 2017 and 2018 Cohorts were required to complete the survey as a component of the IPE curriculum.

Survey Instrument

The Student Perceptions of Interprofessional Clinical Education-Revised instrument, version 2 (SPICE-R2) was used to measure student IPE perceptions. Prior studies including dental students established its validity and reliability in this population.^{16, 21} SPICE-R2 includes ten items across three factors (i.e., subscales): Interprofessional Teamwork and Team-based Practice (TW, 4 items), Roles/Responsibilities for Collaborative Practice (RR, 3 items), and Patient Outcomes from Collaborative Practice (PO, 3 items) (Table 1). Students rate their level of agreement using the following 5-point Likert-type scale: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree. Mean change scores for the overall instrument (items 1-10) and for each of the three subscales are calculated as a method to assess perception change following a defined IPE intervention.

Table 1.

SPICE-R2 Items and Respective Factors

	Question	Factor
1.	Working with students from different disciplines enhances my education.	Teamwork
2.	My role within an interprofessional team is clearly defined.	Roles/Responsibilities
3.	Patient/client satisfaction is improved when care is delivered by an interprofessional team.	Patient Outcomes
4.	Participating in educational experiences with students from different disciplines enhances my ability to work on an interprofessional team.	Teamwork
5.	I have an understanding of the courses taken by, and training requirements of, other health professionals.	Roles/Responsibilities
6.	Healthcare costs are reduced when patients/clients are treated by an interprofessional team.	Patient Outcomes
7.	Health professional students from different disciplines should be educated to establish collaborative relationships with one another.	Teamwork
8.	I understand the roles of other health professionals within an interprofessional team.	Roles/Responsibilities
9.	Patient/client-centeredness increases when care is delivered by an interprofessional team.	Patient Outcomes
10.	During their education, health professional students should be involved in teamwork with students from different disciplines in order to understand their respective roles.	Teamwork

Analysis

Students who completed the survey were included in the analysis, which was performed using the Statistical Analysis System (version 9.4) using paired data sets. Cronbach’s alpha was calculated for the overall instrument and each factor to confirm reliability of SPICE-R2 in the LSUHSCNO population. Significance of mean change scores were calculated using t-tests, and Cohen’s d was calculated to determine effect sizes.²² A one-way analysis of variance was used to compare scores across cohorts.

RESULTS

Sixty-four students in cohort 2017 and 70 students in cohort 2018 completed the SPICE-R2. Cronbach’s alpha for reliability was very good for the overall SPICE-R2 instrument and ranged from good to very good for the three factors (total=0.84; factor 1 [TW]=0.84; factor 2 [RR]=0.75; and factor 3 [PO]=0.79). Tables 2 and 3 provide a summary of descriptive statistics for student cohorts 2017 and 2018, respectively.

Table 2.

Mean, standard deviation (SD) and Cohen’s d for dental student cohorts 2017 and 2018

	Cohort 2017 (n=64)			Cohort 2018 (n=70)
	Pre [Mean (SD)]	Post [Mean (SD)]	Change [Mean (SD)] Cohen’s d	Pre [Mean (SD)]	Post [Mean (SD)]	Change [Mean (SD)] Cohen’s d
Factor 1 (TW)	14.51 (2.94)	16.03 (3.40)	1.51* (2.10) 0.72	14.88 (2.27)	16.90 (2.43)	2.01* (2.51) 0.80
Factor 2 (RR)	9.39 (2.45)	11.18 (2.32)	1.79* (2.20) 0.81	9.37 (1.94)	12.04 (1.75)	2.67* (2.24) 1.19
Factor 3 (PO)	11.17 (2.28)	12.14 (2.56)	0.96* (1.51) 0.64	11.57 (1.76)	12.88 (1.89)	1.31* (1.71) 0.76
Total SPICE-R2	35.07 (6.58)	39.35 (7.80)	4.28* (5.07) 0.84	35.82 (4.33)	41.82 (5.52)	6.00* (5.38) 1.11

^*notes p<0.05

Cohen’s d: 0.20 (small effect); 0.50 (medium effect); 0.80 (large effect)

Table 2 provides descriptive statistics for means and mean differences. When using the retrospective pretest/posttest design at the end of year 2, mean scores positively changed for both student cohorts. Statistical significance (p<0.05) with medium and large effect sizes was found for all factors and total SPICE-R2 scores. The largest mean change was noted in the RR factor for both cohorts. The change in mean scores is larger for the 2018 dental student cohort.

DISCUSSION

A goal of IPE is to develop collaborative practice ready health professionals. Many institutions use attitudinal and perception surveys to measure IPE outcomes in early learners. Although the outcomes from these surveys cannot predict behaviors, IPE researchers use the Theory of Planned Behavior²³ to support the use of these validated instruments. If the decision to change behavior is directly related to a change in attitudes and beliefs,²³ using instruments like the SPICE-R2 throughout an academic journey provides insight to IPE curricula impact. This study is a follow-up to a previously published article establishing a baseline for IPE perceptions within the same dental program, which found no change in perception scores with no IPE intervention or engagement in a single annual IPE activity.¹⁰

This subsequent study found positive perception changes in two dental student cohorts after engaging in a two-year longitudinal IPE curriculum using a retrospective pretest/posttest design. At the end of the Team Up™ curriculum, the largest difference in mean scores was noted in the RR factor, followed by the TW and then PO factors for both student cohorts. Finding statistical significant differences in all three factors is an important outcome as it indicates a shift in three foundational IPE constructs. This finding is different than Lockeman et al. and McGregor et al. which measured dental student perceptions using the SPICE-R2 after two months and one semester, respectively.^16,17 Detailed curricula comparisons cannot be made between the two institutions. However, frequency and duration of IPE exposure can be compared.

Results from Lockeman et al. indicated no change in dental student perceptions after four, 90 minute sessions provided over a period of two months.¹⁶ After one semester of 13 IPE sessions provided through a one-hour credit course, McGregor et al. found dental students’ perceptions improved in the RR factor only.¹⁷ After engaging in Team Up™ for two years, 13-14 sessions, the two dental student cohorts described in this study improved their perceptions of IPE in all three factors. Although the number of sessions was comparatively the same to McGregor et al.¹⁷, delivering IPE over a longer period of time might provide an opportunity for students to strengthen their attitudes regarding teamwork and its impact related to patient outcomes, as they learn more about their own professional role. This finding provides support to HPAC’s guidance on an integrated curriculum throughout the length of an academic program.

The Center for Interprofessional Education and Collaborative Practice at LSUHSCNO will continue to refine the IPE longitudinal curriculum as needed to improve student learning. Curricular changes, such as new topics, refinements to cases and reflections, could have influenced the greater change in mean differences and effect sizes post-Year 2 for the 2018 cohort (Table 2). However, further investigation is needed. Future considerations to further enhance student learning includes increasing active learning through the use simulation and clinical experience exposure.

Attitudinal and perception surveys are one aspect of measuring student IPE outcomes, future research should include a more comprehensive analysis of other measurements, such as knowledge, and/or the use of other theories or frameworks. While findings from this study add to the literature, the use of a control group and/or a multi-institutional study would increase the rigor of the methodology and strengthen the outcomes in this research area.

CONCLUSION

This study provides initial evidence that longitudinal experiences past one semester can have a positive impact on IPE perceptions using the SPICE-R2 in a retrospective pretest/posttest design. As we continue to recognize the importance of team-based interprofessional approaches to person-centered care,²⁴ the future of dental education and practice will need to continue evolving to produce clinicians ready to positively impact the future workforce.²⁵ Interprofessional education and collaboration will continue to grow in importance as dental education changes and evolves.²⁶ More longitudinal research, including and expanding past perception data, is needed specifically for dental students. Additionally, it is necessary for dental education programs to collaboratively measure IPE outcomes across various insitutions and curricular approaches to determine best practices in delivery and learning.