http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(6): 519–525 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.915513
ORIGINAL ARTICLE
Learning collaborative teamwork: an argument for incorporating the humanities Pippa Hall1, Susan Brajtman2, Lynda Weaver3, Pamela Anne Grassau4 and Lara Varpio5 1
Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada, 2School of Nursing, University of Ottawa, Ottawa, Ontario, Canada, Bruyere Continuing Care, Palliative Care, Ottawa, Ontario, Canada, 4Bruye`re Research Institute, Palliative Care Education and Research, Ottawa, Ontario, Canada, and 5Academy of Innovations in Medical Education (AIME), University of Ottawa, Ottawa, Ontario, Canada
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Abstract
Keywords
A holistic, collaborative interprofessional team approach, which includes patients and families as significant decision-making members, has been proposed to address the increasing burden being placed on the health-care system. This project hypothesized that learning activities related to the humanities during clinical placements could enhance interprofessional teamwork. Through an interprofessional team of faculty, clinical staff, students, and patient representatives, we developed and piloted the self-learning module, ‘‘interprofessional education for collaborative person-centred practice through the humanities’’. The module was designed to provide learners from different professions and educational levels with a clinical placement/residency experience that would enable them, through a lens of the humanities, to better understand interprofessional collaborative person-centred care without structured interprofessional placement activities. Learners reported the self-paced and selfdirected module to be a satisfactory learning experience in all four areas of care at our institution, and certain attitudes and knowledge were significantly and positively affected. The module’s evaluation resulted in a revised edition providing improved structure and instruction for students with no experience in self-directed learning. The module was recently adapted into an interactive bilingual (French and English) online e-learning module to facilitate its integration into the pre-licensure curriculum at colleges and universities.
Humanities, interprofessional collaboration, interprofessional education, self-directed learning, work-based learning
Introduction The realities facing today’s healthcare system are driving change. Limited economic and human resources, shifts in the location of caregiving, growing cultural diversity in health-care workers and patients, increasingly complex technologies, heightened patient acuity, and a rapidly expanding older population living longer with chronic and degenerative diseases: these are the new demands our healthcare system must meet (Statistics Canada, 2010; World Health Organization, 2004). A holistic, collaborative interprofessional team approach, which includes patients and families as significant decision-making members, has been proposed as a solution to these challenges (Barr, 2002; Shortell, 2000). Interprofessional education (IPE) has been recommended as a means for preparing health-care professionals to work as effective members of care teams in this complex environment (D’Amour & Oandasan, 2005). IPE seeks to develop competencies in communication, collaboration and shared decisionmaking, understanding roles and responsibilities, patient/ family-centred approach to care, conflict management, and contributing to team function (Canadian Interprofessional Health Collaborative, 2010; Curran et al., 2011). Clearly, research
Correspondence: Ms Lynda Weaver, MHA, MEd, Bruyere Continuing Care, Palliative Care, 43 Bruyere St., Ottawa, Ontario, Canada K1N 5C8. E-mail: [email protected]
History Received 9 April 2013 Revised 24 February 2014 Accepted 13 April 2014 Published online 12 May 2014
has clarified the ‘‘what’’ of IPE. Now scholars are tackling the question of ‘‘how’’. The humanities cover liberal arts topics related to the human condition, including history, literature, fine art, philosophy, and ethics. They teach us to ‘‘think creatively and critically, to reason, and to ask questions’’ (Standford University, 2014). Using the humanities to enhance the education of health professionals has been repeatedly recommended (Brajtman, Hall, & Barnes, 2009; Charon, 2001; Doukas, McCullough, & Wear, 2010; Flexner, 1910; Ku¨bler-Ross, 1970; Nightingale, 1860; Osler, 1919); but critical study of their impact is lacking (Hammer, 2010; Ousager & Johannessen, 2010; Schwartz et al., 2009; Shapiro, Coulehan, Wear, & Montello, 2009). As the biological and scientific knowledge required of healthcare professionals grows, the time available to teach other topics decreases (Dellasega, MiloneNuzzo, Curci, Ballard, & Kirch, 2007). Consequently, educators and administrators committed to the inclusion of the humanities in health education face the challenge of integrating these courses into already overloaded curricula. We posit that the humanities can be infused into existing curriculum to meet IPE goals. Using the humanities to learn together can break down power differentials inherent in health science disciplines/professions and can help reconcile different world-views based on shared values (Brajtman et al., 2009; Shaver, 2005). We hypothesize that the humanities can enable learners to meaningfully interact and connect with patients and members
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of the care team. Health profession education curricula are improving methods to teach skills such as reflective practice, holistic care, and patient-centered care. Recent research suggests that incorporating these humanities-based instructions can provide health profession trainees with a fund of knowledge and skills of reasoning, discernment, and judgment essential to sustainable professionalism (Doukas et al., 2010). Through a humanities-based perspective, learners can reflect on the impact of their personal and professional relationships with patients and families, while appreciating the rich backgrounds and histories held within each patient and family member. The humanities support a holistic and person-centered approach to care, and provide learners with new ‘‘lenses’’ through which to interact with clinical team members to better understand their own roles and those of others. Guided by elements of D’Amour and Oandasan’s (2005) model, our primary research question was: ‘‘Would teaching learners through a humanities-oriented self-learning module during clinical placements change their attitudes about working in healthcare teams and increase their knowledge about holistic care, collaborative practice, and the humanities?’’ The evaluation tools and the mixed method evaluation design used in this study provide results that answer this question as well as insight into a situated understanding of how participants’ attitudes were impacted by the module.
Background From 2006 to 2008, we conducted the pilot project, ‘‘interprofessional education for collaborative person-centred practice through the humanities’’ (IECPCP&H), at a non-acute care teaching hospital. The goal was to provide trainees with humanities-based learning activities within a clinical placement experience to help them to better understand and experience interprofessional collaborative person-centred care. A bilingual (English and French) interprofessional steering committee oversaw the project. Members were recruited from hospital staff, family, and patient representatives, as well as faculty and students of different health professions from four local universities and colleges. Four criteria guided the module development: content must be applicable for any level of learner (i.e. from 1st year pre-licensure
to post-graduate residency) from any health profession; logistics must enable learners to complete the module at their own pace during their clinical placement; length must facilitate completion within a clinical placement of at least 10 days; and learning activities had to be based on the principles of active learning – encouraging reflection and engagement of learners with patients, families, and clinical team members through experiential activities (D’Eon, 2005). Foundational concepts of teamwork were integrated throughout the module (i.e. effective group function, action-reflective learning/practice) (Ferris et al., 2002; Oandasan & Reeves, 2005). After four intensive workshops over 6 months, the committee determined that a self-learning module could address the challenges of scheduling formal interprofessional clinical placements, and could address the learning needs of multiple learners with a variety of health-care backgrounds. The committee’s experience with developing the module is discussed elsewhere (Weaver, McMurtry, Conklin, Brajtman, & Hall, 2011). The bilingual self-learning module was entitled: ‘‘you the learner, the person in your care, and the interprofessional team.’’ a facilitator’s guide was developed for the health-care team members in units where the learners were situated. A self-learning approach was selected to make the learning experience personally meaningful and convenient. The module format, guided by Knowles’ (1975) work, encouraged learners to assess their own learning needs, formulate their own learning goals, reflect on their experiences, and use available resources to meet the module’s requirements. Four care scenarios were developed to ensure that the module’s case work was relevant in all areas where a student could have a clinical placement at our institution: palliative care, care of the elderly and rehabilitation, complex continuing care, and long-term care. The module was composed of three chapters: holistic care, interprofessional teamwork, and the humanities. The module emphasized patients and families as vital parts of the care team. After completing the reading and exercises of each chapter, learners were asked to apply the concepts with a person in their care through a final creative assignment. Table I summarizes the content of the module. The layout followed the self-learning module outline described by Des Marchais, Jean, and Delorme (1990). Objectives were listed at the start of each chapter, allowing learners to self-assess
Table I. Summary of self-learning module content. Chapter
Content
Chapter I – Holistic Care
Presents a model of holistic care, depicting four domains that require attention and care for a person with an illness (physical, emotional/psychological, social/cultural, and spiritual)
Chapter II – Interprofessional Teamwork
Identifies an interprofessional approach to holistic care, including roles, responsibilities, and relationships within the team Provides tools to enhance interactive learning during clinical placements
Chapter III – The Humanities in Health Care
Presents a framework of four pillars for the humanities: Human experience: explores how humans reflect the meaning, value and creativity of the human spirit, often expressed through art, literature, film, and music Historical perspectives: explores how an illness has been treated and understood over time (either by patient or by historically); how each profession/discipline has developed and established its role in caring for persons with a particular condition Ethics and law: explores ethical issues that arise in making decisions about care, and how these decisions are made. Professionalism: explores learner’s reflections on experiences in the health care world as a professional Application of the framework to connect the learner with a person in his/her care and with other team members
Chapter IV – Creative Summary Assignment
In collaboration with a person in their care, who had made an impact on their learning, and with other team members, learners construct a team map illustrating the relationships among that person, their significant family members, and the team members and apply one of the pillars of the humanities framework to develop a more holistic understanding Learners produce a creative summary to express what they had learned from the experience, using any media and format (e.g. painting or drawing, poems, songs, collages, skits, short story, etc.)
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DOI: 10.3109/13561820.2014.915513
their readiness and decide in how much detail they would review the content (Levett-Jones, 2005; Murad & Varkey, 2008; O’Shea, 2003). Each chapter then posed a question to allow learners to express what they already knew about the topic. Formal definitions and additional information were then provided. Learning activities required learners to interact with patients in their care as well as with fellow care team members. The chapters ended with a reflective question designed to encourage learners to delve deeper into the topic.
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Methods A concurrent nested mixed method research design was utilized (Creswell, 2014; Creswell, Plano Clark, Gutmann, & Hanson, 2003). As such, quantitative and qualitative data were collected at the same time, with priority given to the quantitative data. Random allocation to clinical units was not possible due to the curricular and logistical demands of the different school/university programs sending learners to our institution. Instead, specific care units at our institution were designated to be ‘‘module units’’ where learners used the module as a part of the usual educational program, and other units were designated as ‘‘non-module units’’ where learners would not experience the learning module (see Figure 1 for diagram of study design). Module units were chosen through discussions with the staff and managers. Although the module was considered a part of the normal educational program on the selected units, the project was not considered a mandatory component of any learner’s clinical placement by their schools/ universities programs. Approval for this evaluation was received from the Ethics Review Boards of the involved institutions. Two groups of learners (module versus non-module) allowed our analysis to reflect within-group differences, as well as between-group differences. This design was chosen to augment the validity of the study’s findings and to better understand the experiences of participants (Polit, Tatano, & Hungler, 2001). Data collection Learners in both module and non-module units were invited to participate in the evaluation of their interprofessional clinical placement. The evaluation required completion of four instruments: Attitude Scale: Attitudes Towards Healthcare Teams (ATHT) scale (Leipzig et al., 2002) (pre- and post-placement). Knowledge test (pre- and post-placement): open-ended questions asking learners to list important aspects of (a) holistic care, (b) collaborative patient-centred practice, and (c) the humanities in health care (human experience; historical
Pre & Post Licensure Students Approached = 266
Module 110
Non-Module 156
Consented 61/110 (55.5%)
Consented 43/156 (27.6%)
Pre-surveys 61 Post-surveys 44
Pre-surveys 40 Post-surveys 29
(Paired= 38)
(Paired=25)
Creative Summaries: 42 people did 20 summaries (16 by individuals, 3 by 8 people each, and 1 by 2 people)
Creative Summaries: Not requested
Figure 1. Summary of project study design and participants.
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perspectives; ethics and law; and professionalism). At the time of the project, no appropriate knowledge test existed in the literature, therefore, questions were developed for this project with face validity obtained through review by the project team and members of the steering committee. Interprofessional learning experience: Likert scale (three items) (Post-placement). Reactions to working in teams: Open-ended questions (three items) (Post-placement). Additionally, module unit learners were asked to complete one more instrument: satisfaction with and perceived impact from the module. A 26-item Likert scale and three open-ended question (post-placement).1 Recruitment All levels of learners (pre-licensure or post-licensure, French- or English-speaking, from medicine, nursing, pharmacy, physiotherapy, occupational therapy, social work, spiritual care, or human sciences programs) coming to our institution were assigned to a care area through their usual school program’s processes. Thus, participants were unknowingly assigned to either a module or a non-module unit. Upon arrival, all learners were informed about the project and invited to participate. Recognizing recruitment numbers would be limited by students’ availability during their placements, a research assistant made personal contact with students and supervisors. There was no way to pre-determine the number of participants, as we were not provided with a known number of students ahead of time. The sample is not random, thus a power calculation would not be reliable. Data analysis Quantitative data were analyzed using SPSS versions 15 and 16 (SPSS Inc., Chicago, IL) and qualitative data were analyzed using Microsoft Word word processing software. Attitude scale: ATHT pre-post data (instrument #1) were analyzed with the appropriate responses reversed and all items zero-based and summed to create three subscales: attitudes towards the value of a team (team value), attitudes towards physicians sharing the role as decision-maker (physician shared role), and attitudes towards the effectiveness of teams (team effectiveness). Within group pre- and post-placement means for each scale were compared using a paired t-test, and between groups post-placement means were compared using an independent t-test. Knowledge test: The project team, using a scoring rubric with inter-rater reliability achieved through consensus or majority ruling, scored the open-ended knowledge questions on collaboration and humanities (instrument #2). The team was blinded as to whether the responses were pre- or post-placement, or from module or non-module participants. The rubric for scoring was: 0 ¼ wrong; 1 ¼ partially correct; 2 ¼ completely correct. A ‘‘completely correct’’ score meant they had listed three important aspects for the two questions on teamwork and one important aspect each for the four humanities questions. Blank responses were left out of the analysis as we could not assume they did not know the answer as opposed to they did not have time or the motivation to respond. Interprofessional learning experience: The three items in the post-placement Interprofessional Learning Experience Likert scale (instrument #3) were analyzed individually, using t-tests to compare group means (module versus non-module).
1
Tools 1–5 can be found at: http://bruyere.org/en/projects2#Pippa.
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Reactions to working in teams: Content analysis was conducted on the open-ended comments on learners’ reactions to working with other team members (instrument #4) by one of the authors (L. W.). Satisfaction and perceived impact: For the module learners’ post-placement 26-item Likert scale on the module (instrument #5), the items were summed for each of four factors that emerged from principle components factor analysis that accounted for 68.9% of the variance: content, logistics, ease of use, and learning from the module. Content analysis was performed on the openended questions by one of the authors (L. W.).
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Results Of the 266 potential learner participants, 104 participated in the evaluation of the project. Of the 162 learners who did not participate, the majority (70%) were from the non-module group. Non-participants were not required to complete any demographic data or explain why they did not respond; they just did not return the pre- or post-tests. Table II indicates the participants’ professions. Figure 1 illustrates the two study groups and the final sample, including the final paired data sets, i.e. those learners who supplied both pre- and post-data (module, n ¼ 38; non-module, n ¼ 25). Most participants were female: 80% of the module group and 87% of the non-module group. Half of the module group reported having had some previous interprofessional experiences, compared with 30% of the non-module group. The length of the clinical placements in the module group varied between 3 and 52 weeks; in the non-module group from 2 to 12 weeks. Attitudes scores The within-group paired t-tests analysis showed that the placement had an impact on both the module and non-module learners, with significant differences in pre- versus post-placements means for two of the three subscales: team efficiency and physician shared roles. For team values, there were no differences pre versus posts for either module or non-module (Table III). Table II. Participating learners’ professional affiliations. Profession Nursing (RN, RPN) Medicine Pharmacy Psychology Speech/language Spiritual care Occupational therapy Social work Instructor for RPNs Unknown Totals
Module
Non-module
Totals
28 24 3 0 1 3 0 1 0 0 61
26 6 1 1 1 1 3 1 1 2 43
54 30 4 1 2 4 3 2 1 2 104
RN, registered nurse; RPN, registered practical nurse. Table III. Attitude Towards Healthcare Teams (ATHT) paired t-tests, module versus non-module learners (Tool #1). Module N Team efficiency Team value Physician shared roles
37 42 36
Non-module
Means Pre
Post
12.5 45.0 8.1
13.3* 45.0 9.7**
*p50.001, **p50.024. ***p50.000.
Means
N 23 28 22
Pre
Post
14.3 44.6 11.7
15.0* 44.6 11.3***
The between-group analysis showed that one subscale was significant at post-test: module learners were more receptive to physicians sharing their decision-making roles than non-module learners (p ¼ 0.027). Knowledge scores Two of the four open-ended knowledge test questions related to the humanities showed that significantly more module learners answered correctly post-placement than non-module learners. They were human perspectives (F(1,48) ¼ 13.25, p50.001), and professionalism (F(1,48) ¼ 4.36, p50.04). The two knowledge questions related to interprofessional practice were not significantly different between the two groups at post-placement. Interprofessional learning experience There was no difference between module and non-module groups for three Likert questions regarding the interprofessional aspects of their clinical placements. Figure 2 shows both groups agreed or strongly agreed that that they had learned about interprofessional collaborative teamwork and had worked with members from interprofessional teams. Reactions to working in teams The open-ended questions on working with other team members showed some differences between the groups. Module learners used more language that reflected relationship development and the complexities of collaborative teamwork. Both groups equally enjoyed their experiences, and appreciated the different perspectives from various team members, the learning, and the cooperation. Both expressed a strong desire to work more closely with students from other professions. The major differences between groups are displayed in Table IV. Satisfaction with and perceived impact from module From the 26-item Likert scale, module learners showed high satisfaction with the content of the module as indicated by their mean of 25.6 out of a possible 35. Learning from the module was also rated high, with a mean of 42.7 out of a possible 50. Module learners were less satisfied with logistics and ease of learning, as shown by the respective means of 19.7 out of 30 and 5.4 out of 10. Module learners’ responses to the open-ended comments indicated a number of recommended improvements for the module, such as making the questions less repetitive and/or vague, and changing the videos.
Percent "Agree" and "Strongly Agree"
522
100 80
Module Non-module
81.8 70.4 68.8
75
60 40
29.1 21.9
20 0 Worked with students
Worked with team members
Taught me about working collaboratively
Figure 2. Percent of module and non-module learners who ‘‘agree’’ or ‘‘strongly agree’’ with statements related to interprofessional aspects of their clinical placement experiences (Tool #3).
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Table IV. Module versus non-module responses about working with team members (Tool #4). Theme
Module learners
Non-module learners
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What they liked about working with team members: Patient care goals Used words describing patient-centred goals: ‘‘. . . provides better care to the patient and established common care goals’’ ‘‘I was part of a team working together for the patient’’ Team interactions Described benefits of team interactions: ‘‘. . . that we got to do it as a group and communicate with each other’’ ‘‘I learned quite a bit about the other professions and was able to direct my questions to the appropriate person once I had this knowledge’’ Team connections Used words that showed connectivity and collaboration: ‘‘. . . learned more about their roles, always had someone to talk to about the patient and about my feelings’’ ‘‘I felt supported and undivided as an intern member of the interprofessional team. . . . I was part of a team working together for the patient’’ What they did not like about working with team members Conflict Articulated conflict as a result of teamwork: ‘‘If you work with someone who doesn’t like to help, that team is what I don’t like to work with’’ Trust Time
Communication
Hierarchy
Identified importance of establishing trust: ‘‘trust must be established before your opinion is of any weight’’ Identified value of spending time for teamwork: ‘‘Often with changing teams establishing this trust is time consuming and delays delivery of care to patients’’ Demonstrated understanding of challenges to interprofessional communication: ‘‘I may not understand the jargon they need in their profession’’ Identified awareness of power negotiations: ‘‘It was very interesting to get to know other people in the team and to see how roles are shared with slightly blurred boundaries but without stepping on anyone’s toes’’
Discussion The pilot project demonstrated the difficulties and complexities of engaging students in a learning activity during busy clinical placement experiences. Although the numbers are small, the evaluation of the IECPCP&H self-learning module suggests that the self-directed interprofessional module based on the humanities may valuably support IPE. The ATHT results indicate high acceptance of interprofessional teams to begin with. However, there was a small but significant difference between the module and non-module learners’ acceptance of non-physician team members as decision makers. It is not clear which aspect of the module provoked this change. The module learners’ knowledge of two pillars of the humanities (i.e. human perspectives and professionalism) was significantly greater than the non-module learners’ at the end of their placements. This indicates that our module’s learning activities are effective ways to delve into non-clinical aspects of patient care. While interprofessional placements can effectively create opportunities for students to learn together (Reeves, Perrier, Goldman, Freeth, & Zwarensten, 2013), coordinating a common meeting time for the learners was an insurmountable challenge in our hospital. Learners are in placements at different times of the year, and their learning schedules were full. Our module’s goal was to enhance interprofessional learning in a busy clinical context where control over learner placements and educational
Used less patient-centered language: ‘‘Being able to get a more complete picture of the client as the day goes by and the week goes by’’ Few reflections on team interactions: ‘‘They [team members] were very knowledgeable about their professions’’
Used words mainly about information exchange: ‘‘. . . exchanging information, educating each other’’ ‘‘. . . obtain info[rmation] from someone other than nurses’’
Articulated conflict as the result of personalities: ‘‘working with students from practical nursing was sometimes difficult, as some of them had a ‘‘chip’’ on their shoulder’’ Did not identify importance of establishing trust: ‘‘What I [liked] least was my ideas/thoughts weren’t always used’’ Questioned time required for teamwork: ‘‘[I] think the team building is a great idea, but realistically there is not enough time to be having meetings for every single patient all the time’’ Only identified bad communication: ‘‘There was not lot of interaction between other team members’’ Identified own sense of powerlessness: ‘‘I didn’t like being talked down to because I was a student’’ ‘‘. . . everyone not always seen as an equal’’
programs was limited. Our module is an approach that enables integration of self-learning with limited face-to-face interprofessional interaction. However, this is an area worthy of further investigation as the learners did recommend more interactions with other students. The module attempts to increase learner autonomy, to enhance the learner’s sense of control and confidence in the material, and to provide dynamic learning experiences that would motivate learning (Levett-Jones, 2005; Murad & Varkey, 2008; O’Shea, 2003). The module’s evaluation resulted in a revised edition providing improved structure and instruction for students with no experience in self-directed learning (Ainoda, Onishi, & Yusada, 2005). We glean two important lessons from our experience. They speak to process logistics that should be addressed when instituting this kind of program. First, as learners become more knowledgeable about collaborative patient-centred care, clinical staff must be adequately prepared to address these expectations and to act as role models. Although most staff were trained and expected to help learners with the learning activities, not all staff were able to attend our preparatory workshops, despite support from hospital administrators. Additionally, to prevent a decrease in the effectiveness of the training workshop, there should be no lag time between staff workshop and learners’ arrivals. Second, despite representation from all the schools and university programs on the steering committee, and ongoing discussions with curriculum coordinators and placement supervisors, the
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module demanded extra time and effort from the students. Despite this, participants in the module group showed good motivation with 72% completing all aspects of the study (creative summary and all evaluation tools). If the module were integrated into the curricula of the universities/colleges, it could leave more time during placements for clinical IPE activities and reflection. The module (or parts thereof) could be a component of the clinical placement and IPE curricula, and if systematically implemented could offer a stronger integration of IPE across sites and institutions (Arndt et al., 2009; O’Keefe, Burgess, McAllister, & Stupans, 2012; Williamson, Callaghan, Whittlesea, Mutton, & Heath, 2011). Additional aspects of this challenge included the lack of interest between faculties in the coordination of clinical placement schedules, and the fact that profession-specific objectives for clinical placement were overseen by uni-professional supervisors, limiting the focus on IPE. Interprofessional initiatives to establish and coordinate the integration of IPE within clinical placements would allow for the development and better integration of IPE activities. The pre-selection of module units may have resulted in different clinical experiences for the learners on those units. The learners assigned to non-module units may have been intrinsically different from those assigned to the module units, as witnessed by less interprofessional experience, a higher refusal rate among the non-module learners, as well as no data on their professions. Additionally, completion of the evaluation instruments was completely voluntary in both groups, and there was little incentive for them to comply. Medical learners were predominant in the module group because they were the most numerous learners on one of the module units (palliative care) and, therefore, could have biased the results. The evaluation instruments may add to the limits of this study. The knowledge questions were developed by the project team and tested only for face validity. While the team conducted the scoring blindly and came to group consensus for every score, it is not known if another group would have scored the learners’ openended responses similarly. The concepts we were attempting to measure are hard to measure empirically, although some strides have been made more recently (Reeves et al., 2008). The module was recently adapted into an interactive bilingual online e-learning module that will facilitate its integration into pre-licensure curricula with open-access for interested educators.2 The results of the pilot study support further evaluation of the module, including wider integration into clinical placements and research into its long-term impact, using new tools and additional qualitative data collection to assess attitudinal shifts and experiential interprofessional learning (Curran et al., 2011; Hall, Marshall, Weaver, Boyle, & Taniguchi, 2011). The module can easily be adapted to other areas of care requiring a team approach, but would require further testing. Additionally, although the patient’s voice and the family’s perspective were often represented as a part of the creative summaries, studies that would directly report their perspectives in the care model are needed.
Concluding comments While the benefits of IPE have been internationally recognized (World Health Organization, 2004), our experiences implementing an IPE innovation illustrate the complexities and dynamics involved in bringing multiple health professions to the ‘‘education table’’. As health profession education curricula change to meet accreditation standards and to incorporate a growing body of 2
See: http://www.ahc-cas.ca/repo/en
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knowledge into a limited timeframe, the humanities continue to be sidelined, if not completely omitted. In this analysis, we have sought to describe the ‘‘definable’’ skills that a humanities-based IPE learning module can impart to students. The IECPCP&H self-learning module suggests promise for enabling learners from all professions and all levels of pre-licensure education to learn about collaborative teamwork through the lens of the humanities, at their own pace and in their own time during clinical placements. Through the development of relationships, the humanities encouraged learners to interact with and better understand patients and families as unique and holistic beings.
Acknowledgements The authors also wish to thank the study participants and steering committee members.
Declaration of interest This study was supported through a financial contribution from Health Canada. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Ainoda, N., Onishi, H., & Yasuda, Y. (2005). Definitions and goals of ‘‘self-directed learning’’ in contemporary medical education literature. Annals of Academic Medicine Singapore, 34, 515–519. Arndt, J., King, S., Suter, E., Mazonde, J., Taylor, E., & Arthur, N. (2009). Socialization in Health Education: Encouraging an integrated interprofessional socialization process. Journal of Allied Health, 38, 18–23. Barr, H. (2002). Interprofessional education: Today, yesterday, and tomorrow. London: London Learning and Support Network, Center for Health Sciences and Practice. Brajtman, S., Hall, P., & Barnes, P. (2009). Enhancing interprofessional education in end-of-life care: An interdisciplinary exploration of death and dying in literature. Journal of Palliative Care, 25, 125–131. Canadian Interprofessional Health Collaborative. (2010). A national interprofessional competency framework. Retrieved from http:// www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf Charon, R. (2001). The patient–physician relationship. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA, 286, 1897–1902. Creswell, J.W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Thousand Oaks, CA: SAGE Publications. Creswell, J.W., Plano Clark, V.L., Gutmann, M.L., & Hanson, W.E. (2003). Advanced mixed methods research designs. In A. Tashakkori & C. Teddlie (Eds.), Handbook of mixed methods in social & behavioral research (pp. 209–240). Thousand Oaks, CA: Sage Publications. Curran, V., Hollett, A., Casimiro, L.M., Mccarthy, P., Banfield, V., Hall, P., et al. (2011). Development and validation of the Interprofessional Collaborator Assessment Rubric (ICAR). Journal of Interprofessional Care, 25, 339–344. D’Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 19 , 8–20. D’Eon, M. (2005). A blueprint for interprofessional learning. Journal of Interprofessional Care, 19 , 49–59. Dellasega, C., Milone-Nuzzo, P., Curci, K., Ballard, J.O., & Kirch, D. (2007). The humanities interface of nursing and medicine. Journal of Professional Nursing, 23, 174–179. Des Marchais, J.E., Jean, P., & Delorme, P. (1990). Basic training program in medical pedagogy: A 1-year program for medical faculty. Canadian Medical Association Journal, 142, 734–740. Doukas, D.J., McCullough, L.B., & Wear, S. (2010). Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Academic Medicine, 5, 318–323. Ferris, F.D., Balfour, H.M., Bowen, K., Farley, J., Hardwick, M., Lamontagne, C., et al. (2002). A model to guide hospice palliative care. Ottawa, ON: Canadian Hospice Palliative Care Association.
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Flexner, A. (1910). Medical education in the United States and Canada. A report to the Carnegie Foundation for the advancement of teaching. Bulletin No. 4. New York: Carnegie Foundation. Hall, P., Marshall, D., Weaver, L., Boyle, A., & Taniguchi, A. (2011). A method to enhance student teams in palliative care: Piloting the McMaster-Ottawa team observed structured clinical encounter. Journal of Palliative Medicine, 14, 744–750. Hammer, R.R. (2010). An education that pierces what the knife cannot: A student perspective. Anatomical Sciences Education, 3, 151–153. Knowles, M. (1975). Self-directed learning. Englewood Cliffs: Cambridge Adult Education, Prentice Hall Regents. Ku¨bler-Ross, E. (1970). The care of the dying – Whose job is it? Psychiatry Medicine, 1, 103–107. Leipzig, R.M., Hyer, K., Ek, K., Wallenstein, S., Vezina, M.L., Fairchild, S., Cassel, C.K., & Howe, J.L. (2002). Attitudes toward working on interdisciplinary healthcare teams: A comparison by discipline. Journal of the American Geriatric Society, 50, 1141–1148. Levett-Jones, T.L. (2005). Self-directed learning: Implications and limitations for undergraduate nursing education. Nurse Education Today, 25, 363–368. Murad, M.H. & Varkey, P. (2008). Self-directed learning in health professions education. Annals of Academic Medicine Singapore, 37, 580–590. Nightingale, F. (1860). Notes on nursing, what it is, and what it is not. New York: D. Appleton and Company. Retrieved from http:// digital.library.upenn.edu/women/nightingale/nursing/nursing.html Oandasan, I., & Reeves, S. (2005). Key elements of interprofessional education. Part 2: Factors, processes and outcomes. Journal of Interprofessional Care, 19, 39–48. O’Keefe, M., Burgess, T., McAllsiter, S., Stupans, I. (2012). Twelve tips for supporting student learning in multidisciplinary clinical placements. Medical Teacher, 34, 883–887. O’Shea, E. (2003). Self-directed learning in nurse education: A review of the literature. Journal of Advanced Nursing, 43, 62–70. Osler, W. (1919). The old humanities and the new science: The Presidential Address delivered before the Classical Association at Oxford, May, 1919. British Medical Journal, 2, 1–7. Ousager, J., & Johannessen, H. (2010). Humanities in undergraduate medial education: A literature review. Academic Medicine, 85, 988–998.
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Polit, D.F., Tatano, C., & Hungler, B.P. (2001). Essentials of nursing research (5th ed.) Philadelphia: Lippincott. Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Hammick, M., & Koppel, I. (2008). Interprofessional education: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, (1), CD002213. doi: 10.1002/ 14651858.CD002213.pub2. Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarensten, M. (2013). Interprofessional education: Effects on professional practice and healthcare outcomes (update). The Cochrane Library (3). [Epub ahead of print]. doi:10.1002/14651858.CD002213.pub3 Schwartz, A.W., Abramson, J.S., Wojnowich, I., Accordino, R., Ronan, E.J., & Rifkin, M.R. (2009). Evaluating the impact of humanities in medical education. Mount Sinai Journal of Medicine, 76, 372–380. Shapiro, J., Coulehan, J., Wear, D., & Montello, M. (2009). Medical humanities and their discontents: Definitions, critiques and implications. Academic Medicine, 84, 192–198. Shaver, J.L. (2005). Interdisciplinary education and practice: Moving from reformation to transformation. Nursing Outlook, 53, 57–58. Shortell, S.M. (2000). Community health improvement approaches: Accounting for the lack of impact. Health Services Research, 35, 555–560. Standford University. (2014). Why are the humanities important? Insights into everything. Retrieved from: http://humanexperience.stanford.edu/ why on February 24. 2014. Statistics Canada. (2010). Population projections for Canada, provinces and territories 2000–2026. Statistics Canada, Catalogue #91-520. Weaver, L., McMurtry, A., Conkin, J., Brajtman, S., & Hall, P. (2011). Harnessing complexity science for interprofessional education development: A case example. Journal of Research in Interprofessional Practice and Education, 2(1). Retrieved from http://www.jripe.org/ index.php/journal/article/view/48/44 Williamson, G.R., Callaghan, L., Whittlesea, E., Mutton, L., & Heath, V. (2011). Placement Development Teams and interprofessional education with health care students. Journal of Clinical Nursing, 20, 2305–2314. World Health Organization (WHO). (2004). Palliative care: The solid facts. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/ 0003/98418/E82931.pdf
ORIGINAL ARTICLE
Learning collaborative teamwork: an argument for incorporating the humanities Pippa Hall1, Susan Brajtman2, Lynda Weaver3, Pamela Anne Grassau4 and Lara Varpio5 1
Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada, 2School of Nursing, University of Ottawa, Ottawa, Ontario, Canada, Bruyere Continuing Care, Palliative Care, Ottawa, Ontario, Canada, 4Bruye`re Research Institute, Palliative Care Education and Research, Ottawa, Ontario, Canada, and 5Academy of Innovations in Medical Education (AIME), University of Ottawa, Ottawa, Ontario, Canada
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Abstract
Keywords
A holistic, collaborative interprofessional team approach, which includes patients and families as significant decision-making members, has been proposed to address the increasing burden being placed on the health-care system. This project hypothesized that learning activities related to the humanities during clinical placements could enhance interprofessional teamwork. Through an interprofessional team of faculty, clinical staff, students, and patient representatives, we developed and piloted the self-learning module, ‘‘interprofessional education for collaborative person-centred practice through the humanities’’. The module was designed to provide learners from different professions and educational levels with a clinical placement/residency experience that would enable them, through a lens of the humanities, to better understand interprofessional collaborative person-centred care without structured interprofessional placement activities. Learners reported the self-paced and selfdirected module to be a satisfactory learning experience in all four areas of care at our institution, and certain attitudes and knowledge were significantly and positively affected. The module’s evaluation resulted in a revised edition providing improved structure and instruction for students with no experience in self-directed learning. The module was recently adapted into an interactive bilingual (French and English) online e-learning module to facilitate its integration into the pre-licensure curriculum at colleges and universities.
Humanities, interprofessional collaboration, interprofessional education, self-directed learning, work-based learning
Introduction The realities facing today’s healthcare system are driving change. Limited economic and human resources, shifts in the location of caregiving, growing cultural diversity in health-care workers and patients, increasingly complex technologies, heightened patient acuity, and a rapidly expanding older population living longer with chronic and degenerative diseases: these are the new demands our healthcare system must meet (Statistics Canada, 2010; World Health Organization, 2004). A holistic, collaborative interprofessional team approach, which includes patients and families as significant decision-making members, has been proposed as a solution to these challenges (Barr, 2002; Shortell, 2000). Interprofessional education (IPE) has been recommended as a means for preparing health-care professionals to work as effective members of care teams in this complex environment (D’Amour & Oandasan, 2005). IPE seeks to develop competencies in communication, collaboration and shared decisionmaking, understanding roles and responsibilities, patient/ family-centred approach to care, conflict management, and contributing to team function (Canadian Interprofessional Health Collaborative, 2010; Curran et al., 2011). Clearly, research
Correspondence: Ms Lynda Weaver, MHA, MEd, Bruyere Continuing Care, Palliative Care, 43 Bruyere St., Ottawa, Ontario, Canada K1N 5C8. E-mail: [email protected]
History Received 9 April 2013 Revised 24 February 2014 Accepted 13 April 2014 Published online 12 May 2014
has clarified the ‘‘what’’ of IPE. Now scholars are tackling the question of ‘‘how’’. The humanities cover liberal arts topics related to the human condition, including history, literature, fine art, philosophy, and ethics. They teach us to ‘‘think creatively and critically, to reason, and to ask questions’’ (Standford University, 2014). Using the humanities to enhance the education of health professionals has been repeatedly recommended (Brajtman, Hall, & Barnes, 2009; Charon, 2001; Doukas, McCullough, & Wear, 2010; Flexner, 1910; Ku¨bler-Ross, 1970; Nightingale, 1860; Osler, 1919); but critical study of their impact is lacking (Hammer, 2010; Ousager & Johannessen, 2010; Schwartz et al., 2009; Shapiro, Coulehan, Wear, & Montello, 2009). As the biological and scientific knowledge required of healthcare professionals grows, the time available to teach other topics decreases (Dellasega, MiloneNuzzo, Curci, Ballard, & Kirch, 2007). Consequently, educators and administrators committed to the inclusion of the humanities in health education face the challenge of integrating these courses into already overloaded curricula. We posit that the humanities can be infused into existing curriculum to meet IPE goals. Using the humanities to learn together can break down power differentials inherent in health science disciplines/professions and can help reconcile different world-views based on shared values (Brajtman et al., 2009; Shaver, 2005). We hypothesize that the humanities can enable learners to meaningfully interact and connect with patients and members
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of the care team. Health profession education curricula are improving methods to teach skills such as reflective practice, holistic care, and patient-centered care. Recent research suggests that incorporating these humanities-based instructions can provide health profession trainees with a fund of knowledge and skills of reasoning, discernment, and judgment essential to sustainable professionalism (Doukas et al., 2010). Through a humanities-based perspective, learners can reflect on the impact of their personal and professional relationships with patients and families, while appreciating the rich backgrounds and histories held within each patient and family member. The humanities support a holistic and person-centered approach to care, and provide learners with new ‘‘lenses’’ through which to interact with clinical team members to better understand their own roles and those of others. Guided by elements of D’Amour and Oandasan’s (2005) model, our primary research question was: ‘‘Would teaching learners through a humanities-oriented self-learning module during clinical placements change their attitudes about working in healthcare teams and increase their knowledge about holistic care, collaborative practice, and the humanities?’’ The evaluation tools and the mixed method evaluation design used in this study provide results that answer this question as well as insight into a situated understanding of how participants’ attitudes were impacted by the module.
Background From 2006 to 2008, we conducted the pilot project, ‘‘interprofessional education for collaborative person-centred practice through the humanities’’ (IECPCP&H), at a non-acute care teaching hospital. The goal was to provide trainees with humanities-based learning activities within a clinical placement experience to help them to better understand and experience interprofessional collaborative person-centred care. A bilingual (English and French) interprofessional steering committee oversaw the project. Members were recruited from hospital staff, family, and patient representatives, as well as faculty and students of different health professions from four local universities and colleges. Four criteria guided the module development: content must be applicable for any level of learner (i.e. from 1st year pre-licensure
to post-graduate residency) from any health profession; logistics must enable learners to complete the module at their own pace during their clinical placement; length must facilitate completion within a clinical placement of at least 10 days; and learning activities had to be based on the principles of active learning – encouraging reflection and engagement of learners with patients, families, and clinical team members through experiential activities (D’Eon, 2005). Foundational concepts of teamwork were integrated throughout the module (i.e. effective group function, action-reflective learning/practice) (Ferris et al., 2002; Oandasan & Reeves, 2005). After four intensive workshops over 6 months, the committee determined that a self-learning module could address the challenges of scheduling formal interprofessional clinical placements, and could address the learning needs of multiple learners with a variety of health-care backgrounds. The committee’s experience with developing the module is discussed elsewhere (Weaver, McMurtry, Conklin, Brajtman, & Hall, 2011). The bilingual self-learning module was entitled: ‘‘you the learner, the person in your care, and the interprofessional team.’’ a facilitator’s guide was developed for the health-care team members in units where the learners were situated. A self-learning approach was selected to make the learning experience personally meaningful and convenient. The module format, guided by Knowles’ (1975) work, encouraged learners to assess their own learning needs, formulate their own learning goals, reflect on their experiences, and use available resources to meet the module’s requirements. Four care scenarios were developed to ensure that the module’s case work was relevant in all areas where a student could have a clinical placement at our institution: palliative care, care of the elderly and rehabilitation, complex continuing care, and long-term care. The module was composed of three chapters: holistic care, interprofessional teamwork, and the humanities. The module emphasized patients and families as vital parts of the care team. After completing the reading and exercises of each chapter, learners were asked to apply the concepts with a person in their care through a final creative assignment. Table I summarizes the content of the module. The layout followed the self-learning module outline described by Des Marchais, Jean, and Delorme (1990). Objectives were listed at the start of each chapter, allowing learners to self-assess
Table I. Summary of self-learning module content. Chapter
Content
Chapter I – Holistic Care
Presents a model of holistic care, depicting four domains that require attention and care for a person with an illness (physical, emotional/psychological, social/cultural, and spiritual)
Chapter II – Interprofessional Teamwork
Identifies an interprofessional approach to holistic care, including roles, responsibilities, and relationships within the team Provides tools to enhance interactive learning during clinical placements
Chapter III – The Humanities in Health Care
Presents a framework of four pillars for the humanities: Human experience: explores how humans reflect the meaning, value and creativity of the human spirit, often expressed through art, literature, film, and music Historical perspectives: explores how an illness has been treated and understood over time (either by patient or by historically); how each profession/discipline has developed and established its role in caring for persons with a particular condition Ethics and law: explores ethical issues that arise in making decisions about care, and how these decisions are made. Professionalism: explores learner’s reflections on experiences in the health care world as a professional Application of the framework to connect the learner with a person in his/her care and with other team members
Chapter IV – Creative Summary Assignment
In collaboration with a person in their care, who had made an impact on their learning, and with other team members, learners construct a team map illustrating the relationships among that person, their significant family members, and the team members and apply one of the pillars of the humanities framework to develop a more holistic understanding Learners produce a creative summary to express what they had learned from the experience, using any media and format (e.g. painting or drawing, poems, songs, collages, skits, short story, etc.)
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their readiness and decide in how much detail they would review the content (Levett-Jones, 2005; Murad & Varkey, 2008; O’Shea, 2003). Each chapter then posed a question to allow learners to express what they already knew about the topic. Formal definitions and additional information were then provided. Learning activities required learners to interact with patients in their care as well as with fellow care team members. The chapters ended with a reflective question designed to encourage learners to delve deeper into the topic.
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Methods A concurrent nested mixed method research design was utilized (Creswell, 2014; Creswell, Plano Clark, Gutmann, & Hanson, 2003). As such, quantitative and qualitative data were collected at the same time, with priority given to the quantitative data. Random allocation to clinical units was not possible due to the curricular and logistical demands of the different school/university programs sending learners to our institution. Instead, specific care units at our institution were designated to be ‘‘module units’’ where learners used the module as a part of the usual educational program, and other units were designated as ‘‘non-module units’’ where learners would not experience the learning module (see Figure 1 for diagram of study design). Module units were chosen through discussions with the staff and managers. Although the module was considered a part of the normal educational program on the selected units, the project was not considered a mandatory component of any learner’s clinical placement by their schools/ universities programs. Approval for this evaluation was received from the Ethics Review Boards of the involved institutions. Two groups of learners (module versus non-module) allowed our analysis to reflect within-group differences, as well as between-group differences. This design was chosen to augment the validity of the study’s findings and to better understand the experiences of participants (Polit, Tatano, & Hungler, 2001). Data collection Learners in both module and non-module units were invited to participate in the evaluation of their interprofessional clinical placement. The evaluation required completion of four instruments: Attitude Scale: Attitudes Towards Healthcare Teams (ATHT) scale (Leipzig et al., 2002) (pre- and post-placement). Knowledge test (pre- and post-placement): open-ended questions asking learners to list important aspects of (a) holistic care, (b) collaborative patient-centred practice, and (c) the humanities in health care (human experience; historical
Pre & Post Licensure Students Approached = 266
Module 110
Non-Module 156
Consented 61/110 (55.5%)
Consented 43/156 (27.6%)
Pre-surveys 61 Post-surveys 44
Pre-surveys 40 Post-surveys 29
(Paired= 38)
(Paired=25)
Creative Summaries: 42 people did 20 summaries (16 by individuals, 3 by 8 people each, and 1 by 2 people)
Creative Summaries: Not requested
Figure 1. Summary of project study design and participants.
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perspectives; ethics and law; and professionalism). At the time of the project, no appropriate knowledge test existed in the literature, therefore, questions were developed for this project with face validity obtained through review by the project team and members of the steering committee. Interprofessional learning experience: Likert scale (three items) (Post-placement). Reactions to working in teams: Open-ended questions (three items) (Post-placement). Additionally, module unit learners were asked to complete one more instrument: satisfaction with and perceived impact from the module. A 26-item Likert scale and three open-ended question (post-placement).1 Recruitment All levels of learners (pre-licensure or post-licensure, French- or English-speaking, from medicine, nursing, pharmacy, physiotherapy, occupational therapy, social work, spiritual care, or human sciences programs) coming to our institution were assigned to a care area through their usual school program’s processes. Thus, participants were unknowingly assigned to either a module or a non-module unit. Upon arrival, all learners were informed about the project and invited to participate. Recognizing recruitment numbers would be limited by students’ availability during their placements, a research assistant made personal contact with students and supervisors. There was no way to pre-determine the number of participants, as we were not provided with a known number of students ahead of time. The sample is not random, thus a power calculation would not be reliable. Data analysis Quantitative data were analyzed using SPSS versions 15 and 16 (SPSS Inc., Chicago, IL) and qualitative data were analyzed using Microsoft Word word processing software. Attitude scale: ATHT pre-post data (instrument #1) were analyzed with the appropriate responses reversed and all items zero-based and summed to create three subscales: attitudes towards the value of a team (team value), attitudes towards physicians sharing the role as decision-maker (physician shared role), and attitudes towards the effectiveness of teams (team effectiveness). Within group pre- and post-placement means for each scale were compared using a paired t-test, and between groups post-placement means were compared using an independent t-test. Knowledge test: The project team, using a scoring rubric with inter-rater reliability achieved through consensus or majority ruling, scored the open-ended knowledge questions on collaboration and humanities (instrument #2). The team was blinded as to whether the responses were pre- or post-placement, or from module or non-module participants. The rubric for scoring was: 0 ¼ wrong; 1 ¼ partially correct; 2 ¼ completely correct. A ‘‘completely correct’’ score meant they had listed three important aspects for the two questions on teamwork and one important aspect each for the four humanities questions. Blank responses were left out of the analysis as we could not assume they did not know the answer as opposed to they did not have time or the motivation to respond. Interprofessional learning experience: The three items in the post-placement Interprofessional Learning Experience Likert scale (instrument #3) were analyzed individually, using t-tests to compare group means (module versus non-module).
1
Tools 1–5 can be found at: http://bruyere.org/en/projects2#Pippa.
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Reactions to working in teams: Content analysis was conducted on the open-ended comments on learners’ reactions to working with other team members (instrument #4) by one of the authors (L. W.). Satisfaction and perceived impact: For the module learners’ post-placement 26-item Likert scale on the module (instrument #5), the items were summed for each of four factors that emerged from principle components factor analysis that accounted for 68.9% of the variance: content, logistics, ease of use, and learning from the module. Content analysis was performed on the openended questions by one of the authors (L. W.).
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Results Of the 266 potential learner participants, 104 participated in the evaluation of the project. Of the 162 learners who did not participate, the majority (70%) were from the non-module group. Non-participants were not required to complete any demographic data or explain why they did not respond; they just did not return the pre- or post-tests. Table II indicates the participants’ professions. Figure 1 illustrates the two study groups and the final sample, including the final paired data sets, i.e. those learners who supplied both pre- and post-data (module, n ¼ 38; non-module, n ¼ 25). Most participants were female: 80% of the module group and 87% of the non-module group. Half of the module group reported having had some previous interprofessional experiences, compared with 30% of the non-module group. The length of the clinical placements in the module group varied between 3 and 52 weeks; in the non-module group from 2 to 12 weeks. Attitudes scores The within-group paired t-tests analysis showed that the placement had an impact on both the module and non-module learners, with significant differences in pre- versus post-placements means for two of the three subscales: team efficiency and physician shared roles. For team values, there were no differences pre versus posts for either module or non-module (Table III). Table II. Participating learners’ professional affiliations. Profession Nursing (RN, RPN) Medicine Pharmacy Psychology Speech/language Spiritual care Occupational therapy Social work Instructor for RPNs Unknown Totals
Module
Non-module
Totals
28 24 3 0 1 3 0 1 0 0 61
26 6 1 1 1 1 3 1 1 2 43
54 30 4 1 2 4 3 2 1 2 104
RN, registered nurse; RPN, registered practical nurse. Table III. Attitude Towards Healthcare Teams (ATHT) paired t-tests, module versus non-module learners (Tool #1). Module N Team efficiency Team value Physician shared roles
37 42 36
Non-module
Means Pre
Post
12.5 45.0 8.1
13.3* 45.0 9.7**
*p50.001, **p50.024. ***p50.000.
Means
N 23 28 22
Pre
Post
14.3 44.6 11.7
15.0* 44.6 11.3***
The between-group analysis showed that one subscale was significant at post-test: module learners were more receptive to physicians sharing their decision-making roles than non-module learners (p ¼ 0.027). Knowledge scores Two of the four open-ended knowledge test questions related to the humanities showed that significantly more module learners answered correctly post-placement than non-module learners. They were human perspectives (F(1,48) ¼ 13.25, p50.001), and professionalism (F(1,48) ¼ 4.36, p50.04). The two knowledge questions related to interprofessional practice were not significantly different between the two groups at post-placement. Interprofessional learning experience There was no difference between module and non-module groups for three Likert questions regarding the interprofessional aspects of their clinical placements. Figure 2 shows both groups agreed or strongly agreed that that they had learned about interprofessional collaborative teamwork and had worked with members from interprofessional teams. Reactions to working in teams The open-ended questions on working with other team members showed some differences between the groups. Module learners used more language that reflected relationship development and the complexities of collaborative teamwork. Both groups equally enjoyed their experiences, and appreciated the different perspectives from various team members, the learning, and the cooperation. Both expressed a strong desire to work more closely with students from other professions. The major differences between groups are displayed in Table IV. Satisfaction with and perceived impact from module From the 26-item Likert scale, module learners showed high satisfaction with the content of the module as indicated by their mean of 25.6 out of a possible 35. Learning from the module was also rated high, with a mean of 42.7 out of a possible 50. Module learners were less satisfied with logistics and ease of learning, as shown by the respective means of 19.7 out of 30 and 5.4 out of 10. Module learners’ responses to the open-ended comments indicated a number of recommended improvements for the module, such as making the questions less repetitive and/or vague, and changing the videos.
Percent "Agree" and "Strongly Agree"
522
100 80
Module Non-module
81.8 70.4 68.8
75
60 40
29.1 21.9
20 0 Worked with students
Worked with team members
Taught me about working collaboratively
Figure 2. Percent of module and non-module learners who ‘‘agree’’ or ‘‘strongly agree’’ with statements related to interprofessional aspects of their clinical placement experiences (Tool #3).
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Table IV. Module versus non-module responses about working with team members (Tool #4). Theme
Module learners
Non-module learners
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What they liked about working with team members: Patient care goals Used words describing patient-centred goals: ‘‘. . . provides better care to the patient and established common care goals’’ ‘‘I was part of a team working together for the patient’’ Team interactions Described benefits of team interactions: ‘‘. . . that we got to do it as a group and communicate with each other’’ ‘‘I learned quite a bit about the other professions and was able to direct my questions to the appropriate person once I had this knowledge’’ Team connections Used words that showed connectivity and collaboration: ‘‘. . . learned more about their roles, always had someone to talk to about the patient and about my feelings’’ ‘‘I felt supported and undivided as an intern member of the interprofessional team. . . . I was part of a team working together for the patient’’ What they did not like about working with team members Conflict Articulated conflict as a result of teamwork: ‘‘If you work with someone who doesn’t like to help, that team is what I don’t like to work with’’ Trust Time
Communication
Hierarchy
Identified importance of establishing trust: ‘‘trust must be established before your opinion is of any weight’’ Identified value of spending time for teamwork: ‘‘Often with changing teams establishing this trust is time consuming and delays delivery of care to patients’’ Demonstrated understanding of challenges to interprofessional communication: ‘‘I may not understand the jargon they need in their profession’’ Identified awareness of power negotiations: ‘‘It was very interesting to get to know other people in the team and to see how roles are shared with slightly blurred boundaries but without stepping on anyone’s toes’’
Discussion The pilot project demonstrated the difficulties and complexities of engaging students in a learning activity during busy clinical placement experiences. Although the numbers are small, the evaluation of the IECPCP&H self-learning module suggests that the self-directed interprofessional module based on the humanities may valuably support IPE. The ATHT results indicate high acceptance of interprofessional teams to begin with. However, there was a small but significant difference between the module and non-module learners’ acceptance of non-physician team members as decision makers. It is not clear which aspect of the module provoked this change. The module learners’ knowledge of two pillars of the humanities (i.e. human perspectives and professionalism) was significantly greater than the non-module learners’ at the end of their placements. This indicates that our module’s learning activities are effective ways to delve into non-clinical aspects of patient care. While interprofessional placements can effectively create opportunities for students to learn together (Reeves, Perrier, Goldman, Freeth, & Zwarensten, 2013), coordinating a common meeting time for the learners was an insurmountable challenge in our hospital. Learners are in placements at different times of the year, and their learning schedules were full. Our module’s goal was to enhance interprofessional learning in a busy clinical context where control over learner placements and educational
Used less patient-centered language: ‘‘Being able to get a more complete picture of the client as the day goes by and the week goes by’’ Few reflections on team interactions: ‘‘They [team members] were very knowledgeable about their professions’’
Used words mainly about information exchange: ‘‘. . . exchanging information, educating each other’’ ‘‘. . . obtain info[rmation] from someone other than nurses’’
Articulated conflict as the result of personalities: ‘‘working with students from practical nursing was sometimes difficult, as some of them had a ‘‘chip’’ on their shoulder’’ Did not identify importance of establishing trust: ‘‘What I [liked] least was my ideas/thoughts weren’t always used’’ Questioned time required for teamwork: ‘‘[I] think the team building is a great idea, but realistically there is not enough time to be having meetings for every single patient all the time’’ Only identified bad communication: ‘‘There was not lot of interaction between other team members’’ Identified own sense of powerlessness: ‘‘I didn’t like being talked down to because I was a student’’ ‘‘. . . everyone not always seen as an equal’’
programs was limited. Our module is an approach that enables integration of self-learning with limited face-to-face interprofessional interaction. However, this is an area worthy of further investigation as the learners did recommend more interactions with other students. The module attempts to increase learner autonomy, to enhance the learner’s sense of control and confidence in the material, and to provide dynamic learning experiences that would motivate learning (Levett-Jones, 2005; Murad & Varkey, 2008; O’Shea, 2003). The module’s evaluation resulted in a revised edition providing improved structure and instruction for students with no experience in self-directed learning (Ainoda, Onishi, & Yusada, 2005). We glean two important lessons from our experience. They speak to process logistics that should be addressed when instituting this kind of program. First, as learners become more knowledgeable about collaborative patient-centred care, clinical staff must be adequately prepared to address these expectations and to act as role models. Although most staff were trained and expected to help learners with the learning activities, not all staff were able to attend our preparatory workshops, despite support from hospital administrators. Additionally, to prevent a decrease in the effectiveness of the training workshop, there should be no lag time between staff workshop and learners’ arrivals. Second, despite representation from all the schools and university programs on the steering committee, and ongoing discussions with curriculum coordinators and placement supervisors, the
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module demanded extra time and effort from the students. Despite this, participants in the module group showed good motivation with 72% completing all aspects of the study (creative summary and all evaluation tools). If the module were integrated into the curricula of the universities/colleges, it could leave more time during placements for clinical IPE activities and reflection. The module (or parts thereof) could be a component of the clinical placement and IPE curricula, and if systematically implemented could offer a stronger integration of IPE across sites and institutions (Arndt et al., 2009; O’Keefe, Burgess, McAllister, & Stupans, 2012; Williamson, Callaghan, Whittlesea, Mutton, & Heath, 2011). Additional aspects of this challenge included the lack of interest between faculties in the coordination of clinical placement schedules, and the fact that profession-specific objectives for clinical placement were overseen by uni-professional supervisors, limiting the focus on IPE. Interprofessional initiatives to establish and coordinate the integration of IPE within clinical placements would allow for the development and better integration of IPE activities. The pre-selection of module units may have resulted in different clinical experiences for the learners on those units. The learners assigned to non-module units may have been intrinsically different from those assigned to the module units, as witnessed by less interprofessional experience, a higher refusal rate among the non-module learners, as well as no data on their professions. Additionally, completion of the evaluation instruments was completely voluntary in both groups, and there was little incentive for them to comply. Medical learners were predominant in the module group because they were the most numerous learners on one of the module units (palliative care) and, therefore, could have biased the results. The evaluation instruments may add to the limits of this study. The knowledge questions were developed by the project team and tested only for face validity. While the team conducted the scoring blindly and came to group consensus for every score, it is not known if another group would have scored the learners’ openended responses similarly. The concepts we were attempting to measure are hard to measure empirically, although some strides have been made more recently (Reeves et al., 2008). The module was recently adapted into an interactive bilingual online e-learning module that will facilitate its integration into pre-licensure curricula with open-access for interested educators.2 The results of the pilot study support further evaluation of the module, including wider integration into clinical placements and research into its long-term impact, using new tools and additional qualitative data collection to assess attitudinal shifts and experiential interprofessional learning (Curran et al., 2011; Hall, Marshall, Weaver, Boyle, & Taniguchi, 2011). The module can easily be adapted to other areas of care requiring a team approach, but would require further testing. Additionally, although the patient’s voice and the family’s perspective were often represented as a part of the creative summaries, studies that would directly report their perspectives in the care model are needed.
Concluding comments While the benefits of IPE have been internationally recognized (World Health Organization, 2004), our experiences implementing an IPE innovation illustrate the complexities and dynamics involved in bringing multiple health professions to the ‘‘education table’’. As health profession education curricula change to meet accreditation standards and to incorporate a growing body of 2
See: http://www.ahc-cas.ca/repo/en
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knowledge into a limited timeframe, the humanities continue to be sidelined, if not completely omitted. In this analysis, we have sought to describe the ‘‘definable’’ skills that a humanities-based IPE learning module can impart to students. The IECPCP&H self-learning module suggests promise for enabling learners from all professions and all levels of pre-licensure education to learn about collaborative teamwork through the lens of the humanities, at their own pace and in their own time during clinical placements. Through the development of relationships, the humanities encouraged learners to interact with and better understand patients and families as unique and holistic beings.
Acknowledgements The authors also wish to thank the study participants and steering committee members.
Declaration of interest This study was supported through a financial contribution from Health Canada. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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