Abstract
Context:
Mastering the art of assessing interprofessional outcomes has been a topic of interest in academic research. Specifically, the Interprofessional Education Collaborative has been publishing thorough bodies of work that aim to strengthen teamwork among health professionals and reinforce competencies that will lead to better patient care.
Objective:
To determine osteopathic medical students’ perceived effectiveness of simulated clinical experiences in cultivating interprofessional competencies with nursing students.
Methods:
Second-year osteopathic medical students (classes of 2016 and 2017) and nursing students participated in a simulated clinical experience using a simulated patient mannequin. Students were assessed on clinical and humanistic skills using graded evaluations performed by faculty and actors portraying family members and given feedback on their performance. Evaluation grades were not analyzed. Students were asked to complete an anonymous survey that assessed their attitudes toward the collaborative experience.
Results:
A total of 743 medical students participated in the study—371 from the class of 2016 and 372 from the class of 2017. Incomplete surveys (1 from the class of 2016 and 3 from the class of 2017) were included in the analysis. Statistically significant differences were found between the 2 classes of medical students in their responses to 2 items. With regard to appropriate patient data collection, the ranked distribution of scores was significantly greater for the class of 2014-2015 than for the class of 2013-2014 (mean rank, 389.3 vs 354.64, respectively; U=75,445.50; P=.017). For the item on effective communication with family members, the ranked distribution of scores was significantly greater for the class of 2014-2015 than for the class of 2013-2014 (mean rank, 390.61 vs 353.34, respectively; U=75,928.50; P=.006). Overall, medical students reported feeling better prepared to care for real patients after the simulation.
Conclusion:
Simulated interprofessional experiences during the second year of medical school may help prepare students to collaborate with other health care professionals in a clinical setting, take care of patients, and communicate with patients’ family members.
The health care system has undergone many changes in the past few decades, with renewed focus on safety, communication, and a holistic approach to patients.
1 There has been a distinct shift from the traditional hierarchical model of top-down physician-nurse interactions to a team-based model that may include a number of health care professionals, such as pharmacists, physical and occupational therapists, and social workers. Collaborative work ethic among health care professionals and caretakers has become a critical foundation in the development of health care curricula.
Six professional health care organizations (including the American Association of Nursing and the American Association of Colleges of Osteopathic Medicine) came together in 2009 to create core competency recommendations for interprofessional collaborative practice that would help with educational curricula development. The ultimate goal of this work group was to improve patient outcomes and to help prepare future health care professionals for team-based care. The
Core Competencies for Interprofessional Collaborative Practice2 document was published in 2011
2 and updated in 2016.
3 Four core competencies facilitate patient-centered care: (1) values and ethics (“work with individuals of other professions to maintain a climate of mutual respect and shared values”); roles and responsibilities (“use the knowledge of one's own role and those of other professions to appropriately assess and address the health care needs of the patients and populations served”); interprofessional communication (“communicate with patients, families, communities, and health professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease”); and teams and teamwork (“apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient/population-centered care that is safe, timely, efficient, effective, and equitable”).
2 These competencies form theoretical constructs that students must embody throughout residency and in their career.
In traditional health care education, no formal training in interprofessional communication and conflict resolution has been uniformly provided. Typically, medical students are not provided learning opportunities to interact with nurses, patients, and family members until their third-year clinical rotations. Concern about medical errors and inadequate supervision of students and residents has made it increasingly difficult for medical students to bridge the gap between theoretical knowledge and application of clinical skills.
4
Simulation, long popular in fields such as aviation and law enforcement, is being used with increasing frequency in medical education.
5 The Lake Erie College of Osteopathic Medicine-Bradenton (LECOM-Bradenton) and the State College of Florida (SCF) Manatee-Sarasota nursing department created a joint program using the latter's state-of-the-art simulation facility to provide these educational clinical experiences in a safe and supportive environment. Simulation-based experiences with patient simulators allow educators to approach training from a patient-centered perspective.
6 This study was conducted to determine osteopathic medical students’ perceived value and effectiveness of simulated clinical experiences (SCEs) in cultivating interprofessional competencies. We also compared responses from 2 cohorts of osteopathic medical students.
This retrospective nonexperimental mixed-methods study was performed from the fall 2013 semester through the spring 2015 semester. The SCEs took place at SCF. These experiences were designed to simulate the first days of clinical rotation as residents. The SCEs are realistic enough to engage the students emotionally, thus providing a unique learning experience in which the mannequin actually talks, breathes, blinks, and moves like a real patient.
7 Second-year osteopathic medical students have 2 opportunities to participate in an SCE—the spring and fall semesters. After completing the SCEs, they participate in a comprehensive debriefing with medical and nursing faculty, the patient's nurse, and the actors portraying family members. Afterward, they answer a brief survey and provide comments.
The SCE program has several goals. It enables students to overcome any fear of interacting with patients, nurses, and families by providing a safe environment in which to make errors. Students are able to practice a complete bedside assessment for the first time and give a formal oral presentation to an attending just as they would on their rotations in residency. Finally, they are able to practice communication skills with standardized family members. We performed this retrospective study as the first phase of an investigation into how well students felt we were meeting these goals. The study was approved by the Lake Erie College of Osteopathic Medicine's Institutional Review Board, which waived the need for informed consent.
This study included second-year osteopathic medical students from LECOM-Bradenton, comprising 2 medical student cohorts from the graduating classes of 2016 and 2017. The 2016 cohort included second-year medical students who completed the SCE in fall 2013 and spring 2014. The 2017 cohort included second-year medical students who completed the SCE in fall 2014 and spring 2015. Although nursing students participated in the SCE alongside the medical students, we did not evaluate their responses.
Students were tasked with participating in an SCE by performing a history and physical examination on a high-fidelity human patient simulator. The medical case scenarios included acute myocardial infarction, metastatic lung cancer, long-bone trauma, and other common disease states. Medical students were assigned to work with a nursing student in completing the assigned tasks. The students were asked to report their findings to the attending physician in a standard SOAP (subjective, objective, assessment, and plan) fashion. The students then discussed the status of the patient with the family, portrayed by actors, who followed scripts to present difficult or stressful scenarios. Students were debriefed while watching a video-recorded playback of their personal simulation experience. Nursing staff and medical instructors provided constructive feedback and prompted students to personally reflect on the experience. After the debriefing, a graded evaluation was completed by faculty, assessing each student on his or her communication and professionalism with nurses, patients, and family, as well as their physical examination skills. The purpose of this evaluation was to provide students with informational and personal formative feedback. Raters had not completed intra- and interrater reliability training before the evaluations, and scores were not analyzed for this study. The SCEs were kept the same throughout the study; students were exposed to the same case type and same group of patient families.
After the SCE, students responded to survey items about attitudes toward their ability to communicate and collaborate during the session (
Table 1). Surveys were administered electronically on computers located directly outside of the patient suites. The face validity of the survey items was established by creating them based on IPEC's core competencies.
2 Faculty from LECOM-Bradenton and SCF who held expertise in the areas assessed provided expert panel review and feedback, adding additional validity to the survey before the study. The survey items used a 5-point Likert-type scale ranging from strongly agree (5 points) to strongly disagree (1 point). An open comment box was available at the end of the survey.
Open survey responses were analyzed using grounded theory.
8 This approach involves identification of common themes across survey data and the subsequent development and testing of a unifying theory of understanding. The survey data were extracted anonymously; students were not asked to provide any identifying information. Authors trained in qualitative theory (A.M.C. and M.A.H.) individually extracted thematic data from the surveys and met bimonthly to identify repeated themes with supporting data until all surveys were coded. The process was then repeated until authors were satisfied that all themes were identified and tabulated.
Analyzing each concept and assessing its presence repeatedly throughout the study achieved rigor. To eliminate bias, questioning and comparison of the data during acquisition was performed intermittently.
SPSS software (IBM) was used to analyze the data. Responses were compared between the 2 medical student cohorts using a Mann Whitney U test. A nonparametric test was chosen because the data were assumed to not have a normal distribution. The sample means came from the same population. A 2-tailed test was used. Statistical significance was defined as P<.05.
A total of 743 students participated in the study—371 from the class of 2016 and 372 from the class of 2017. Four students submitted incomplete surveys (1 from the class of 2016 and 3 from the class of 2017), but these surveys were included in the analysis. Seventy-four students (20%) had previous health care experience.
Most students from both cohorts strongly agreed or agreed with all of the survey items (
Table 1 and
Table 2). With the class of 2016, the item with the highest agreement rating (strongly agree or agree) was “I feel better prepared to communicate with family members” (357 of 371 [96.2%]). The class of 2017 had the highest agreement with the item “I was challenged in my thinking and decision-making skills” (358 of 369 [97.3%]). Agreement scores for both classes were lowest for the item pertaining to collecting appropriate data during the patient family interview, with 287 of 371 [77.4%] from the class of 2016 and 260 of 372 [72.9%] from the class of 2017 indicating strongly agree or agree.
The null hypothesis was “the distribution of frequency is the same across categories of year.” There were statistically significant differences between the 2 groups of medical students in their responses to 2 items. For the item “I collected appropriate data during a client/family interview including data which reflect the specific needs of the client,” the Mann Whitney U test indicated that the ranked distribution of scores was significantly greater for the class of 2017 than for the class of 2016 (mean rank, 389.3 vs 354.64, respectively; U=75,445.50; P=.017). The item “I feel better prepared to communicate with family members” also indicated that the ranked distribution of scores was significantly greater for the class of 2017 than for the class of 2016 (mean rank, 390.61 vs 353.34, respectively; U=75,928.50; P=.006). The null hypothesis was rejected in both instances.
Using the core competencies developed by the Interprofessional Education Collaborative (IPEC) as a guideline, themes were extracted from the survey responses and categorized by contribution to the study outcome (
Figure). Two of the authors (A.M.C. and M.A.H.) looked for themes independently and scored them accordingly.
Human patient simulators can be used in a variety of ways to facilitate learning for medical and nursing students, as well as residents. Medical simulation allows for the acquisition of clinical and communication skills through deliberate practice rather than an apprentice style of learning. Simulation mannequins provide a safe method to practice the aforementioned skills without high-risk stakes. A student can make mistakes and learn valuable lessons without fear of harming the patient.
4 In a similar fashion, SCEs can provide valuable opportunities for applying IPEC's 4 core competencies.
2
In the current study, we demonstrated the importance of collaboration among different health care professionals to establish mutual respect. Students were able to take ownership of their roles as future medical providers to adequately serve the needs of their patients. They bore the responsibility of communicating interpersonally during the experience, including delivering bad news to families, a skill that is technically and emotionally challenging. Students were instructed to independently devise their course of action during the simulation experience, fulfilling the final core competency.
In 2009, the utility of simulation in medical education was reviewed through a Medline search of hundreds of articles.
9 Two outcomes were shown to directly lead to clinical improvement. Simulation-based training improved procedural performance in the operating room, and students who experienced simulation were more likely to execute algorithms for Advanced Cardiac Life Support protocol more effectively. Teamwork, communication, and the delivery of medical knowledge have been proven outcomes in simulation teachings, but the impact on actual patient care has not been evaluated, to our knowledge.
A large response rate was obtained because of ease of access to the surveys. Laptops were placed at the kiosk next to the simulation rooms, which facilitated the increased completion of surveys after debriefing sessions. Student comments indicated that after completing this exercise, they felt better able to interact with patients, nurses, and families. More than 95% of students in the class of 2016 and nearly 90% in the class of 2017 felt better prepared to care for real patients after the simulation. One student reported, “It was a tough first experience, but I feel better for a real patient encounter.” Another student reported, “I feel like it was a great way to practice. We can make mistakes here, not in the hospital.” Students who have interprofessional education integrated into their curricula are more likely to have less adverse attitudes toward interprofessional peers.
10 Collaboration is more likely when high-functioning cooperative practices are engaged between nurses and doctors.
11 Levels of mutual respect, which correlate with the theory of relational coordination, have been shown to improve quality of care in the hospital setting.
12 Students in the current study appreciated the opportunity to role play as third-year students on clinical rotations, examining patients and presenting the results of those examinations to attending physicians. Students felt that the interactions with the patient's family members were realistic and challenging. The study contributes to positive outcomes in student performance by using a combination of patient simulation, standardized patients and family members, facilitated debriefing, and collaboration with nursing.
The study was administered during a variety of rigorous academic events, eg, final examinations and board preparation periods. Thus, some students may have felt less prepared than others, owing to distracting academic obligations. Also, some students were able to practice on the mannequins while waiting in the queue for the SCE. The nursing students were not surveyed after the experience, and we were unable to control for variability in the previous health care experience of the nursing students. It is not clear as to why the 2 classes differed in their responses to items 3 and 7. The 2 classes had different course directors for learning examination skills and may have entered the scenarios with varying degrees of comfort with the process. The students may have felt more comfortable with the process if provided with a more extensive orientation.
This study can be viewed through the lens of the third osteopathic tenet: structure and function are reciprocally interrelated.
13 Successful health care relies heavily on teams that strive to meet protocol and strengthen communication among members. Interrelationships among osteopathic medical students and nursing students in this study demonstrated the importance of integrated health care structure. Health care teams are better equipped to function properly when the members are collaborating. Ultimately, productive outcomes and excellent patient care reciprocally support the continuation of integrating physician practice with nursing staff and other health care professionals.
Phase 2 of this study will involve testing the theory that effective clinical simulation provides third- and fourth-year medical students with valuable preparation for clinical rotations and interactions with actual patients, staff, and family members. Subcore IPEC competencies
3 will be further integrated into the study; for example, within the framework of interprofessional communication, one subcompetency focus aims to “communicate information with patients, families, community members, and health team members in a form that is understandable, avoiding discipline-specific terminology when possible.” Additionally, we will look at the differences between the findings in the first simulation (fall semester) and the second simulation (spring semester). Increasing the frequency of SCEs may lead to increased validity and identification of additional themes. The current study can be replicated in facilities that have simulation mannequins and partnerships with local nursing programs.
Research published in 2018 on quantitative methods discusses the utility of the item-response theory (eg, Likert scales, self-reports, reactions, attitudes) to increase the rigor of interprofessional education research.
14 Combining scores from multiple resources and content types using the item-response theory elevates study conclusions to have more of a blanketed impact on the body of interprofessional education research as a whole vs independent impact.
14 We will apply suggestions from this review to strengthen the future study. Additionally, a review
15 published in November 2017 suggested standardizing the methods of reporting data and outcomes; we aim to incorporate more reproducible methods in future studies, which will aid in creating results-based curricula.
Students found the SCEs to be highly valuable. From a humanistic standpoint, students felt better prepared to empathize and communicate with family members. Students expressed that they would be better prepared to work in a collaborative setting after participating in these SCEs. Although described as stressful, the majority of students wished for more SCE opportunities. Through examining these themes, we believe that SCEs will improve students’ performance and comfort level during clinical rotations, while promoting collaborative interprofessional practices. Beginning in fall 2018, the program will incorporate the IPEC Competency Survey Instrument.
16
We thank SCF for allowing us to partner with their nursing program and use their facilities.