YAPNR-50566; No of Pages 5 Applied Nursing Research xxx (2014) xxx–xxx
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Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Teaching the teachers: Faculty development in inter-professional education Beth P. Davis, DPT, MBA a,⁎, Carolyn K. Clevenger, DNP, GNP-BC b, 1, Samuel Posnock, MS, PhD(c) c, 2, Bethany D. Robertson, DNP, CNM b, 1, Douglas S. Ander, MD d, 3 a
Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine,1462 Clifton Road NE, Suite 314, Atlanta, GA 30322, USA Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, Suite 314, Atlanta, GA 30322, USA School of Psychology, Georgia Institute of Technology, 654 Cherry Street, Atlanta, GA 30332-0170, USA d Emory Center for Experiential Learning, Emory University School of Medicine, 1648 Pierce Drive, Suite B31, Atlanta, GA 30322, USA b c
a r t i c l e
i n f o
Article history: Received 13 March 2013 Revised 2 March 2014 Accepted 8 March 2014 Available online xxxx Keywords: Faculty Interprofessional relations Continuing education Healthcare teams Interdisciplinary
a b s t r a c t Aims: The purpose of this study is to evaluate changes in self-concept for the knowledge, skills and attitudes toward inter-professional teamwork of facilitators who participated in training and an inter-professional team training event. Background: Inter-professional education requires dedicated and educated faculty. Methods: A pretest posttest quasi-experimental design was used for the evaluation. Fifty-three facilitators were asked to complete pre–post questionnaires to measure inter-professional team self-concept (IPTSC), assessing self-concept for the knowledge, skills, and attitudes required for performing in an inter-professional team. Results: Post-session scores on inter-professional team knowledge, skills and attitudes were significantly higher (F(1, 31) = 5.59, p = .02). Conclusion: A facilitator development course and participation in the teaching event had a positive impact on perceived knowledge, skills and attitudes toward inter-professional teamwork. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Patient safety concerns and potential solutions have been highlighted in several reports from the Institute of Medicine (Institute of Medicine, 1999, 2001). Subsequent IOM reports include recommendations for intervention in undergraduate health professions education (Institute of Medicine, 2003). Emerging from this focus on patient safety is the importance of inter-professional teamwork within health professions education (Accreditation Council for Graduate Medical Education, 2011; Cronenwett et al., 2007). In 2011, the Interprofessional Education Collaborative (IPEC) published core competencies for inter-professional education (IPE) in the health professions along with strategies for implementation (Interprofessional Education Collaborative Expert Panel, 2011a). A number of IPE models exist, dating back to the 1940s (Baldwin, 2007), and the use of faculty as facilitators to teach IPE is increasingly common (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011). However, until the most recent IPEC reports (Interprofessional
⁎ Corresponding author. Tel.: +1 404 712 5884; fax: +1 404 712 4130. E-mail addresses: [email protected] (B.P. Davis), [email protected] (C.K. Clevenger), [email protected] (S. Posnock), [email protected] (B.D. Robertson), [email protected] (D.S. Ander). 1 Tel.: +1 404 712 2394; fax: +1 404 727 8514. 2 Tel.: +1 404 894 8712; fax: +1 404 894 8905. 3 Tel.: +1 404 251 8828; fax: +1 404 688 6351.
Education Collaborative Expert Panel, 2011b), the need for faculty development as a key component of successful IPE (Buring et al., 2009) was not widely appreciated. The IPEC report emphasized that a core strategy for incorporating IPE education into health professions education involves the improved preparation of faculty to teach students to work as part of the team (Interprofessional Education Collaborative Expert Panel, 2011b). Thus, faculty IPE training has been identified as a key challenge to the implementation of the IPE core competencies. Inter-professional education training builds faculty members' capacity to effectively teach, precept and role model behaviors to inter-professional students (Egan-Lee et al., 2011). As a result of effective IPE training, faculty should emerge with a positive attitude toward IPE, competence in the skills necessary to create and deliver curricula to inter-professional students (Begley, 2009), and a strong understanding of the theoretical content for safety and team science in order to educate students. Faculty development in IPE is critical for effective clinician modeling and has the potential to improve patient care (Anderson & Thorpe, 2010). Studies of IPE faculty development programs typically employ qualitative approaches such as semi-structured interviews and focus groups (Anderson & Thorpe, 2010; Egan-Lee et al., 2011). We found no quantitative evaluations of such programs. This paper reports on a quantitative examination of the impact of IPE training and participation as a facilitator of a large, 1-day interdisciplinary team training day exercise on volunteer faculty facilitators' knowledge, skills, and attitudes toward IPE.
http://dx.doi.org/10.1016/j.apnr.2014.03.003 0897-1897/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
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B.P. Davis et al. / Applied Nursing Research xxx (2014) xxx–xxx
2. Background Following the trend toward integrating IPE training efforts into general health education, faculty members from the Schools of Nursing (SON) and Medicine (SOM) at Emory University developed an IPE curriculum that was implemented in 2008. The training day now includes students from medicine, nursing, physician assistant, physical therapy, medical imaging and anesthesia assistant programs. The local program was developed using a modified Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) model and curriculum. TeamSTEPPS is a program developed jointly by the Department of Defense and the Agency for Healthcare Research and Quality to improve patient safety, communication and teamwork skills for health care professionals (Department of Defense, 2006). Key to implementing our IPE curriculum was faculty participation as facilitators during the program's small group sessions. To this end, we created a faculty training program to educate and prepare faculty for their facilitator role. Although the primary purpose of facilitator training was to improve students' educational experience, we speculated that facilitator training and facilitation may have benefited faculty participants. Being trained in IPE practices and then gaining additional experience in IPE education constituted a powerful continuingeducation experience for the facilitators themselves. Hypothesizing that the training session and student facilitation would improve our faculty's knowledge, skills and attitudes toward inter-professional teamwork, we conducted an evaluation of the experience. 3. Methods We used a pretest posttest quasi-experimental design for the evaluation. Faculty members were asked to volunteer as facilitators in an inter-professional team training day (ITTD), a portion of our longitudinal IPE student curriculum. Facilitators were recruited through direct emails sent to faculty within the SOM, SON and employees of the academic medical center. No member of the university community with a general background in healthcare was excluded from volunteering. 3.1. Intervention All volunteer facilitators attended a 2-hour training session designed to resemble the actual ITTD event. In this session, the volunteers simulated co-facilitating (with another health professional) a small group of inter-professional students. The training sessions were offered at various dates and times, and were led by individuals who were experts in the science of teamwork and TeamSTEPPS Master Trainers. There were two knowledge components in the facilitator training. A lecture portion reviewed the quality and patient safety literature. A second, more interactive, portion focused on key TeamSTEPPS communication tools to be used in the ITTD: SituationBackground-Assessment-Recommendation (SBAR) and Check-Back. The communication tools were reviewed in the lecture and were practiced in small group role playing. Led by the course organizers, volunteers in small groups were led through the role plays and debriefed in the same format that would be used with the students.
Each volunteer received a facilitator handbook that included the key educational material for review. The ITTD event was structured as follows: a brief overview lecture on teamwork skills emphasizing standard communication tools was followed by a panel in which health professionals discussed members' roles and responsibilities (Table 1). Following the large group session, inter-professional pairs of facilitators—one with ITTD experience and one first-time facilitator – led small groups of 10–12 students through the process of role modeling a small inter-professional team. Each small group participated in a short icebreaker exercise and then engaged in two role play exercises that allowed them to practice using the standardized SBAR and check back communication tools. 3.2. Method of evaluation and analysis Faculty participants completed two Web-based surveys, one prior to training and another 8 weeks following the ITTD event; the surveys were designed to assess their knowledge, skills and attitudes. Anonymity was maintained by asking individual facilitators to create a “unique identifier” enabling researchers to link pre and post data survey results. The first survey collected basic demographic information including health profession, years of experience, and previous team experience. The survey also assessed inter-professional knowledge, skills, and attitudes, including participants' self-concept. The post-event survey assessed participants' inter-professional knowledge, skills, and attitudes, including participants' self-concept, their ratings of the importance of inter-professional team training goals, and their assessment of course impact. Additionally, facilitators were asked to report any other teamwork activities in which they had engaged in the 8 weeks since the ITTD event. Only the results of interprofessional team self-concept (IPTSC) and course impact are reported. This evaluation of a training program was granted “exempt status” by the university institutional review board. 3.3. Measures 3.3.1. Inter-professional training self-concept The core variable of interest in the study was inter-professional team self-concept (IPTSC), a team member's self-assessment of the degree to which she or he possessed the knowledge, skills, and attitudes required for performing effectively in an inter-professional team. Self-concept thus refers to a core self-evaluation of one's abilities to be successful in a single, specific, but relatively broad area of competencies. We used a 23-item IPTSC measure adapted from existing scales to assess inter-professional team self-concept on a broad range of behaviors critical to successful inter-professional patient care. The IPTSC measure used in this study was a composite of several validated tools including 16 items from King, Shaw, Orchard, and Miller (2010) Inter-professional Socialization and Valuing Scale (ISVS) and 7 items from Earley and Ang's (2003) Cultural Intelligence Scale. Items were selected for content relevance to the team training format, reflecting the core knowledge, skills and attitudes (KSAs) required for successful inter-professional collaboration. The scale comprised 11 items related to knowledge (e.g., “I know the norms for communicating information in other healthcare professions”), 6
Table 1 Structure of ITTD event. Topic
Time allotted
Teaching strategy
Presenter
High-functioning teams Team member roles SBAR and Check Back
15 min 20 min 90 min
Lecture Panel discussion Small group role plays
TeamSTEPPS trainer Healthcare professionals Inter-professional facilitator pairs
ITTD: Inter-Professional Team Training Day. SBAR: Situation-Background-Assessment-Recommendation. TeamSTEPPS: Team Strategies to Enhance Performance and Patient Safety.
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
B.P. Davis et al. / Applied Nursing Research xxx (2014) xxx–xxx Table 2 Inter-professional Team Self-Concept (IPTSC) measure. Items I feel able to act as a fully collaborative member of an IPT. I have a good understanding of my own approach to care within an IPT. I am comfortable engaging in shared decision making with others on the IPT. I have a good understanding of the patient's involvement in decision making around their care. I feel comfortable clarifying misconceptions with other members of the team about the role of someone in my profession. I feel comfortable in accepting responsibility delegated to me within a team. I am able to share and exchange ideas in a team discussion. I feel confident in taking on different roles in a team. I feel comfortable debating issues in a team. I have gained an enhanced awareness of the roles of other professionals on a team. I feel comfortable in being accountable for responsibilities I have taken on. I more highly value open and honest communication with team members. I feel comfortable initiating discussions about sharing responsibility for client care. I feel comfortable speaking out within the team when others are not keeping the best interest of the patient in mind. I have gained more realistic expectations of other professional on a team. I see myself as preferring to work on an inter-professional team (IPT). N I have gained an appreciation for the benefits of inter-professional teamwork. I enjoy interacting with people in other healthcare professions I am confident that I can work with people from other healthcare professions. I know the norms for communicating information in other healthcare professions. I know the beliefs and values of other healthcare professions. I generally enjoy the differences that exist between my profession and other professions. I am interested in understanding the norms and values in other healthcare professions.
related to skills (e.g., “I feel able to act as a fully collaborative member of an inter-professional team”), and 6 related to attitudes (e.g., “I enjoy interacting with people in other healthcare professions”). Responses to IPTSC items were recorded along a 6-point Likerttype scale from 1 (strongly disagree) to 6 (strongly agree). Scale values were calculated by averaging individual item responses. Overall scores on the measure retained the properties of the original response scale, simplifying interpretation. Responses for both pre- and postsession assessments had Cronbach alpha internal-consistency values of .94, suggesting that the item responses were highly related within each measurement occasion. Across measurement occasions, the correlation between scale scores was .61. While validation of the IPTSC measure was not the focus of our study, considering that the internal reliability estimates exceeded pre-/post-session correlations, and the content relevance of the IPTSC items, we conclude that our measurements are distinct assessments of a homogenous variable.
Table 3 Course impact measure.
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3.3.2. Course impact Reactions to faculty training and participation as a facilitator, as reflected in perceived changes in IPT KSAs, were captured using a locally-developed, 10-item measure of the perceived impact of the course. The scale sought to capture specific training utility judgments as delineated by Alliger, Tannenbaum, Bennett, Traver, and Shotland (1997). Utility-type reactions have been shown to be related to training transfer (Alliger et al., 1997). Participants responded to questions assessing specific elements of improvement in IPT competencies along a 6-point scale from 1 (strongly disagree) to 6 (strongly agree). The scale had an internal consistency coefficient (Cronbach's alpha) of .93. Specific items in the IPTSC measure can be found in Table 2; items in the course impact measure can be found in Table 3. Pre-/post-session measures of this variable were compared using a repeated-measures ANOVA procedure and analyzed to assess the impact of the training event. 4. Results 4.1. Sample demographics Fifty-three volunteer faculty from the schools of medicine and nursing along with health professionals from affiliated clinical agencies participated as facilitators in the ITTD. Fifty-one facilitators also attended the separate facilitator training. Of the 53 individuals who were sent the pre-course survey, 51 responded (96% response rate); 49 completed the full battery of survey questions. Of those 51 individuals, 40 responded to the post-event survey (78% response rate). Demographic information collected in the pre-session survey is reported in Table 4. The sample was 78% female. The largest group by experience had greater than 20 years of experience in their field, n = 28 (55%). Each of the participating health professions was represented by facilitators from that profession. 4.2. Outcomes Results of our repeated-measures analysis revealed that scores on IPTSC were significantly higher post-session (F(1, 31) = 5.59, p = .02), indicating that facilitators left the session with higher selfconcept on inter-professional knowledge, skills, and attitudes. Partial eta-squared effect-size estimate indicated that post-session IPTSC scores were 0.15 SD higher than pre-session scores. All facilitators perceived a positive impact of the ITTD participation on their IPT KSA scores yielding a mean score of 5.52 on a 6-point scale, corresponding to an anchor value between “agree” and “strongly agree” in terms of whether they perceived the course to have had an impact on their KSAs for inter-professional teamwork. Descriptive statistics for preand post-session assessments are presented in Table 5. Correlations
Items Participating in the IPT training session had a positive impact on my attitudes toward teamwork. Facilitating the IPT training session increased my awareness of the role that teamwork plays in good healthcare delivery. Since participating in the IPT training session I have made a greater effort to foster more effective teamwork in my own work. My participation in the IPT training session gave me new insights into the role of effective teamwork. Facilitating the IPT training session increased my insight into the importance of student teamwork training. Facilitating the IPT training session provided me a better understanding of how teamwork communication failures can impair team effectiveness and patient safety. Since participating in the IPT training session I have been more aware of teamwork issues in my own daily work and teaching activities. Participating in the IPT training session had a positive impact on my attitude toward providing students with inter-professional team training. All teaching faculty could benefit from a short course covering basic inter-professional team communication principles. Participating in the IPT training session increased my interest in how to improve teamwork in my own activities.
Table 4 Description of the facilitator sample. Demographic variables Gender Male Female Experience 1–5 yrs 6–10 yrs 11–15 yrs 16–20 yrs N20 yrs Program Nursing Medicine PT PA MI
11 40 2 6 8 7 28 18 19 5 5 4
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
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B.P. Davis et al. / Applied Nursing Research xxx (2014) xxx–xxx
Table 5 Results. Scale Pre-session measures IPT self-concept (Pre) Post-session measures IPT self-concept (post) Impact
Mean
SD
Maximum
α
n
5.52
0.40
6
0.94
50
5.65 5.52
0.40 0.57
6 6
0.94 0.93
34 33
IPTSC: Inter-Professional Teamwork Self-Concept.
between perceptions of course impact and self-concept for IPT KSAs were low for both pre-course (r = .19) and post-course (r = .33) IPTSC measures, providing preliminary discriminant validity evidence for our measures. 5. Discussion Inter-professional education with a focus on teamwork is becoming more prevalent within health professions' educational programs. The ITTD has become an established and valued part of the university health professions' curriculum. The event utilizes inter-professional clinical faculty as facilitators and serves a large group of interprofessional students (around 450 per event). The ITTD curriculum is based on the TeamSTEPPS evidence-based tool for improving communication among healthcare professionals (Department of Defense, 2006) and emphasizes team communication, specifically SBAR and Check-Back. The ITTD faculty IPE training element is intended to educate and prepare faculty for facilitation of diverse inter-professional groups, increasing the likelihood of a successful IPE event. While the literature has provided sufficient evidence that IPE training positively impacts students, there has been less examination of the effect of such training sessions on faculty members who facilitate them. The results of the current study demonstrate that systemic effects of IPE training programs go beyond the impact on students to include the faculty facilitators. Educated and engaged facilitators are vital to the successful implementation of IPE. Knowledge about IPE and a positive attitude about the topic must be initially present or developed through training to support faculty effectiveness (Buring et al., 2009). Faculty development was a core component of the ITTD, and 51 out of 53 facilitators attended a facilitator training session. In this study, the majority group of volunteer facilitators reported greater than 20 years of professional experience and prior experience working in teams. As a whole the group held strongly positive views about teamwork prior to the ITTD event. The high level of experience working in teams and positive feeling toward teamwork may have been motivating factors for individuals to serve as volunteer facilitators for the ITTD event. In previous qualitative studies, faculty facilitators acknowledged that faculty development aided in their understanding of IPE fundamentals (Egan-Lee et al., 2011) and is central to the success of the IPE educational model (Anderson & Thorpe, 2010). Faculty facilitators also described additional professional benefits of IPE including the opportunity to work with other disciplines, enhance their own teaching practice, and potentially improve patient care (Anderson & Thorpe, 2010). Results of our study indicate faculty facilitators of the ITTD also appreciated the added value of serving in this role which is demonstrated by the high scores on the course impact scale. Facilitators felt the ITTD facilitator training session and facilitation during the event had a strong impact on their knowledge, skills, and attitudes for inter-professional teamwork. Participation in the ITTD event was expected to result in higher self-concept of knowledge, skills, and attitudes related to interprofessional teamwork by faculty facilitators. Scores on the IPTSC prior to the session were quite high; however, even in a group with a
high baseline self-concept there was a significant improvement after the ITTD event. Facilitators also reported a perceived positive impact on their IPTSC directly from participation in the ITTD event. Since participation required facilitators to attend a training session and to facilitate small groups during the ITTD event, the combined experience likely contributed to this positive impact and significant improvement in IPTSC scores. 5.1. Limitations This study contained several methodological limitations. First, the small sample size limited the generalizability of the findings beyond the sample population. Additionally, the small professional group sizes did not allow for comparison of outcomes by profession. Another issue was restriction of range. Results revealed a ceiling effect for IPTSC such that most respondents were scoring near the maximum. This lack of variability decreased the likelihood that analyses would find group differences, since very small differences existed between the groups. Due to the less robust response rate for the post-session survey (96% vs. 78%), there was a possibility of response bias. It was possible that only those individuals who felt more positive after the session responded to the second survey, and if results were available for all 51 original respondents this effect would be non-significant. Despite the limitation it is clear that the original 51 respondents had positive attitudes towards teamwork even prior to our training. Participation as a volunteer faculty facilitator may have also reduced the generalizability of the findings. Volunteer facilitators may have been more motivated and dedicated to teamwork, collaboration and IPE. The same impact on IPTSC may be difficult to achieve in a sample of all faculty who may have varying attitudes toward teams at baseline. Finally, this was a survey of self-concept for teamwork knowledge skills, and attitudes. At no point during this program did we directly observe or assess the facilitator's ability to work within a team. Results may have been different if we had the opportunity to directly assess knowledge, skills, and attitudes toward teamwork in a simulated or actual clinical environment. 6. Conclusions The importance of inter-professional education is clear and well outlined in the literature. The future generation of healthcare professionals will be practicing in an increasingly inter-professional and team-oriented environment. If health professions education is to include competencies in teamwork and collaboration (such as those described by IPEC), faculty must be competent in teaching this content. Faculty IPE development is key to successful participant experiences. Faculty should demonstrate the knowledge, skills and attitudes related to inter-professional teamwork and have the tools to effectively teach these skills. Our study demonstrates that a short facilitator development course and participation in an ITTD event has a positive impact on perceived knowledge, skills and attitudes toward inter-professional teamwork. Future studies should assess similar training programs with a larger and more diverse cohort and translation to the clinical environment. References Accreditation Council for Graduate Medical Education (2011). In Ingrid Philibert, & J. Steve Amis (Eds.), The ACGME 2011 Duty Hour Standards: Enhancing quality of care, supervision, and resident professional development (pp. 53–55) (Chicago, IL). Alliger, G. M., Tannenbaum, S. I., Bennett, W., Jr., Traver, H., & Shotland, A. (1997). A meta-analysis of the relations among training criteria. Personnel Psychology, 50, 341–358, http://dx.doi.org/10.1111/j.1744-6570.1997.tb00911.x. Anderson, E. S., & Thorpe, L. N. (2010). Interprofessional educator ambassadors: An empirical study of motivation and added value. [Research Support, Non-U.S. Gov't]. Medical Teacher, 32(11), e492–500.
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
B.P. Davis et al. / Applied Nursing Research xxx (2014) xxx–xxx Baldwin, D. C., Jr. (2007). Some historical notes on interdisciplinary and interprofessional education and practice in health care in the USA. Journal of Interprofessional Care, 21(1), 23–37. Begley, C. M. (2009). Developing inter-professional learning: Tactics, teamwork and talk. [Review]. Nurse Education Today, 29(3), 276–283. Bridges, D. R., Davidson, R. A., Odegard, P. S., Maki, I. V., & Tomkowiak, J. (2011). Interprofessional collaboration: Three best practice models of interprofessional education. [Research Support, Non-U.S. Gov't]. Medical Education Online, 16, http:// dx.doi.org/10.3402/meo.v16i0.6035. Buring, S. M., Bhushan, A., Brazeau, G., Conway, S., Hansen, L., & Westberg, S. (2009). Keys to successful implementation of interprofessional education: Learning location, faculty development, and curricular themes. American Journal of Pharmaceutical Education, 73(4), 60 ([Comparative Study]). Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., et al. (2007). Quality and safety education for nurses. [Research Support, Non-U.S. Gov't]. Nursing Outlook, 55(3), 122–131. Department of Defense (2006). TeamSTEPPS(TM): Team strategies & tools to enhance performance and patient safety. Rockville, MD: Agency for Healthcare Research and Quality (06-0020).
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Earley, P. C., & Ang, S. (2003). Cultural intelligence: Individual interactions across cultures. Stanford, CA: Stanford University Press. Egan-Lee, E., Baker, L., Tobin, S., Hollenberg, E., Dematteo, D., & Reeves, S. (2011). Neophyte facilitator experiences of interprofessional education: Implications for faculty development. Journal of Interprofessional Care, 25(5), 333–338. Institute of Medicine (1999). To err is human: Building a safer health system. : National Academy Press. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Institute of Medicine (2003). In A. C. Greiner, & E. Knebel (Eds.), Health professions education: A bridge to quality. Interprofessional Education Collaborative Expert Panel. (2011a). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Interprofessional Education Collaborative Expert Panel. (2011, Feb 16-17b). Team-Based Competencies: Building a shared foundation for education and clinical practice. Washington, DC. King, G., Shaw, L., Orchard, C. A., & Miller, S. (2010). The interprofessional socialization and valuing scale: A tool for evaluating the shift toward collaborative care approaches in health care settings. Work, 35(1), 77–85, http://dx.doi.org/10.3233/WOR-2010-0959.
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
Contents lists available at ScienceDirect
Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Teaching the teachers: Faculty development in inter-professional education Beth P. Davis, DPT, MBA a,⁎, Carolyn K. Clevenger, DNP, GNP-BC b, 1, Samuel Posnock, MS, PhD(c) c, 2, Bethany D. Robertson, DNP, CNM b, 1, Douglas S. Ander, MD d, 3 a
Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine,1462 Clifton Road NE, Suite 314, Atlanta, GA 30322, USA Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, Suite 314, Atlanta, GA 30322, USA School of Psychology, Georgia Institute of Technology, 654 Cherry Street, Atlanta, GA 30332-0170, USA d Emory Center for Experiential Learning, Emory University School of Medicine, 1648 Pierce Drive, Suite B31, Atlanta, GA 30322, USA b c
a r t i c l e
i n f o
Article history: Received 13 March 2013 Revised 2 March 2014 Accepted 8 March 2014 Available online xxxx Keywords: Faculty Interprofessional relations Continuing education Healthcare teams Interdisciplinary
a b s t r a c t Aims: The purpose of this study is to evaluate changes in self-concept for the knowledge, skills and attitudes toward inter-professional teamwork of facilitators who participated in training and an inter-professional team training event. Background: Inter-professional education requires dedicated and educated faculty. Methods: A pretest posttest quasi-experimental design was used for the evaluation. Fifty-three facilitators were asked to complete pre–post questionnaires to measure inter-professional team self-concept (IPTSC), assessing self-concept for the knowledge, skills, and attitudes required for performing in an inter-professional team. Results: Post-session scores on inter-professional team knowledge, skills and attitudes were significantly higher (F(1, 31) = 5.59, p = .02). Conclusion: A facilitator development course and participation in the teaching event had a positive impact on perceived knowledge, skills and attitudes toward inter-professional teamwork. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Patient safety concerns and potential solutions have been highlighted in several reports from the Institute of Medicine (Institute of Medicine, 1999, 2001). Subsequent IOM reports include recommendations for intervention in undergraduate health professions education (Institute of Medicine, 2003). Emerging from this focus on patient safety is the importance of inter-professional teamwork within health professions education (Accreditation Council for Graduate Medical Education, 2011; Cronenwett et al., 2007). In 2011, the Interprofessional Education Collaborative (IPEC) published core competencies for inter-professional education (IPE) in the health professions along with strategies for implementation (Interprofessional Education Collaborative Expert Panel, 2011a). A number of IPE models exist, dating back to the 1940s (Baldwin, 2007), and the use of faculty as facilitators to teach IPE is increasingly common (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011). However, until the most recent IPEC reports (Interprofessional
⁎ Corresponding author. Tel.: +1 404 712 5884; fax: +1 404 712 4130. E-mail addresses: [email protected] (B.P. Davis), [email protected] (C.K. Clevenger), [email protected] (S. Posnock), [email protected] (B.D. Robertson), [email protected] (D.S. Ander). 1 Tel.: +1 404 712 2394; fax: +1 404 727 8514. 2 Tel.: +1 404 894 8712; fax: +1 404 894 8905. 3 Tel.: +1 404 251 8828; fax: +1 404 688 6351.
Education Collaborative Expert Panel, 2011b), the need for faculty development as a key component of successful IPE (Buring et al., 2009) was not widely appreciated. The IPEC report emphasized that a core strategy for incorporating IPE education into health professions education involves the improved preparation of faculty to teach students to work as part of the team (Interprofessional Education Collaborative Expert Panel, 2011b). Thus, faculty IPE training has been identified as a key challenge to the implementation of the IPE core competencies. Inter-professional education training builds faculty members' capacity to effectively teach, precept and role model behaviors to inter-professional students (Egan-Lee et al., 2011). As a result of effective IPE training, faculty should emerge with a positive attitude toward IPE, competence in the skills necessary to create and deliver curricula to inter-professional students (Begley, 2009), and a strong understanding of the theoretical content for safety and team science in order to educate students. Faculty development in IPE is critical for effective clinician modeling and has the potential to improve patient care (Anderson & Thorpe, 2010). Studies of IPE faculty development programs typically employ qualitative approaches such as semi-structured interviews and focus groups (Anderson & Thorpe, 2010; Egan-Lee et al., 2011). We found no quantitative evaluations of such programs. This paper reports on a quantitative examination of the impact of IPE training and participation as a facilitator of a large, 1-day interdisciplinary team training day exercise on volunteer faculty facilitators' knowledge, skills, and attitudes toward IPE.
http://dx.doi.org/10.1016/j.apnr.2014.03.003 0897-1897/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
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B.P. Davis et al. / Applied Nursing Research xxx (2014) xxx–xxx
2. Background Following the trend toward integrating IPE training efforts into general health education, faculty members from the Schools of Nursing (SON) and Medicine (SOM) at Emory University developed an IPE curriculum that was implemented in 2008. The training day now includes students from medicine, nursing, physician assistant, physical therapy, medical imaging and anesthesia assistant programs. The local program was developed using a modified Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) model and curriculum. TeamSTEPPS is a program developed jointly by the Department of Defense and the Agency for Healthcare Research and Quality to improve patient safety, communication and teamwork skills for health care professionals (Department of Defense, 2006). Key to implementing our IPE curriculum was faculty participation as facilitators during the program's small group sessions. To this end, we created a faculty training program to educate and prepare faculty for their facilitator role. Although the primary purpose of facilitator training was to improve students' educational experience, we speculated that facilitator training and facilitation may have benefited faculty participants. Being trained in IPE practices and then gaining additional experience in IPE education constituted a powerful continuingeducation experience for the facilitators themselves. Hypothesizing that the training session and student facilitation would improve our faculty's knowledge, skills and attitudes toward inter-professional teamwork, we conducted an evaluation of the experience. 3. Methods We used a pretest posttest quasi-experimental design for the evaluation. Faculty members were asked to volunteer as facilitators in an inter-professional team training day (ITTD), a portion of our longitudinal IPE student curriculum. Facilitators were recruited through direct emails sent to faculty within the SOM, SON and employees of the academic medical center. No member of the university community with a general background in healthcare was excluded from volunteering. 3.1. Intervention All volunteer facilitators attended a 2-hour training session designed to resemble the actual ITTD event. In this session, the volunteers simulated co-facilitating (with another health professional) a small group of inter-professional students. The training sessions were offered at various dates and times, and were led by individuals who were experts in the science of teamwork and TeamSTEPPS Master Trainers. There were two knowledge components in the facilitator training. A lecture portion reviewed the quality and patient safety literature. A second, more interactive, portion focused on key TeamSTEPPS communication tools to be used in the ITTD: SituationBackground-Assessment-Recommendation (SBAR) and Check-Back. The communication tools were reviewed in the lecture and were practiced in small group role playing. Led by the course organizers, volunteers in small groups were led through the role plays and debriefed in the same format that would be used with the students.
Each volunteer received a facilitator handbook that included the key educational material for review. The ITTD event was structured as follows: a brief overview lecture on teamwork skills emphasizing standard communication tools was followed by a panel in which health professionals discussed members' roles and responsibilities (Table 1). Following the large group session, inter-professional pairs of facilitators—one with ITTD experience and one first-time facilitator – led small groups of 10–12 students through the process of role modeling a small inter-professional team. Each small group participated in a short icebreaker exercise and then engaged in two role play exercises that allowed them to practice using the standardized SBAR and check back communication tools. 3.2. Method of evaluation and analysis Faculty participants completed two Web-based surveys, one prior to training and another 8 weeks following the ITTD event; the surveys were designed to assess their knowledge, skills and attitudes. Anonymity was maintained by asking individual facilitators to create a “unique identifier” enabling researchers to link pre and post data survey results. The first survey collected basic demographic information including health profession, years of experience, and previous team experience. The survey also assessed inter-professional knowledge, skills, and attitudes, including participants' self-concept. The post-event survey assessed participants' inter-professional knowledge, skills, and attitudes, including participants' self-concept, their ratings of the importance of inter-professional team training goals, and their assessment of course impact. Additionally, facilitators were asked to report any other teamwork activities in which they had engaged in the 8 weeks since the ITTD event. Only the results of interprofessional team self-concept (IPTSC) and course impact are reported. This evaluation of a training program was granted “exempt status” by the university institutional review board. 3.3. Measures 3.3.1. Inter-professional training self-concept The core variable of interest in the study was inter-professional team self-concept (IPTSC), a team member's self-assessment of the degree to which she or he possessed the knowledge, skills, and attitudes required for performing effectively in an inter-professional team. Self-concept thus refers to a core self-evaluation of one's abilities to be successful in a single, specific, but relatively broad area of competencies. We used a 23-item IPTSC measure adapted from existing scales to assess inter-professional team self-concept on a broad range of behaviors critical to successful inter-professional patient care. The IPTSC measure used in this study was a composite of several validated tools including 16 items from King, Shaw, Orchard, and Miller (2010) Inter-professional Socialization and Valuing Scale (ISVS) and 7 items from Earley and Ang's (2003) Cultural Intelligence Scale. Items were selected for content relevance to the team training format, reflecting the core knowledge, skills and attitudes (KSAs) required for successful inter-professional collaboration. The scale comprised 11 items related to knowledge (e.g., “I know the norms for communicating information in other healthcare professions”), 6
Table 1 Structure of ITTD event. Topic
Time allotted
Teaching strategy
Presenter
High-functioning teams Team member roles SBAR and Check Back
15 min 20 min 90 min
Lecture Panel discussion Small group role plays
TeamSTEPPS trainer Healthcare professionals Inter-professional facilitator pairs
ITTD: Inter-Professional Team Training Day. SBAR: Situation-Background-Assessment-Recommendation. TeamSTEPPS: Team Strategies to Enhance Performance and Patient Safety.
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
B.P. Davis et al. / Applied Nursing Research xxx (2014) xxx–xxx Table 2 Inter-professional Team Self-Concept (IPTSC) measure. Items I feel able to act as a fully collaborative member of an IPT. I have a good understanding of my own approach to care within an IPT. I am comfortable engaging in shared decision making with others on the IPT. I have a good understanding of the patient's involvement in decision making around their care. I feel comfortable clarifying misconceptions with other members of the team about the role of someone in my profession. I feel comfortable in accepting responsibility delegated to me within a team. I am able to share and exchange ideas in a team discussion. I feel confident in taking on different roles in a team. I feel comfortable debating issues in a team. I have gained an enhanced awareness of the roles of other professionals on a team. I feel comfortable in being accountable for responsibilities I have taken on. I more highly value open and honest communication with team members. I feel comfortable initiating discussions about sharing responsibility for client care. I feel comfortable speaking out within the team when others are not keeping the best interest of the patient in mind. I have gained more realistic expectations of other professional on a team. I see myself as preferring to work on an inter-professional team (IPT). N I have gained an appreciation for the benefits of inter-professional teamwork. I enjoy interacting with people in other healthcare professions I am confident that I can work with people from other healthcare professions. I know the norms for communicating information in other healthcare professions. I know the beliefs and values of other healthcare professions. I generally enjoy the differences that exist between my profession and other professions. I am interested in understanding the norms and values in other healthcare professions.
related to skills (e.g., “I feel able to act as a fully collaborative member of an inter-professional team”), and 6 related to attitudes (e.g., “I enjoy interacting with people in other healthcare professions”). Responses to IPTSC items were recorded along a 6-point Likerttype scale from 1 (strongly disagree) to 6 (strongly agree). Scale values were calculated by averaging individual item responses. Overall scores on the measure retained the properties of the original response scale, simplifying interpretation. Responses for both pre- and postsession assessments had Cronbach alpha internal-consistency values of .94, suggesting that the item responses were highly related within each measurement occasion. Across measurement occasions, the correlation between scale scores was .61. While validation of the IPTSC measure was not the focus of our study, considering that the internal reliability estimates exceeded pre-/post-session correlations, and the content relevance of the IPTSC items, we conclude that our measurements are distinct assessments of a homogenous variable.
Table 3 Course impact measure.
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3.3.2. Course impact Reactions to faculty training and participation as a facilitator, as reflected in perceived changes in IPT KSAs, were captured using a locally-developed, 10-item measure of the perceived impact of the course. The scale sought to capture specific training utility judgments as delineated by Alliger, Tannenbaum, Bennett, Traver, and Shotland (1997). Utility-type reactions have been shown to be related to training transfer (Alliger et al., 1997). Participants responded to questions assessing specific elements of improvement in IPT competencies along a 6-point scale from 1 (strongly disagree) to 6 (strongly agree). The scale had an internal consistency coefficient (Cronbach's alpha) of .93. Specific items in the IPTSC measure can be found in Table 2; items in the course impact measure can be found in Table 3. Pre-/post-session measures of this variable were compared using a repeated-measures ANOVA procedure and analyzed to assess the impact of the training event. 4. Results 4.1. Sample demographics Fifty-three volunteer faculty from the schools of medicine and nursing along with health professionals from affiliated clinical agencies participated as facilitators in the ITTD. Fifty-one facilitators also attended the separate facilitator training. Of the 53 individuals who were sent the pre-course survey, 51 responded (96% response rate); 49 completed the full battery of survey questions. Of those 51 individuals, 40 responded to the post-event survey (78% response rate). Demographic information collected in the pre-session survey is reported in Table 4. The sample was 78% female. The largest group by experience had greater than 20 years of experience in their field, n = 28 (55%). Each of the participating health professions was represented by facilitators from that profession. 4.2. Outcomes Results of our repeated-measures analysis revealed that scores on IPTSC were significantly higher post-session (F(1, 31) = 5.59, p = .02), indicating that facilitators left the session with higher selfconcept on inter-professional knowledge, skills, and attitudes. Partial eta-squared effect-size estimate indicated that post-session IPTSC scores were 0.15 SD higher than pre-session scores. All facilitators perceived a positive impact of the ITTD participation on their IPT KSA scores yielding a mean score of 5.52 on a 6-point scale, corresponding to an anchor value between “agree” and “strongly agree” in terms of whether they perceived the course to have had an impact on their KSAs for inter-professional teamwork. Descriptive statistics for preand post-session assessments are presented in Table 5. Correlations
Items Participating in the IPT training session had a positive impact on my attitudes toward teamwork. Facilitating the IPT training session increased my awareness of the role that teamwork plays in good healthcare delivery. Since participating in the IPT training session I have made a greater effort to foster more effective teamwork in my own work. My participation in the IPT training session gave me new insights into the role of effective teamwork. Facilitating the IPT training session increased my insight into the importance of student teamwork training. Facilitating the IPT training session provided me a better understanding of how teamwork communication failures can impair team effectiveness and patient safety. Since participating in the IPT training session I have been more aware of teamwork issues in my own daily work and teaching activities. Participating in the IPT training session had a positive impact on my attitude toward providing students with inter-professional team training. All teaching faculty could benefit from a short course covering basic inter-professional team communication principles. Participating in the IPT training session increased my interest in how to improve teamwork in my own activities.
Table 4 Description of the facilitator sample. Demographic variables Gender Male Female Experience 1–5 yrs 6–10 yrs 11–15 yrs 16–20 yrs N20 yrs Program Nursing Medicine PT PA MI
11 40 2 6 8 7 28 18 19 5 5 4
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
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B.P. Davis et al. / Applied Nursing Research xxx (2014) xxx–xxx
Table 5 Results. Scale Pre-session measures IPT self-concept (Pre) Post-session measures IPT self-concept (post) Impact
Mean
SD
Maximum
α
n
5.52
0.40
6
0.94
50
5.65 5.52
0.40 0.57
6 6
0.94 0.93
34 33
IPTSC: Inter-Professional Teamwork Self-Concept.
between perceptions of course impact and self-concept for IPT KSAs were low for both pre-course (r = .19) and post-course (r = .33) IPTSC measures, providing preliminary discriminant validity evidence for our measures. 5. Discussion Inter-professional education with a focus on teamwork is becoming more prevalent within health professions' educational programs. The ITTD has become an established and valued part of the university health professions' curriculum. The event utilizes inter-professional clinical faculty as facilitators and serves a large group of interprofessional students (around 450 per event). The ITTD curriculum is based on the TeamSTEPPS evidence-based tool for improving communication among healthcare professionals (Department of Defense, 2006) and emphasizes team communication, specifically SBAR and Check-Back. The ITTD faculty IPE training element is intended to educate and prepare faculty for facilitation of diverse inter-professional groups, increasing the likelihood of a successful IPE event. While the literature has provided sufficient evidence that IPE training positively impacts students, there has been less examination of the effect of such training sessions on faculty members who facilitate them. The results of the current study demonstrate that systemic effects of IPE training programs go beyond the impact on students to include the faculty facilitators. Educated and engaged facilitators are vital to the successful implementation of IPE. Knowledge about IPE and a positive attitude about the topic must be initially present or developed through training to support faculty effectiveness (Buring et al., 2009). Faculty development was a core component of the ITTD, and 51 out of 53 facilitators attended a facilitator training session. In this study, the majority group of volunteer facilitators reported greater than 20 years of professional experience and prior experience working in teams. As a whole the group held strongly positive views about teamwork prior to the ITTD event. The high level of experience working in teams and positive feeling toward teamwork may have been motivating factors for individuals to serve as volunteer facilitators for the ITTD event. In previous qualitative studies, faculty facilitators acknowledged that faculty development aided in their understanding of IPE fundamentals (Egan-Lee et al., 2011) and is central to the success of the IPE educational model (Anderson & Thorpe, 2010). Faculty facilitators also described additional professional benefits of IPE including the opportunity to work with other disciplines, enhance their own teaching practice, and potentially improve patient care (Anderson & Thorpe, 2010). Results of our study indicate faculty facilitators of the ITTD also appreciated the added value of serving in this role which is demonstrated by the high scores on the course impact scale. Facilitators felt the ITTD facilitator training session and facilitation during the event had a strong impact on their knowledge, skills, and attitudes for inter-professional teamwork. Participation in the ITTD event was expected to result in higher self-concept of knowledge, skills, and attitudes related to interprofessional teamwork by faculty facilitators. Scores on the IPTSC prior to the session were quite high; however, even in a group with a
high baseline self-concept there was a significant improvement after the ITTD event. Facilitators also reported a perceived positive impact on their IPTSC directly from participation in the ITTD event. Since participation required facilitators to attend a training session and to facilitate small groups during the ITTD event, the combined experience likely contributed to this positive impact and significant improvement in IPTSC scores. 5.1. Limitations This study contained several methodological limitations. First, the small sample size limited the generalizability of the findings beyond the sample population. Additionally, the small professional group sizes did not allow for comparison of outcomes by profession. Another issue was restriction of range. Results revealed a ceiling effect for IPTSC such that most respondents were scoring near the maximum. This lack of variability decreased the likelihood that analyses would find group differences, since very small differences existed between the groups. Due to the less robust response rate for the post-session survey (96% vs. 78%), there was a possibility of response bias. It was possible that only those individuals who felt more positive after the session responded to the second survey, and if results were available for all 51 original respondents this effect would be non-significant. Despite the limitation it is clear that the original 51 respondents had positive attitudes towards teamwork even prior to our training. Participation as a volunteer faculty facilitator may have also reduced the generalizability of the findings. Volunteer facilitators may have been more motivated and dedicated to teamwork, collaboration and IPE. The same impact on IPTSC may be difficult to achieve in a sample of all faculty who may have varying attitudes toward teams at baseline. Finally, this was a survey of self-concept for teamwork knowledge skills, and attitudes. At no point during this program did we directly observe or assess the facilitator's ability to work within a team. Results may have been different if we had the opportunity to directly assess knowledge, skills, and attitudes toward teamwork in a simulated or actual clinical environment. 6. Conclusions The importance of inter-professional education is clear and well outlined in the literature. The future generation of healthcare professionals will be practicing in an increasingly inter-professional and team-oriented environment. If health professions education is to include competencies in teamwork and collaboration (such as those described by IPEC), faculty must be competent in teaching this content. Faculty IPE development is key to successful participant experiences. Faculty should demonstrate the knowledge, skills and attitudes related to inter-professional teamwork and have the tools to effectively teach these skills. Our study demonstrates that a short facilitator development course and participation in an ITTD event has a positive impact on perceived knowledge, skills and attitudes toward inter-professional teamwork. Future studies should assess similar training programs with a larger and more diverse cohort and translation to the clinical environment. References Accreditation Council for Graduate Medical Education (2011). In Ingrid Philibert, & J. Steve Amis (Eds.), The ACGME 2011 Duty Hour Standards: Enhancing quality of care, supervision, and resident professional development (pp. 53–55) (Chicago, IL). Alliger, G. M., Tannenbaum, S. I., Bennett, W., Jr., Traver, H., & Shotland, A. (1997). A meta-analysis of the relations among training criteria. Personnel Psychology, 50, 341–358, http://dx.doi.org/10.1111/j.1744-6570.1997.tb00911.x. Anderson, E. S., & Thorpe, L. N. (2010). Interprofessional educator ambassadors: An empirical study of motivation and added value. [Research Support, Non-U.S. Gov't]. Medical Teacher, 32(11), e492–500.
Please cite this article as: Davis, B.P., et al., Teaching the teachers: Faculty development in inter-professional education, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.03.003
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