Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Assessing 3rd year medical students’ interprofessional collaborative practice behaviors during a standardized patient encounter: A multiinstitutional, cross-sectional study Sandra K. Oza, Christy K. Boscardin, Maria Wamsley, Aimee Sznewajs, Win May, Andrew Nevins, Malathi Srinivasan & Karen E. Hauer To cite this article: Sandra K. Oza, Christy K. Boscardin, Maria Wamsley, Aimee Sznewajs, Win May, Andrew Nevins, Malathi Srinivasan & Karen E. Hauer (2015) Assessing 3rd year medical students’ interprofessional collaborative practice behaviors during a standardized patient encounter: A multi-institutional, cross-sectional study, Medical Teacher, 37:10, 915-925, DOI: 10.3109/0142159X.2014.970628 To link to this article: http://dx.doi.org/10.3109/0142159X.2014.970628

Published online: 14 Oct 2014.

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Date: 16 October 2015, At: 08:45

2015, 37: 915–925

Assessing 3rd year medical students’ interprofessional collaborative practice behaviors during a standardized patient encounter: A multi-institutional, cross-sectional study SANDRA K. OZA1, CHRISTY K. BOSCARDIN1, MARIA WAMSLEY1, AIMEE SZNEWAJS1, WIN MAY2, ANDREW NEVINS3, MALATHI SRINIVASAN4 & KAREN E. HAUER1

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1 University of California, San Francisco School of Medicine, USA, 2Keck School of Medicine of the University of Southern California, USA, 3Stanford University School of Medicine, USA, 4University of California, Davis School of Medicine, USA

Abstract Background: To understand how third-year medical student interprofessional collaborative practice (IPCP) is affected by selfefficacy and interprofessional experiences (extracurricular experiences and formal curricula). Methods: The authors measured learner IPCP using an objective structured clinical examination (OSCE) with a standardized nurse (SN) and standardized patient (SP) during a statewide clinical performance examination. At four California medical schools from April to August 2012, SPs and SNs rated learner IPCP (10 items, range 0–100) and patient-centered communication (10 items, range 0–100). Post-OSCE, students reported their interprofessional self-efficacy (16 items, 2 factors, range 1–10) and prior extracurricular interprofessional experiences (3 items). School representatives shared their interprofessional curricula during guided interviews. Results: Four hundred sixty-four of 530 eligible medical students (88%) participated. Mean IPCP performance was 79.6  14.1 and mean self-efficacy scores were 7.9 (interprofessional teamwork) and 7.1 (interprofessional feedback and evaluation). Seventy percent of students reported prior extracurricular interprofessional experiences; all schools offered formal interprofessional curricula. IPCP was associated with self-efficacy for interprofessional teamwork (b ¼ 1.6, 95% CI [0.1, 3.1], p ¼ 0.04) and patientcentered communication (b ¼ 12.5, 95% CI [2.7, 22.3], p ¼ 0.01). Conclusions: Medical student IPCP performance was associated with self-efficacy for interprofessional teamwork and patientcentered communication. Increasing interprofessional opportunities that influence medical students’ self-efficacy may increase engagement in IPCP.

Introduction

Practice points

The Institute of Medicine (IOM) and World Health Organization (WHO) highlight the importance of interprofessional education (IPE) to prepare health professions trainees for collaborative practice (IOM 2003; WHO 2010). In interprofessional collaborative practice (IPCP), each team member participates within a defined scope of practice in coordination with other team members to enhance patient care, while respecting others’ contributions. IPCP can improve patient satisfaction and outcomes, access to healthcare services, patient safety and error rates (Zwarenstein et al. 2009; WHO 2010). Interprofessional learning within health professions curricula promotes the knowledge, skills and attitudes necessary to function as an integral member of a multidisciplinary team (IOM 2003; Dow et al. 2013). IPE interventions can enhance trainees’ insight into their own and others’ professional roles (Pelling et al. 2011) and improve collaborative



 



The factors influencing medical student engagement in interprofessional collaborative practice behaviors (IPCP) are not well known. Self-efficacy for interprofessional teamwork is associated with IPCP. Self-efficacy for interprofessional teamwork is also associated with extracurricular interprofessional experiences. Further study is needed to understand the contribution of the formal medical-school curriculum to student self-efficacy for and engagement with IPCP.

practice attitudes and behaviors (Reeves et al. 2008; Curran et al. 2010; Hobgood et al. 2010; McFayden et al. 2010; Joseph et al. 2012; Kenaszchuk et al. 2012; Wamsley et al. 2012; Brock et al. 2013).

Correspondence: Sandra K. Oza, Department of Medicine, University of California, San Francisco School of Medicine, 1545 Divisadero Street, Suite 322, San Francisco, CA 94143-0320, USA. Tel: 415-514-8640; Fax: 415-514-8666; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/100915–11 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.970628

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Despite increasing evidence supporting the benefits of IPE, the ways that students learn about interprofessional care are varied and incompletely understood. A systematic review of IPE curricular interventions found only six studies of IPE employing rigorous experimental design, with mixed findings regarding the characteristics of effective IPE and its outcomes (Reeves et al. 2010). Learning is a social process, and can occur in any activity in which an individual is engaged (Lave & Wenger 1991; John-Steiner & Mahn 1996; Dornan et al. 2006). Meaningful extracurricular and personal experiences may also supplement formal IPE curricula and influence learner interactions around IPCP. Interprofessional learning opportunities arise during students’ extracurricular interest groups, studentrun clinics and research endeavors (Sheu et al. 2011, 2013). Additionally, some students have previously worked in other healthcare professions or have family members who are nonphysician health professionals (Andriole & Jeffe 2011). Despite training and experience for successful IPCP, health professionals can fall short of the collaborative ideal. Self-efficacy for IPCP may influence engagement in collaborative practice behaviors (Gist et al. 1991). Self-efficacy, also referred to as task-specific self-confidence, derives from social cognitive theory and is related to confidence in executing a particular behavior (Bandura 1977, 1986). Importantly, selfefficacy affects the likelihood of undertaking and persisting with tasks or behaviors (Stajkovic & Luthans 1998). Individuals derive their self-efficacy from four major sources, the most important being ‘‘enactive mastery experiences’’ or previous opportunities to engage in the task of interest (Bandura 1997; Artino 2012). A study of medical student self-efficacy and performance of clinical skills during an objective, structured clinical examination (OSCE) found that students with higher self-efficacy ratings scored higher than students with lower self-efficacy ratings (Mavis 2001). Self-efficacy for interprofessional work may similarly influence health profession students’ engagement in IPCP. This study explored the relationship between third-year medical students’ IPCP behaviors with self-efficacy for interprofessional teamwork and practice, prior extracurricular interprofessional experiences, and formal, curriculum-based IPE. We sought to describe the relationship between these factors, and hypothesized that medical students with greater self-efficacy for interprofessional teamwork and practice, more extracurricular interprofessional experiences and who attend medical schools with more formal, curriculum-based IPE opportunities would demonstrate greater interprofessional collaboration. Enhanced understanding of the factors that underlie students’ IPCP competence can inform medical educators’ curricular interventions.

Methods Design We conducted a cross-sectional observational study of medical student performance on an interprofessional OSCE during a statewide clinical performance examination at the end of the core clinical clerkships. We administered surveys to assess students’ self-efficacy for interprofessional learning and 916

practice and their extracurricular interprofessional experiences, and conducted institutional interviews to assess formal, curriculum-based IPE.

Sites and participants Four schools of medicine participated in this study: Stanford University, University of California, Davis (UCD), University of California, San Francisco (UCSF) and University of Southern California (USC). These institutions belong to the eightmember California Consortium for the Assessment of Clinical Competence. Through the Consortium, the medical schools jointly administer an annual Clinical Performance Examination (CPX) at the end of the core clerkships. The CPX is a required eight-station, summative, standardized patient (SP)-based examination that assesses students’ clinical and communication skills. Actors are trained for 20 hours per case in role portrayal and use checklists to assess students’ performance. Each encounter lasts 15 min, followed by a 10-min postencounter written exercise. All medical students taking the 2012 CPX (April to August) at the four study schools were invited to participate in the study after encounter completion. Each school’s institutional review board approved the study.

Study measures Interprofessional SP case Four authors (SKO, MW, AS and KEH) developed an interprofessional SP case: a 55 year-old woman initially hospitalized for cellulitis, who develops acute chest pain on hospital day 2. A team of physicians, nurses and standardized patient program directors participated throughout case development, case testing/revisions and actor training. During this encounter, medical students were expected to gather a pertinent history, perform a focused physical examination, and counsel the SP about her condition and next steps in management. A standardized nurse (SN) was present during the first 3 and last 5 minutes of the encounter to provide critical history and help with patient management (Appendix A). A post-encounter survey asked students about interprofessional self-efficacy and prior extracurricular interprofessional experiences. The same three SPs and three SNs portrayed the case at Stanford, UCD and UCSF (geographically co-located); four SPs and four SNs portrayed the case at USC.

Outcome measure Interprofessional collaborative practice. After each student encounter, the SN completed an 11-item checklist (Appendix B) based on the Core Competencies for Interprofessional Collaborative Practice [Interprofessional Education Collaborative Expert Panel (IPEC) 2011] assessing the student’s information gathering (4 items) and interprofessional communication, collaboration and professionalism (6 items) scored as ‘‘no’’ (0) or ‘‘yes’’ (1). This measure was newly developed for this study due to the nature and constraints of our setting (a required clinical skills examination), which necessitated a straightforward instrument that could be completed within 10 min by a layperson portraying the role of a healthcare professional. All SN checklist items

Assessing interprofessional collaboration

were developed following the standard protocol for development of checklist items. An overall satisfaction item was not included in our analysis. Our primary outcome was SN ratings of medical student information gathering, interprofessional communication, collaboration and professionalism (percentage scored as ‘‘yes’’; range 0–100.0).

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Independent variables Interprofessional self-efficacy. After the encounter, students completed a 16-item survey about their interprofessional selfefficacy (‘‘Self-Efficacy for Interprofessional Experiential Learning’’ [SEIEL], Cronbach a ¼ 0.96 overall) (Mann et al. 2012). The original analysis of the instrument revealed two subscales on interprofessional interaction (a ¼ 0.94) and for interprofessional team evaluation and feedback (a ¼ 0.93). For each item, students rated their confidence in performing various activities involving interprofessional learning and teamwork/collaborative practice on a 10-point scale (‘‘low confidence’’ [1] to ‘‘high confidence’’ [10]). Extracurricular interprofessional experiences. After the encounter, medical students were asked about three extracurricular interprofessional experiences: (1) Whether they had ever personally studied to become, or worked as, a nonphysician health professional (yes ¼ 1); (2) Whether they had a first-degree relative (parent, sibling or spouse) who has worked as a non-physician health professional (yes ¼ 1); and (3) Whether they had spent a significant amount of time (410 hours) working on an interprofessional project, team or activity that fell outside of their usual or required medical school curriculum (yes ¼ 1). We were not aware of any published instruments assessing extracurricular IPCP experiences. Thus, guided by theories of sociocultural learning (John-Steiner & Mahn 1996), we asked about extracurricular experiences that could serve as rich sources of interprofessional learning. Formal, curriculum-based IPE. Two authors (SKO, AS) interviewed each school’s IPE curriculum representative identified by the school’s CPX Director to gather descriptive information about the formal IPE curriculum. Respondents described the type (e.g. didactic, workshop, shadowing), duration and nature (e.g. required, elective) of IPE activities within their formal medical school curriculum, as well as barriers to successful implementation of IPE (Appendix C). We conducted interviews by telephone or in person. We analyzed the audio-recorded interviews for the presence of curricular components that were defined a priori: non-clinical or clinical; single or longitudinal (occurring at least twice); and required, elective or informal. Patient-centered communication score. After each encounter, the SP completed a 29-item checklist that included 10 items evaluating patient-centered communication based on the SEGUE framework (Makoul 2001) scored as ‘‘no’’ (0) or ‘‘yes’’ (1). A student’s patient-centered communication score was a measure of students’ general communication skills (range from 0 to 100.0).

Data analysis We conducted bivariate regression analyses to examine the relationship between independent variables and the outcome measure. We conducted a principal axis factoring analysis for the self-efficacy scale using Varimax rotation and factor loading greater than 0.4 to investigate the instrument’s properties in our sample (Nunnally 1978). Our analysis identified two factors accounting for 62% of the total variance: factor 1 (items related to interprofessional teamwork) and factor 2 (items related to interprofessional feedback and evaluation). Consistent with previously reported reliability (Mann et al. 2012), internal consistency was high for the overall instrument (a ¼ 0.93) and each factor: interprofessional teamwork (9 items, a ¼ 0.91); interprofessional feedback and evaluation (7 items, a ¼ 0.90) (Table 1). Self-efficacy responses were averaged for an overall and factor-specific score (range 1.0–10.0). Because each medical school’s formal IPE curriculum differed markedly, we included ‘‘medical school attended’’ in subsequent analyses. ‘‘Medical school attended’’ is included in the model as a fixed effect to account for the fact that students are nested within schools. We used bivariate linear regression to examine the relationship between interprofessional selfefficacy and the independent variables of extracurricular interprofessional experiences and formal, curriculumbased IPE. After exploratory bivariate analyses, we performed multivariable regression analyses to explore the association between our primary outcome (SN ratings of student IPCP) and our independent variables: interprofessional self-efficacy; extracurricular interprofessional experiences; formal, curriculum-based IPE and patient-centered communication. Prior to fitting the regression analyses, key assumptions of regression analyses, such as normality and homoscedasticity were tested to ensure appropriate interpretation of the results. We aimed to use these results to develop a conceptual model of the inter-relationships between factors and IPCP. All statistical analyses were conducted using StataÕ 12 (StataCorp LP, College Station, TX).

Results From the four schools, 464 of 530 eligible students (88%) consented to study participation; individual school’s participation rates ranged from 68 to 95%. Mean performance on the SN checklist assessing students’ IPCP was 79.6 (standard deviation [SD] 14.1, range 20.5–100.0).

Independent variables Interprofessional self-efficacy Mean self-efficacy scores were high. For factor 1, interprofessional teamwork, the mean score was 7.9 (SD 1.3, range 2.0–10.0) and for factor 2, interprofessional feedback and evaluation, the mean score was 7.1 (SD 1.5, range 1.3–10.0).

Extracurricular interprofessional experiences Overall, 70% of students reported at least one type of extracurricular interprofessional experience. Thirty-six percent

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Table 1. SEIEL item by two factors.

Factor 1: Interprofessional teamwork

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Factor 2: Interprofessional feedback and evaluation

Items: Respondents are asked to rate their confidence on a 1–10 scale (1 ¼ low confidence, 10 ¼ high confidence) Working with other students from other professions to form a team. Working with other students from different professions to resolve problems in the team. Working with other students from different professions to develop a realistic appropriate patient care plan. Working with other students from different professions to understand our respective roles in an interprofessional team. Working with other students from different professions to understand the benefits to patients of team care. Understanding and discussing the objectives of interprofessional learning. Interacting with students from other professions and disciplines than my own. Learning together cooperatively with students from other professions. Communicating effectively with other members of an interprofessional team. Providing feedback to an interprofessional team on our function and work as a team. Providing feedback to individual team members of an interprofessional team on their function and work on the team. Helping clinical sites understand an interprofessional team’s role in a clinical setting. Helping the patient to understand the objectives of the interprofessional learning. Evaluating the quality of the work as an interprofessional team. Evaluating the degree to which an interprofessional team has achieved its goals. Interacting with teachers and preceptors from other professions and disciplines than my own.

Internal consistency for the interprofessional teamwork factor was 0.91 with 9 items. Internal consistency for the interprofessional feedback and evaluation factor was 0.90 with 7 items.

of students had a first-degree relative who was a non-physician health professional, 23% had previously studied to become or worked as a non-physician health professional, and 50% reported having spent more than 10 hours on an interprofessional project or activity.

Formal, curriculum-based IPE As shown in Table 2, each school’s IPE representative reported some curriculum-based IPE, although activities varied across schools and not all were required. Each school offered elective and informal IPE activities. Two schools reported an evolving IPE curriculum, and one school did not offer required IPE curricula during the study participants’ first three years in medical school. The remaining schools offered required IPE in both clinical and non-clinical settings. Interviewees cited scheduling conflicts between students in different professional schools, insufficient funding and physical space constraints as barriers to successful implementation of IPE.

Patient-centered communication score Mean performance on the SP checklist assessing patient-centered communication was high: 87.8 (SD 13.2, range 30.0–100.0).

Factors associated with interprofessional self-efficacy We performed a multivariable linear regression with each of the interprofessional self-efficacy factors. We regressed each factor on the independent variables of prior extracurricular interprofessional experiences and medical school attended. Having previously studied to become or worked as a nonphysician health professional (p ¼ 0.002), having worked on an extracurricular interprofessional project (p ¼ 0.037) and medical school attended (p ¼ 0.001) were significantly positively associated with the interprofessional teamwork factor. Having worked on an extracurricular interprofessional project 918

(p ¼ 0.036) was significantly positively associated with the interprofessional feedback and evaluation factor.

Interprofessional collaborative practice We found an association between students’ IPCP and two independent variables on bivariate analyses (Table 3). The interprofessional teamwork factor was significantly associated with IPCP, with a one unit increase on this self-efficacy scale corresponding to a 1.2 point increase in SN checklist score (p ¼ 0.02, 95% CI [0.2, 2.1]). The interprofessional feedback and evaluation self-efficacy factor was not significantly associated with IPCP. The patient-centered communication score was also significantly associated with IPCP, with a one unit increase in score on this checklist corresponding to a 13.0 point increase in the SN checklist score (p ¼ 0.009, 95% CI [3.2, 22.7]). Extracurricular interprofessional activities were not significantly associated with students’ IPCP. We also found no significant relationship between medical school attended and student IPCP. Because there was no evidence for multicollinearity among our independent variables, all were included in the final multivariate linear regression. We present the results of our final multivariate regression model exploring the relationship between IPCP and all independent variables in Table 3. The interprofessional teamwork self-efficacy factor was again significantly associated with IPCP (b coefficient ¼ 1.6, p ¼ 0.04, 95% CI [0.1, 3.1]). The patient-centered communication score was also significantly associated with IPCP (b coefficient ¼ 12.5, p ¼ 0.01, 95% CI 2.7, 22.3). None of the other independent variables were significantly associated with IPCP. This regression model explains approximately 4% of the total variation in IPCP in our population (R2 ¼ 0.04). Finally, we present a conceptual model diagramming the relationship between our independent variables and the outcome variable of IPCP behaviors, as well as those variables that are associated with interprofessional self-efficacy (Figure 1).

Year 1:  One-time large-group didactic with subsequent longitudinal follow-up small group-sessions  One-time small-group physical exam practice session Year 2:  Longitudinal small-group didactics

UCSF

1: Longitudinal small-group hands-on sessions 2: One-time resuscitation simulation

2: One-time clinical shadowing 3: Some one-time shadowing sessions

Year 1:  One-time small-group clinical shadowing

Year 3:  Longitudinal rural clinical experience (required for only some students)

Year  Year 

Required IPE, clinical

Year 3:  Longitudinal clinical electives

Year 1:  Longitudinal curriculum development summer program Year 3:  One-time interprofessional standardized patient exercise  Longitudinal clinical electives

Year 3:  Longitudinal clinical electives

Year 3:  Longitudinal clinical electives

Elective IPE

1–3: Student run clinics Student interest groups Interprofessional coalition of student interest groups  Ad-hoc interprofessional collaborations during clerkships

Year   

Year 1–3:  Student run clinics

Year 1–3:  Student run clinics  Interprofessional interest group

Year 1–3:  Student run clinics

Informal IPE

The curricula described here were available to the students who participated in the 2012 CPX. Required and elective activities are designated as one-time or longitudinal (two or more times per student) activities.

USC

Year  Year 

large group didactic and discussion

interprofessional standardized patient exercise ‘‘working with interpreters’’ exercise interpreter exercise in focused H&P

UCD

1: One-time One-time One-time 2: One-time

Year    Year 

Stanford

Required IPE, non-clinical

Table 2. Interprofessional education curricula at four study schools.

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Table 3. Multivariable regression results.

Three multivariable regression analyses with independent variables grouped

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Beta-coefficient (% change on SN Checklist score) Self-Efficacy Self-efficacy, interprofessional teamwork Self-efficacy, interprofessional feedback and evaluation Prior IP extracurricular experiences Family Study/work IP project Medical school attended Stanford UCD USC Reference (UCSF) Patient-centered communication

p Value

95% Confidence Interval

Multivariable regression analyses including all independent variables (R2 ¼ 0.04) Beta-coefficient 95% (% change on SN Confidence Checklist score) p Value Interval

1.9 0.8

0.02 0.22

[0.4, 3.4] [2.1, 0.5]

1.6 0.7

0.04 0.29

[0.1, 3.1] [2.1, 0.6]

1.9 1.9 50.1

0.17 0.24 40.99

[4.6, 0.8] [5.1, 1.3] [2.7, 2.7]

1.8 2.4 0.1

0.20 0.14 0.96

[4.5, 0.9] [5.6, 0.8] [2.6, 2.8]

0.4 2.2 0.9 79.8

0.86 0.25 0.59

[4.4, 3.7] [5.8, 1.5] [2.3, 4.1]

0.1 1.9 0.6 62.5 12.5

0.96 0.32 0.72

[4.2, 3.9] [5.6, 1.8] [2.7, 3.9]

0.01

[2.7, 22.3]

We regressed IPCP (outcome measure) on each group of independent variables (self-efficacy variables, prior IP extracurricular experience variables, and medical school [as proxy of the formal IPE curriculum]). Next, we regressed IPCP (outcome measure) on all independent variables: the interprofessional teamwork selfefficacy factor, the interprofessional feedback and evaluation self-efficacy factor, student extracurricular interprofessional experiences, medical school attended (as proxy of the formal IPE curriculum) and patient-centered communication. UCSF serves as the reference school. family ¼ having a first-degree relative who works as a non-physician health professional; study/work ¼ having previously studied to become or worked as a non-physician health professional; IP project ¼ participation in an extracurricular interprofessional project or activity.

Figure 1.

Independent variables and the association with IPCP and interprofessional self-efficacy.

Discussion We developed and implemented an interprofessional OSCE to evaluate medical students’ IPCP during a high-stakes clinical skills examination at four California medical schools. We found that students’ self-efficacy for interprofessional teamwork and patient-centered communication skills were associated with IPCP, whereas self-efficacy for interprofessional feedback and 920

evaluation, involvement in extracurricular interprofessional activities and the medical school attended were not significant factors. Despite these significant results, our multivariable linear regression model explained only 4% of the overall variation in students’ IPCP. This finding suggests that our model does not account for other important influences on students’ attitudes towards and engagement in IPCP. The nature of these other influences is unclear from our study, but could include student

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age and gender (Pollard et al. 2005), overall clinical skills after their core clerkships, biases about IPCP, text anxiety, or the influence of other experiences and attitudes. Medical schools vary in their approach to IPE curricula, although overall attention to this curricular content area is increasing. All schools in our study reported some form of IPE within the formal curriculum, and two were planning to expand their IPE content for students subsequent to this study. This finding is consistent with the results of a national study of medical schools that found that 66% of respondent schools offered either informal or formal IPE and an additional 12% of respondents were in the process of developing an IPE curriculum (Blue et al. 2010). As in our study, institutions nationally use a variety of formats, including didactic and small group sessions, simulations and clinical activities to engage students in interprofessional learning (Blue et al. 2010; Bridges et al. 2011; Aston et al. 2012). Each of our study schools reported that the major barrier to the implementation of IPE was scheduling constraints among students at different professional schools with different academic calendars, challenges echoed in the published literature on formal, curriculum-based IPE (Blue et al. 2010; Bridges et al. 2011; Aston et al. 2012). Effective IPE affords students the opportunity to attain the knowledge, skills and attitudes necessary to function collaboratively in a highly complex healthcare system. Theoretical foundations of learning imply that effective IPE should be experiential; permit collaborative knowledge creation; address barriers posed by stereotypes, social identity and professional socialization; and encourage reflective practice (Sargeant 2009). A systematic review of evidence for IPE demonstrated the multiple variables that influence the effectiveness of any IPE intervention: environmental and institutional features; learner and teacher characteristics; process variables including the authenticity of the educational setting; and the outcome measure chosen to determine curriculum effectiveness (Hammick et al. 2007). A systematic review of teamwork training within medical schools showed improvement in self-reported knowledge of team skills, improvement in selfassessed team skills, and improved attitudes towards interdisciplinary health care teams (Chakraborti et al. 2008). In our study, we approximated the formal, curriculum-based IPE by including medical school of attendance in our analyses. However, our study cannot determine which curricular aspects may be most effective for cultivating IPCP behaviors. Student learning occurs both within and outside the formal curriculum. For instance, student-run health clinics are found at many United States medical schools (Simpson & Long 2007) and are perceived to be rich learning environments for systems-based practice and interprofessional collaboration (Meah et al. 2009; Sheu et al. 2013). We did not find an association between extracurricular interprofessional experiences and IPCP, perhaps because we were unable to quantify the quality or depth of these experiences. While we did not find an association between extracurricular interprofessional experiences and IPCP, we did find an association between extracurricular interprofessional activities and self-efficacy for both interprofessional teamwork and interprofessional feedback and evaluation. Self-efficacy theory postulates that individuals rely on four key sources of

information that inform their self-efficacy: mastery experiences, social modeling, social persuasion and psychological responses; enactive mastery experiences are those opportunities that allow the individual to engage in the task of interest (Bandura 1997; Artino 2012). We found that students’ selfefficacy for interprofessional teamwork was significantly associated with IPCP. Engagement in extracurricular interprofessional activities may enhance students’ self-efficacy through a potent influence: the opportunity to practice IPCP skills in a lower-stress context than the evaluative environment of medical school. Self-efficacy can also be modified by curricular interventions. For example, a recent study of a remediation program for medical students that was based on promoting self-efficacy found significant improvements in medical students’ selfefficacy and OSCE performance (Malau-Aduli et al. 2013). Medical educators could study the relative impact of extracurricular interprofessional activities and formal, curriculumbased IPE to enhance student self-efficacy for IPCP. We found that students’ patient-centered communication was also associated with IPCP. Prior studies have shown that communication skills can be effectively taught to medical students (Yedidia et al. 2003) and an ongoing study plans to assess the outcome of an interprofessional communication curriculum (Zwarenstein et al. 2007). Effective interprofessional communication likely overlaps with patient-centered communication skills, and is recognized as a core competency for IPCP (San Martin-Rodriguez et al. 2005; Suter et al. 2009; IPEC 2011). Curricula dedicated to improving students’ interprofessional communication skills may result in better overall communication skills and greater engagement in IPCP. Our study has several limitations. We assessed performance in a simulated exam with a simulated nurse (an OSCE format that may have been unfamiliar to some students) rather than in real clinical practice. Our SN checklist, which served as our study outcome, may not have captured the full spectrum of IPCP skills. Published tools for measuring interprofessional collaborative practice, including the Collaboration and Satisfaction About Care Decisions (CSCD) (Baggs 1994), the Collaborative Practice Assessment Tool (CPAT) (Schroder et al. 2011), and the Relational Coordination Scale (RCS) [as employed by Nadolski et al. 2006], were not feasible due to the length and/or complexity of the instruments for use by trained laypersons to assess student IPCP during our CPX. The lack of significant effect of the formal, curriculum-based IPE on IPCP may be due to a true lack of association or measures that did not detect an association; our study was not powered to detect the impact of IPE curricula on performance outcomes. Finally, our study was conducted at four schools in a single US state, which may limit the generalizability of our findings to other schools and settings, although the high participation rate and multi-institutional nature of this study are strengths.

Conclusion We found that medical students’ engagement in IPCP is associated with their self-efficacy for interprofessional

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teamwork and patient-centered communication skills. Future work should seek to deepen our understanding of the types of formal and informal IPE that influence medical students’ interprofessional self-efficacy, which we found is associated with their engagement in IPCP. Determining what IPE strategies most effectively foster the knowledge, skills and attitudes necessary for IPCP, and curricular approaches to incorporate this content into medical training would promote interprofessional learning and skill acquisition.

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Glossary Interprofessional collaborative practice (IPCP): When each team member participates within a defined scope of practice in coordination with other team members to enhance patient care while respecting others’ contributions. Reference: World Health Organization (WHO). 2010. Framework for action on interprofessional education & collaborative practice. Geneva: World Health Organization.

Notes on contributors Dr. SANDRA K. OZA, MD, MA, is an Assistant Professor in the Department of Medicine at the University of California, San Francisco School of Medicine in San Francisco, California. Dr. CHRISTY K. BOSCARDIN, PhD, is an Assistant Professor in the Department of Medicine at the University of California, San Francisco School of Medicine in San Francisco, California. Dr. MARIA WAMSLEY, MD, is a Professor in the Department of Medicine at the University of California, San Francisco School of Medicine in San Francisco, California. Dr. AIMEE SZNEWAJS, RN, NP, MD, is a resident in the Department of Pediatrics at the University of California, San Francisco School of Medicine in San Francisco, California. Dr. WIN MAY, MD, PhD, is a Professor in the Department of Medical Education at the Keck School of Medicine of the University of Southern California in Los Angeles, California. Dr. ANDREW NEVINS, MD, is an Associate Professor in the Department of Medicine at the Stanford University School of Medicine in Palo Alto, California. Dr. MALATHI SRINIVASAN, MD, is an Associate Professor in the Department of Medicine, University of California, Davis School of Medicine in Sacramento, California. Dr. KAREN E. HAUER, MD, is a Professor in the Department of Medicine at the University of California, San Francisco School of Medicine in San Francisco, California.

Acknowledgments The authors wish to acknowledge Ann Homan, Bernie Miller, Sandrijn van Schaik and the standardized patient trainers at the participating schools, as well as the standardized patient actors and participating students. Declaration of interest: The authors have no declarations of interest to report. 922

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Appendix A Interprofessional OSCE summary Scenario: In this interprofessional OSCE, the student sees a hospitalized patient on hospital day #2 with new chest pain. The patient (VL) is a 55-year-old woman who has been hospitalized for a left leg cellulitis that was refractory to oral antibiotics but is now responding to appropriate intravenous antibiotics. VL has a past medical history of hypertension, hyperlipidemia and GERD and is a former cigarette smoker. She has a family history of cardiovascular disease and leads a fairly sedentary life. During her hospitalization she has been refusing DVT prophylaxis. On the morning of hospital day #2, she awakens with a vague epigastric discomfort that then evolves to a central chest pressure and is associated with diaphoresis, mild nausea, dyspnea and worsening of pain on inspiration. She is alarmed and calls for her nurse (CJ). CJ evaluates the patient, measures vital signs, obtains an ECG and pages the covering resident. When the resident physician does not return CJ’s page, she pages the medical student sub-intern on the team to come and assess the patient. Student role: The student is instructed that s/he has been paged to the patient’s room for evaluation of a patient with new chest pain. The student is charged with taking an appropriate history, performing a focused physical examination, and counseling the patient on her condition and next steps in her care plan. The student is alerted that there will be another health professional in the room for collaboration in the care of the patient.

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Appendix B Standardized Nurse IPCP assessment checklist SNs completed an 11-item checklist assessing students’ IPCP including information sharing, communication and collaboration skills, and professionalism. Item 1. Overall satisfaction: Based on my level of satisfaction with this encounter, I would choose to work with this student doctor again. * Strongly Agree: the student doctor was so exceptional that I would seek them out as a team member. * Agree: your experience with the student doctor was overall a positive one. * Disagree: you are dissatisfied with the encounter and you would not choose to interact with this student doctor. * Red Flag: the experience was bad enough for you to want to report the student doctor to his/her supervisor. Items 2–11:

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Question prompt The student clearly identified him/herself to me (The student’s ‘‘introduction’’ must include at least 2 of the items below). * Gave name * Indicated level of training (‘‘I am a 4th year medical student’’) * Identify what s/he would do as the medical student (place orders, ask resident to cosign orders, examine the patient, take a history from the patient, etc.) The student asked for at least 1 of the following pieces of information from the nurse: * Overnight events * Allergies or current medications * Recent medications or prns (as needed medications) * Any food or drink that day * In’s and out’s The student asked me to obtain an EKG or ECG. The student asked me to do the following tasks (Must ask for at least 2): * Administer oxygen * Re-check vitals * Call resident or attending physician * Place patient on telemetry * Administer appropriate medications [Must be at least one of the following: aspirin, sublingual nitroglycerin, Maalox (or another antacid), Morphine] The student established a collaborative relationship with me by planning together to make the care decisions. The student gave me an opportunity/time to talk (e.g., didn’t interrupt). The student listened. Gave me undivided attention (e.g., eye contact, verbal acknowledgment, non-verbal feedback). The student was clear and direct when communicating with me (e.g. was direct with requests for information all or most of the time; I was clear what s/he wanted me to do at least some of the time). The student demonstrated professional behavior (e.g., communicated in a way that demonstrated mindfulness that both patient and nurse were in the room). The student maintained a respectful tone (e.g., did not belittle me; did not use humor inappropriately, did not talk down to me).

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Appendix C

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Guided interview questions Interprofessional education representatives from each of the participating schools participated in a telephone or in-person interview answering the following questions about the IPE activities at their medical school. (1) Please confirm for me which interprofessional schools or degree programs you have at your institution/on your campus (this list was obtained from your institution website) and tell me if there are any that may have been overlooked (including schools of public health, social work): (2) Is there an interprofessional curriculum of any type at your MEDICAL school? (3) Who (leaders of which schools) organizes the curriculum and determines its content? (4) How long has the curriculum been in place? (5) Tell me what forms of interprofessional curricula exist at your MEDICAL school? (6) Tell me the time commitment of these various curricula? (7) Tell me who participates? (8) Tell me about participation and buy-in from institutional leaders (for example, deans or vice deans)? (9) What types of assessments are utilized in these curricula? (10) Is there student evaluation data on the curriculum? We do not need to see the data, but in general what are the findings? (11) Will the students who are taking this year’s CPX exam have experienced this curriculum? (12) What are the challenges of this/these curricular activities at your institution? (13) Anything else you’d like to add about IPE at your institution?

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