‘We might as well be speaking different languages’: an innovative interprofessional education tool to teach and assess communication skills critical to patient safety

Abstract

Introduction

All practicing health professionals must be able to communicate effectively with their colleagues around the care of patients. Better communication between health professionals not only improves patient outcomes, but also cuts down on costly and unnecessary tests or healthcare services. At New York University (NYU), we have addressed the need for interprofessional education (IPE) by incorporating a set of interprofessional objective structured clinical examinations (OSCEs) cases into our performance-based assessment programme to expand the educational tools for interprofessional collaborative (IPC) practice, assessment and feedback.

Methods

We identified and operationalised IPC competencies to create an assessment tool for use in IPC clinical cases, delineating core domains and then identifying observable behaviours that represented the broader competencies. IPC cases (for use in OSCEs) were designed in a way that required medical students and residents to collaborate effectively with a health professional from another discipline (standardised registered nurse (RN)) in order to provide quality care to a (standardised) patient. Feedback from the standardised RN and the participants was content analysed and our own experience in implementing was described.

Results

This method demonstrates that IPC practice can effectively be incorporated into medical education training and assessment, at the undergraduate and graduate level. We found high internal consistency among items within each of the core IPC competency domains (Cronbach's α 0.80–0.85). Based on both standardised RN and faculty feedback, the cases were effective in discriminating among learners within and across undergraduate medical education (UME) and graduate medical education (GME) levels, and within learners, in identifying individual strengths and weaknesses. Learners found these cases to be realistic, challenging and stimulating.

Conclusions

OSCE-based IPC training is a feasible and useful methodology. Ultimately, IPC OSCE cases are training tools that provide learners with a safe environment to practice, receive feedback and develop the critical skills needed for our evolving healthcare system. The next steps are to expand the scope of IPE cases to include more team members, and team work to also incorporate faculty development to ensure that our teachers and role models are effective in providing feedback on IPC practice.

Introduction

All practicing health professionals must be able to communicate effectively with the healthcare team in order to effectively care for patients.¹ Better communication between health professionals not only improves patient outcomes, but also cuts down on costly and unnecessary tests or healthcare services. While the health profession's education has traditionally occurred in professional silos (eg, MDs with MDs by MDs, nurses with nurses by nurses), there has been an international movement to change this from uniprofessional to interprofessional education (IPE). The US healthcare system is now embracing new models of care that rely heavily on effective interprofessional collaborative practice. The two most prevalent of these models are the patient centered medical home and the accountable care organisation, which focus on team-based patient care and reduction of communication errors to streamline the healthcare system and cut costs.²

The health profession's educators are responding innovatively to meet the need to prepare trainees for effective and safe interprofessional practice. Because recent studies have identified that many medical errors stem from a lack of communication between the members of the medical team,³ there has been an increased focus on teaching interprofessional communication skills at the undergraduate and graduate levels of health profession training. Current methods employed include online modules, mixed classroom experiences, shadowing experiences and a growing number of simulation activities.⁴

Although often lumped together with general patient-focused communication skills, teaching interprofessional collaboration is a unique skill set that requires attention to attitudes about roles, and focused teaching, feedback and assessment to adequately prepare learners for team-based work in professional life.⁵ Despite these findings, specific curricula for medical students and residents are still evolving and there is limited experiential training. Though a few studies have been conducted to gauge the efficacy of targeted IPC training,⁶ almost no programmes incorporate simulated practice, feedback and assessment of an interprofessional situation. At New York University (NYU), we have addressed the need for IPC education by incorporating a set of IPC objective structured clinical examinations (OSCEs) cases into our performance-based assessment programme to expand the educational tools for interprofessional collaborative (IPC) education.

OSCE for IPC learning

OSCEs are training or assessment programmes in which learners rotate through a series of timed ‘stations’ during which they interact with actors who are highly-trained to both portray a patient and assess the quality of the communication skills using a rating forms with predetermined performance criteria. These actors are referred to as standardised patients (SPs). OSCEs are highly valuable teaching tools in the healthcare professions because they provide opportunities to address multiple dimensions of care, those being, preparation, clinical reasoning, time management, preventive medicine, error prevention and complex potential stressful situations in a standardised and low risk setting.⁷ OSCEs generate accurate and reproducible information about several dimensions of performance, which makes them appealing tools for formative and summative learning experiences. OSCEs are increasingly common in graduate medical education,⁸ and are used throughout nursing students’ and medical curricula.^9–11 OSCEs have been developed to address the full range of competencies, and generate useful and unique feedback about performance in areas that may be difficult to evaluate by traditional means.^12–14 Debriefing OSCE performance provides the ability to note, investigate and to start closing salient performance gaps.¹⁵ Interprofessional collaborative OSCE cases allow educators an outstanding opportunity to teach and assess the next generation of healthcare professionals in these new core competencies.

Operationalising IPC competencies for assessment purposes

While there is no widely accepted definition of IPC in the healthcare literature, there is a growing consensus on its core ingredients, which include recognising common goals, establishing trust, demonstrating respect and using specific collaborative skills. Within medicine, two key competency frameworks have incorporated the IPC process as essential to effective practice. The first framework, developed through expert consensus, is called the Physician Competency Reference Set (PCRS),¹⁶ which includes the IPC system as a distinct competency category. In this framework, physicians are expected to “demonstrate the ability to engage in an interprofessional team in a manner that optimises safe, effective patient- and population-centred care”. Competencies within this category include:

• Work with other health professionals to establish and maintain a climate of mutual respect, dignity, diversity, ethical integrity and trust

• Use the knowledge of one's own role and the roles of other health professionals, to appropriately assess and address the healthcare needs of the patients and populations served

• Communicate with other health professionals in a responsive and responsible manner that supports the maintenance of health and improves patient outcomes

• Participate in different team roles to establish, develop and continuously enhance interprofessional teams to provide patient-centred and population-centred care that is safe, timely, efficient, effective and equitable.

In addition, residency programmes are using the concept of entrustable professional activities (EPAs), units of professional practice, to determine when trainees can be trusted to perform relevant functions without direct supervision.¹⁷ The IPC process is a core EPA in virtually all medical specialties. For example, in internal medicine, 1 of the 16 core EPAs that constitute the profession is to lead and work within interprofessional healthcare teams. Defining EPAs allows faculty to make informed decisions about the level of supervision required by trainees when engaging in actual IPC practice.

While many argue that the best way to learn IPC skills is by engaging in synchronous, interactive IPE activities,¹⁸ there are many significant barriers to doing this, including the difficulty of aligning medical and nursing student schedules and curricular time, and of finding time for residents and nursing staff to learn together outside of the busy clinical context. We developed IPC OSCE cases to assess whether our trainees should be trusted to practice the IPC system independently. We started by identifying and developing a core set of IPC practice skills that could be addressed in an OSCE, and then reinforced it in actual practice through supervisor feedback, and cycles of reflection and deliberate practice. We followed Barr's¹⁹ division of the types of competency into those that are common or overlapping across health professionals (eg, core communication and history gathering skills, clinical reasoning, etc); those that are complementary (ie, competencies that enhance the qualities of other professions in providing care); and those that are distinctly collaborative in that they are the competencies that each profession needs in order to be able to work together effectively with other health professionals. We focused on this last type of competency—the set of skills needed by medical students and residents to be able to effectively collaborate with other health professionals. Therefore, our goals in developing the IPC OSCE cases were to provide students and residents with structured opportunities to:

1. Understand what it takes to engage in effective interprofessional collaboration;

2. Understand the impact of interprofessional collaboration on patient care; and

3. Practice and receive feedback on the specific skills necessary for effective interprofessional collaborative practice.

In this paper, we describe how we identified and operationalised core IPC competencies in order to create a performance-based IPC assessment tool, describe the design of cases that call for and provide feedback on the enactment of these core IPC competencies, and share our experience implementing this with our learners.

Methods

Developing IPC competencies assessment

We modelled our assessment after the shared competency model developed by the Interprofessional Education Collaborative (IPEC).²⁰ This model, developed by experts across healthcare professions and endorsed by the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Society of Public Health, the American Association of Colleges of Pharmacy, the American Dental Education Association and the American Association of Medical Colleges, represents a common core set of competencies relevant across the professions and identifies the essential knowledge, values, attitudes and, most importantly, skills that prepare healthcare professionals for effective collaborative practice.

The IPEC competency framework is based on four broad domains of competency: (1) values/ethics for interprofessional practice, (2) roles/responsibilities, (3) Inter-professional Communication, and (4) Teams and Teamwork. For example, the cases requiring a medical student or resident to recognise and respond to an error in care (systems-based practice and commitment to quality) were designed to ensure that the learner could “work with individuals of other professions to maintain a climate of mutual respect and shared values”, which is the IPEC's general competency representing values/ethics for interprofessional practice. Within that general competency, successful resolution of these cases depended on three specific values/ethics competencies:

• Respect the unique cultures, values, roles/responsibilities and expertise of other health professions.

• Work in cooperation with those who receive care, those who provide care, and others who contribute to or support the delivery of prevention and health services.

• Develop a trusting relationship with patients, families and other team members.

The challenge, however, in measuring whether learners exhibited these competencies in a clinical situation is that they are too general and abstract to evaluate consistently and accurately. We therefore translated these into the specific behaviours in this clinical situation that would serve as indicators that the learners could call on the competencies when needed. Table 1 shows our general IPC assessment tool with individual items within each of the 4 broad IPEC competency domains as well as the specific behavioural anchors for each item.

Table 1.

Assessing interprofessional collaborative (IPC) practice in standardised ‘healthcare professional’ cases: sample IPC checklist

IPC competency domains	Checklist item (skill)	Not done	Partly done	Well done
Values/ethics	Expressed value for the information RN provides	Did not listen or dismissed	Attended to information	Attended to information AND expressed value of information
	Responded well to RN suggestions	Did not listen or dismissed	Listened to suggestions but did not act on them	Listened to and acted on suggestions
	Treated RN respectfully (responded to RN as a person, treated as a colleague; not condescending)	Did not treat respectfully/was condescending	Responded to RN as a person but not as a colleague	Responded to RN as a personal, equal colleague
Roles/responsibilities	Introduced self and role	Did not introduce	Introduced self but not role	Introduced self AND role
	Discussed, roles, responsibilities and task distribution	Did not do	Discussed roles/ responsibilities but not task distribution	Discussed roles/responsibilities AND task distribution
Interprofessional communication	Used SBAR format to organise clinical data when presenting case to the RN	Discussed case information in a disorganised manner, leaving out pertinent elements of the case	Discussed case in a somewhat organised fashion but did not use SBAR	Fully employed SBAR in presenting case
	Used CUS to communicate mistake respectfully	Did not do	Communicated mistake but did not use CUS and/or was not respectful	Communicated mistake using CUS respectfully
	Fully explored RN knowledge of problem (concerns, symptoms, ideas, conclusions)	Did not explore	Partially explored	Fully explored
	Explored RN assessment of situation	Did not explore	Asked about but did not fully explore	Fully explored including RN's conclusions
	Determined what RN has done for the patient	Did not elicit or did not pay attention	Elicited or paid attention to some but not all	Fully elicited and paid attention
Teamwork	Discussed and developed follow-up plan with RN	Did not do	Discussed follow-up plan and allowed RN input	Developed follow-up plan in collaboration with RN
	Managed team in crisis (recognised need to ‘stop the line’ and got everyone's attention)	Did not recognise	Recognised and tried to ‘stop the line’ but was only somewhat successful	Recognised and effectively engaged team in responding to crisis

CUS, concern, uncomfortable, safety issue; RN, registered nurse; SBAR, situation, background, assessment and recommendation.

Creating IPC cases

We developed a set of OSCE cases focused on interprofessional collaboration for medical students, residents and nurses, which allow learners to both practice their skill set and reflect on their current capabilities (table 2). These cases were developed by two clinical educators, a nurse and an education assessment expert, using a standard case development process.⁷ Each case was designed as a 10–15 min encounter. All cases underwent iterative revisions and re-enactments, with input from a broad range of faculty and learners, to ensure that the clinical scenario and details adequately called for the predetermined competencies.

Table 2.

Interprofessional collaboration OSCE cases—physician trainees collaborating with nurses

Case	Case details	Learner	Case objective(s)	Interprofessional objectives	Clinical condition	Setting/visit	Standardised health professional
Acute systems-based practice Check back error	Learner sees patient with acute onset dyspnoea and must present case to nurse and build a collaborative action plan	Medical student (MS3)	Accurately develop dyspnoea treatment plan in collaboration with nurse	▸ Elicit and obtain information from team members ▸ Present information to team members	Acute	Emergency room	RN
Non-acute systems-based practice Clinical protocol error	Patient returning for a nurse visit to recheck laboratories and follow-up after being started on blood pressure medication 3 weeks prior. Nurse rechecks blood pressure but does not recheck laboratories. Learner must respectfully educate nurse on proper protocol and make an action plan with the nurse.	Medical resident (PGY1,2,3)	Recognise and professionally alert RN to a medical error Develop follow-up plan to remedy error and get patient to return for needed care	▸ Interact respectfully ▸ Communicate effectively with team members ▸ Work to improve quality of care	Chronic	Outpatient Follow-up	RN
Phone consult Clinical protocol and check back error	In a phone conversation, the learner must correctly identify a medication error made by the nurse and use collaboration and education to work with the nurse in order to treat the patient	Medicine Resident (PGY1, 2, 3)	Work collaboratively with RN on the phone to develop patient's diabetes treatment plan	▸ Recognise and act within role and task distribution ▸ Delegate tasks/responsibilities	Chronic	Outpatient follow-up Phone	RN (Phone)
Acute case collaboration	The learner must make the correct diagnosis of right ventricular infarct or ruptured abdominal aneurysm and maintain a calm and professional manner in the crisis when interacting with the patient and the nurse	Medicine Resident (PGY 1, 2,3)	Accurately diagnose RV-infarction or right sided infarct while leading a medical team in a crisis situation	▸ Engage team ▸ Manage conflict ▸ Develop interprofessional treatment plan	Acute	Emergency Room	Patient RN
Difficult colleague	The learner must collaborate on the phone with an irate ER resident who has been waiting for a consult for hours to develop a plan for a patient with ovarian torsion	OB/GYN Resident	Ensure accurate diagnosis of ovarian torsion Calm an irritated colleague and refocus on patient care		Acute	Outpatient	ER resident
Transfer of care	The learner must collaborate with the primary care provider to develop a comprehensive plan for the discharge of a patient with mitral regurgitation	Medicine resident (PGY 1,2,3)	Ensure that comprehensive IPC plan is completed prior to discharge of an elderly patient Encourage optimal inpatient to outpatient handoff		Acute	Outpatient and inpatient	Resident

ER, emergency room; IPC, interprofessional collaborative; MS, medical student; PGY, post-graduate year; RN, registered nurse; RV, right ventricle.

Obtaining feedback from learners and standardised health professionals

After completing the assessment tool shown in table 1, the standardised health professionals also provided open-ended comments in response to a request to reflect on the IPC skills of the learners. Our resident learners were asked, after they completed the multi-station OSCE in which the IPC case was embedded, to rate the realism of each case and to describe what was challenging about each case. Both sets of comments were content analysed using a simple process of coding the content and organising by themes with review by co-authors and discussion to achieve agreement.

IPC cases

The six IPC cases we developed are outlined in table 2, and we have provided greater detail on the four general medicine cases.

Sample OSCE cases

Acute systems-based practice (check back error)

Participants: Standardised nurse (SN) and a fourth year medical student.

Goal: To complete an interdisciplinary care plan with a nurse.

The scenario: The medical student will have just spent 15 min interviewing a patient in an urgent care setting with a chief complaint of shortness of breath. The SN is instructed to play the role of a nurse who has many years of experience working with an array of providers and can find it difficult to work with such young students and doctors because his or her experience is so much greater than theirs. He or she has had a very long day and is tired. The SN starts by asking the medical student to tell him or her about the patient. If the student does not introduce themselves the SN should ask them their level of training. The student is allowed to speak as much as he or she wants. If the student presents the case using SBAR (situation, background, assessment and recommendation), the SN is instructed to respond positively and become a partner in the patient's care. The SN is instructed to respond with more prompting questions if the medical student does not use SBAR or offers vague or short answers during the assessment. Once the student moves on to recommendation, the student is allowed to create a plan of action. If the student collaborates with the SN, then the nurse engages as an active participant in the plan. If the student is not respectful or does not include the SN in the plan, then the SN is instructed to challenge the student. Once the student has presented a plan, the SN is instructed to use check-back to confirm the plan and to insert a basic mistake during the process. The mistake can vary but the default mistake was to say ‘so I will start the antibiotics…ok?’. The goal is to have the student respond with CUS (concern, uncomfortable, safety issue).

Non-acute systems-based practice (clinical protocol error)

Participants: SN and resident.

Goal: To formulate a plan with the SN to adapt the treatment plan for the best care of the patient. The resident is expected to use communication strategies such as SBAR and CUS to explain the situation and assess the SN's clinical error.

Scenario: The patient is a 50-year-old African-American man with a history of hypertension. The resident saw this patient 3 weeks earlier for refills on his medications. The patient's blood pressure (BP) was 160/95 and the resident scheduled him for a nursing visit in 4 weeks for a BP and lab check, and opted to give the patient benazepril. Now, on the follow-up nurse visit, the SN checks the patient's BP and finds that it is 148/92, which she thinks is excellent, and sends him back home, asking him to return to clinic in 6 months. The SN does not address if the patient has had his laboratories drawn to address the new medication. The SN approaches the resident to sign off on the nursing visit. Ideally, the resident should be spending the majority of time assessing the SN's knowledge and educating the SN about caring for patients with hypertension and discussing the plan. The resident should identify the SN's mistake (that the patient's BP is too high and he needs a basic metabolic) and address it respectfully using SBAR and CUS. Ideally, if the resident has made the SN feel comfortable, educated and taught about the error, the SN will offer to call back the patient.

Phone consult

Participants: SN and a resident.

Goal: Interprofessional collaboration between the SN and the resident learner caring for a patient in clinic while the resident is off site. The resident is expected to use communication strategies such as SBAR and CUS to explain the situation and assess the SN's clinical error.

Scenario: The case involves a resident who is on a busy inpatient rotation, who is not going to be in the clinic for 2 weeks and has asked the patient to come in for a nurse visit for medication compliance, to check BP and for a review of the blood test results. The patient is a 55-year-old woman with diabetes, hypertension and osteoarthritis of the knee, who takes insulin, metformin, benazepril, simvastatin and aspirin. The SN calls the resident on the phone to report the medications that the patient has brought and her sugar level. The SN is programmed to ask the resident whether she can increase the patient's dose of metformin because of the newly documented high sugar. Ideally, the resident should ask for the current medications and laboratory result and would recognise that due to the patient's worsening kidney function, the metformin should be stopped and the insulin increased. The resident should identify the mistake of increasing metformin and answer using CUS. Once the resident creates a plan, the SN confirms the plan and is instructed to make a mistake on closing the loop. If the resident has effectively engaged the SN in the plan, the SN is instructed to be active and helpful in offering to set the patient up for follow-up. If the resident did not partner with the SN, the encounter ends with the SN moving to the end of the call without offering to help the resident obtain care for the patient.

Acute case collaboration

Participants: SN, SP and resident.

Goal: To assess and manage a patient in critical condition with the SN as a partner.

Scenario: The patient is brought in by ambulance, presenting with squeezing chest pain, which came on suddenly at rest. The interview challenge is to not only make the correct diagnosis of right ventricular infarction or a ruptured abdominal aneurysm (depending on scenario), but to maintain a calm and professional manner in a crisis when interacting with a patient and a nurse. The SN is instructed to act engaged and be extremely helpful if the resident introduces himself or herself, and works respectfully and collaboratively to define roles and responsibilities. The SN is trained to administer medication, report the responding effects and present laboratory reports should the resident ask for them. If the resident does not huddle with the SN to discuss the case and develop a care plan, then the SN is programmed to make sure to ask what he or she thinks is going on. If the resident seems paralysed and has shown a respectful manner that promotes interprofessional care, the SN can prompt the resident with questions such as ‘what would you like to do?’ or ‘would you like me to send labs?’.

Results

IPC assessment

As illustrated in table 1, value competencies around respect, trust, cooperation and high standards of care were operationalised as directly expressing/communicating that the learner valued the information the RN provided, being responsive to the RN's suggestions and being respectful. We developed not done, partly done and well done anchors for each of these behaviours, with the well done anchor establishing the ‘standard of care’. For example, learners were judged to have demonstrated respect when they treated the RN as an individual and expressed value for the RN's input. The built-in element of recognising and responding to an error, set the context for high standards of ethical conduct and quality of care, and managing ethical dilemmas; however, we assessed the learner's actual skill in addressing the error effectively as a specific communication skill, building on the use of the CUS approach.

Within the domain of roles/responsibilities, we focused on the very basic skill of the learner introducing not only herself but her role in this particular clinical context, and then the more advanced skill of explicitly discussing roles and responsibilities, and especially the distribution of tasks with the RN.

This assessment tool is used by the standardised healthcare professionals to evaluate the performance of the learner. For each OSCE case, actors were trained to be either a SN or resident by expert SP trainers for 2 h for character training (details of cases and proper portrayal in attitude, tone and pacing) and for 2 h on behavioural-specific checklists developed by an inter-disciplinary team. Overall, across several samples and OSCEs (160 medical students annually and approximately 50 residents annually for 3 years), the items within each domain have been internally consistent (Cronbach's α >0.80; table 3), providing evidence that these competencies are distinct and conceptually meaningful competencies that represent IPC practice.

Table 3.

Internal consistency-IPC competency domains

IPC competency domains	Checklist item (skill)	Internal consistency (Cronbach's α)
Values/ethics	Expressed value for the information registered nurse provides	0.85
	Responded well to registered nurse suggestions
	Treated registered nurse respectfully (responded to registered nurse as a person, treated as a colleague; not condescending)
Roles/responsibilities	Introduced self and role	0.82
	Discussed, roles, responsibilities and task distribution
Interprofessional communication	Used SBAR format to organise clinical data when presenting case to the registered nurse	0.81
	Used to communicate mistake respectfully
	Fully explored registered nurse knowledge of problem (concerns, symptoms, ideas, conclusions)
	Explored the registered nurse's assessment of situation
	Determined what the registered nurse has done for the patient
Teamwork	Discussed and developed follow-up plan with registered nurse	N/A (not assessed in same case; separate items)
	Managed team in crisis (recognised need to ‘stop the line’ and got everyone's attention)

CUS, concern, uncomfortable, safety issue; IPC, interprofessional collaborative; SBAR, situation, background, assessment and recommendation.

Standardised health professional (nurse) and learner feedback

SNs provided insightful feedback to the learners about the IPC skills. Content analysis showed that, with respect to interprofessional communication, a common theme was the importance of eliciting information from the nurse as well as listening to the nurse for vital information. The SNs also provided feedback in the realm of teamwork, highlighting the importance of partnership and engaging with the nurse to form a team. A final theme was balancing competencies. SNs pointed out that while some learners worked to make the nurses feel like part of the healthcare team, they missed other objectives of the case; other learners handled core clinical tasks effectively while failing to elicit critical information from the nurse.

Learners found these cases to be challenging and stimulating. In all iterations of the case, a strong majority of residents reported that the case was realistic (>70%). Table 4 provides a summary of common themes and exemplar quotes from surveys that learners completed after the OSCEs in which these cases were embedded, when asked to indicate what was challenging about the IPC case.

Table 4.

Challenging aspects of the case for learners

IPC domains	Common theme	Exemplar quotes
Values/ethics	Difficulty bringing up error	“Correcting the registered nurse's mistake”. “Notifying the registered nurse of her mistake”.
	Lack of comfort ‘teaching’ another healthcare professional	“Having no experience with registered nurse precepting”.
Roles/responsibilities	Understanding of roles	“Understanding the role of the registered nurse”.
	Acting on role definition/defining responsibilities	“Figuring out how best to involve the registered nurse”. “I wasn't clear on the goal. I focused on the patient rather than on the registered nurse”.
Interprofessional communication	Differences and balance of communicating with patient versus registered nurse	“Trying to improve my communication with the registered nurse”. “Communicating effectively with both the patient and the registered nurse”.
	Failing to elicit needed information from the RN/Failing to communicate about collaboration	“Realising I should have gotten more information from the registered nurse and then made better use of her”.
Teamwork	Failing to work as a team	“Forgetting to ask the registered nurse about the follow-up plan”. “Figuring out how and who should do what parts of the follow-up plan without asking the registered nurse what he or she could or should do”.

Discussion

At NYU, we have addressed the need for IPC education by creating and implementing a set of IPC OSCEs cases that could be integrated into our performance-based assessment programme to expand the educational tools for interprofessional collaborative (IPC) education, training and feedback. These cases have been adopted and adapted with our medical students and among a growing number of our residency programmes (Primary Care Internal Medicine, Categorical Internal Medicine, Orthopaedics and Surgery, to date) and requested by other institutions. It is important to note that our IPC cases are limited in that they focus on medical students and residents, and largely on interactions with RNs and not with the entire care team or other healthcare professionals. The cases were designed to focus on the interaction between a medical professional and a nursing professional both because that is a critical interprofessional competency we felt that our learners needed to further develop and due to the inherent challenges of implementing true team-based collaborative practice clinical scenarios. Our assessment of the broad IPEC competency of teamwork is therefore quite limited and focuses on development of an interprofessional follow-up plan, and in the one case where we were able to simulate a team, on engaging that team in recognising and responding to a crisis. Expansion of these IPC competencies is possible and needed. Using our framework for case development and assessment, colleagues in the OB/GYN Residency Program have created a team-based care case involving hybrid simulation (a ‘mom’ mannequin patient for resuscitation and a SP for interaction) and a SN in which the resident must work with a nurse to resuscitate a patient after delivery. Similarly, our GI Fellowship Program has created a team-based scenario to give fellows practice and feedback in managing a team in order to effectively respond to a colonoscopy complication.

Our use of these IPC cases has helped identify both curricula gaps and differences in how learners perform. Discussing the error the RN made was one of the most difficult aspects of the IPC cases for all learners. For medical students, this may well have stemmed from the fact that they were students interacting with an RN, but residents also reported difficulty in this area with one resident, for example, explaining that she had not had experience in ‘precepting’ nurses. The implication here is that what was difficult was correcting an error a nurse had made—that, had a fellow junior resident or medical student made an error, teaching them about that error would not have been difficult. Learners definitely reported that they struggled with understanding the role of the RN and tended to focus so much on the patient that they did not take full advantage of the contributions of the RN. This lack of clarification around roles and responsibilities led to communication challenges, and ultimately to difficulty in developing a truly interprofessional follow-up plan that could take advantage of the strengths and availability of two health professionals. We also made sure that our cases focused specifically on patient safety and effective transfer of information, in order to help our faculty and students adapt to new healthcare standards that improve outpatient safety. Addressing and practicing how one actually clarifies roles and responsibilities as part of formative learning will hopefully translate to the next generation of healthcare professionals’ workplace performance.

There is a need to expand these cases to other health professional learners. Our future plans include adapting these cases for nursing students and practicing nurses to hone their interaction with physicians and other non-nursing disciplines. We also plan on expanding our cases to include other healthcare professionals (eg, physician's assistants, cross-discipline specialties and social workers) and cases that focus on team-based patient care. In addition, IPE cases should also be used for faculty development to ensure that our teachers/role models are effective in providing feedback on IPC skills. OSCE-based IPC training is a feasible and useful methodology. Ultimately, IPC OSCE cases are training tools that provide learners with a safe environment to practice, receive feedback and develop the critical skills needed for our evolving healthcare system.