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Team-Based Learning for Nursing and Medical Students Focus Group Results From an Interprofessional Education Project Rebecca A. Feather, PhD, RN, NE-BC & Doug E. Carr, MD, FACS Deanna L. Reising, PhD, RN, ACNS-BC, ANEF & Derrick M. Garletts, BSN, RN, MPH

Past research indicates that inadequacies in health care delivery create substantial preventable quality issues that can be addressed through improving relationships among clinicians to decrease the negative effects on patient outcomes. The purpose of this article is to describe the implementation of an interprofessional education project with senior nursing and third-year medical students working in teams in a clinical setting. Results include data from focus groups conducted at the conclusion of the project.

Keywords: coaching; communication; interprofessional education; medical students; motivational interviewing; nursing students

R esearch has indicated that inadequacies in systems of health care delivery create substantial prevent- able quality issues that can be addressed through

improving relationships among clinicians.1 However, these improvements will not occur without changing how health care students are educated prior to entering the workforce. It is important for nurses and physicians to learn about each other’s roles and how to communicate in teams to break down the educational separateness of the past and develop strong collaborative relationships that will extend into their professional careers.

The purpose of this article is to describe how an inter- professional education (IPE) project involving nursing and medical students working in IPE teams with patients was developed, implemented, and evaluated. The teams met with patients once a month for 6 months and worked together to develop health care plans and provided coaching to patients with 1 or multiple chronic health conditions.

What Is IPE and Why Is It Important? Many definitions for IPE exist, but the one often cited in the IPE literature and used for this study is that IPE occurs when 2 or more professions learn together to develop the knowl-

edge and skills for effective collaboration and team func- tioning.2 With the IPE movement becoming active in the 1990s through foundations such as the Hartford Foundation, Robert Wood Johnson Foundation, and Josiah Macy Foun- dation1 and the formation of the Interprofessional Education Collaborative (IPEC) in 2009,3 in 2010 the vision repeatedly set forth by the Institute of Medicine for IPE and collabora- tion was finally taking hold.4<6 The IPEC report in 2011, Core Competencies for Interprofessional Collaborative Practice, along with the World Health Organization report, presented a plan of action for IPE and collaborative practice,7,8 which set the stage for changes to occur in the practice of health professionals and how they are educated in academic settings.

Thus, the purpose of implementing IPE in graduate and undergraduate health professions programs is to increase students’ awareness of the common issues they will face in clinical practice, improve their understanding of each other’s roles, enable them to serve as team members to solve problems and provide high-quality care, encourage interprofessional collaboration, and acquaint them with interprofessional ex- periences in the educational setting.1,9 However, in most current health professions education environments, students either share classes only with those in their own disciplines or have guest lecturers from other disciplines,10 but do not work together in teams while providing actual patient care. To make IPE effective, administrators and faculty should move from merely adding IPE content to a few courses or creating electives with an IPE focus to a comprehensive, integrated, curricular approach that promotes the students working together in a patient care setting.1

There are many benefits of IPE for both health care students and patients. Among some are advanced key concepts for students such as learning about each other’s

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Author Affiliations: Assistant Professor (Dr Feather), Associate Profes- sor (Dr Reising), and Adjunct Faculty (Mr Garletts), School of Nursing, and Lecturer (Dr Carr), School of Medical Sciences, Indiana University, Bloomington, Indiana. The authors declare no conflicts of interest. Correspondence: Dr Feather, School of Nursing, Indiana University, Sycamore Hall, Room 445, 1033 E 3rd St, Bloomington, IN 47405 ([email protected]). Accepted for publication: November 22, 2015 Published ahead of print: January 14, 2016 DOI: 10.1097/NNE.0000000000000240

roles and building skill sets to work with other professionals to improve collaborative practice. Others include increased job satisfaction through modification of negative attitudes and perceptions and higher levels of trust and communica- tion. Some benefits of IPE for patients are increased patient safety, reduction of errors, maximization of resources, and improved overall quality of care.11 Therefore, IPE has been strongly embraced as a major strategy to promote develop- ment of health care teams, collaboration, and better coor- dination of care through combined efforts of the health disciplines in a team concept.10

Theoretical Framework The theoretical framework used for the development and implementation of the project is the National Interpro- fessional Competency Framework.8 There are 6 compe- tency domains that highlight the knowledge, skills, attitudes, and values that shape the judgments essential for interprofessional collaboration. The framework pos- tulates that interprofessional communication affects 4 other domains with the final goal of interprofessional collabora- tion. There is a strong indication that the interprofessional field is maturing, and IPE influences a range of collaborative educational and practice activities as well as the outcomes that are produced by these activities.

Purpose In recognition of the impact created by learning environ- ments that occur in silos and a lack of knowledge about students’ experience of working in interprofessional teams in a practice setting,13 key faculty in both the nursing and medical schools came together to design an IPE project aimed at senior nursing and third-year medical students. The purpose of this study was to explore student percep- tions and experiences related to their working in teams with patients in the practice setting. The project was de- signed specifically to focus on learner outcomes such as increased individual and team-based communication skills, enjoyment with the IPE learning experience, self-reported gains in knowledge of interprofessional roles, and self- reported positive changes in attitudes toward collaborative practice in teams. It is important to examine if these changes occur and can be associated with interprofessional collab- oration with the goal that students apply their learning to their clinical practice settings upon graduation.14

Methods Development of the IPE Project The IPE project was part of the students’ practicum courses for both the fall and spring semesters. Students were as- signed to 6 teams that included 12 senior BSN students, 6 third-year medical students, and 6 patients. All were volunteers who attended class on the campus, with the nursing students being recruited from a cohort of 60 students and the medical students from the entire class of third-year students. All participants were part of the study for both semesters. The patients were volunteers who had at least 1 chronic disease and were in need of lifestyle and/or be- havioral modifications to improve their health status.

The students who participated in the IPE project re- ceived IPE training in previous courses involving simulation

experiences, Advanced Cardiac Life Support Training certi- fication in teams, error disclosure, and TeamSTEPPS.

15 In both

the simulation and IPE project, teams were challenged to focus on team awareness and communication, their individual re- sponsibilities to the team, and patient outcomes.

Students received training as an IPE team on motivational interviewing and health coaching techniques prior to the ini- tial meeting with the patient. The training lasted 3 hours and was provided by certified health coaches who also were available as resources for the students during the term of the project.

The IPE teams scheduled meetings in person with pa- tients (with faculty present) approximately once a month, for 6 months, during the fall and spring semesters. The location for the IPE team meetings was conference rooms at the offices of an integrated health advocacy program (IHAP). This is a program that addresses the needs of the employees who use the highest level of health care dollars. The IHAP program assists employers in maximizing the health of this population while reducing costs and future liabilities. The volunteers for the IPE project were employees of a hospital who were not part of the IHAP program but were at high risk of moving into this category in the short-term future based on their health status profiles. Health care coaches and the director employed by IHAP recruited the volunteers.

The students developed ongoing health care plans and individual coaching that provided the patients with assis- tance in accomplishing their goals. For example, 1 student group recommended downloading an application for the patient’s smart phone that would track calories, offer meal plans, and log daily exercise. Students also had follow-up conversations between meetings with the patients by phone, texting, and e-mail if available and agreed upon by the IPE team and patient. The IPE group and the faculty members had no contact with the patient’s primary care provider; therefore, it was the responsibility of the patient to communicate any changes in health care status. Faculty reviewed the health care and coaching plans and provided input as needed. The IPE team and the patient pairing stayed consistent through each semester.

Goals were determined at the beginning of the team meetings and measured at the end of the project based on the medical diagnosis and specific needs of each individ- ual patient. The goals had to be measurable and attainable within the 6-month time frame of the project (such as weight control, diet, exercise, blood pressure, blood sugars, etc). How- ever, the patient goals and outcomes at the end of the team meetings were not part of the data collection for this IPE project as the initial pilot was to focus on the student outcomes.

Design A descriptive design was chosen to allow for observation to occur without changing the environment. Even though it is not experimental, the design can provide information about the naturally occurring health status, behavior, atti- tudes, or characteristics of a particular group (Office of Re- search Integrity).

16 The project was approved as an exempt

study through the institutional review board.

Setting The setting for the study took place at a large Midwestern university with a student population of approximately 42 300 students, including both undergraduate and graduate

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programs. However, the program of studies involved in the IPE project is small in number. The nursing program on the campus is undergraduate only and enrolls 60 students per year beginning with the sophomore year of study. The medi- cal school includes approximately 35 first-, 35 second-, and 6 to 8 third-year students. The IPE project combined teams of undergraduate senior nursing and third-year medical students, after 2 years of previous training in teams as pre- viously described.

Procedures The process of the focus groups involved dividing the 6 IPE teams of students into 2 separate groups of 9 stu- dents each. The date and time of the focus groups were agreed on by the students in relation to their individual schedules. It was agreed that 1 focus group would take place before the IPE team presentations, and the other would occur afterward. The students were seated at tables placed in a circle facing each other, with both nursing and medical school faculty present. The students were told the focus groups were being recorded for data collection purposes to assist faculty in data analysis and provide feedback for future projects. Each group lasted approximately 1 hour and was semistructured with questions, but also allowed time for students to discuss their opinions in an open manner.

Data Collection The focus groups were conducted by the faculty on com- pletion of the IPE project to evaluate the students’ reflections of what they learned with, from, and about each other as a result of participating in the project. Questions involved asking the students how they performed as an individual and a team member, what they learned about communica- tion, and what they learned from others on the team. Stu- dents also were asked to talk about what went well, what went poorly, and what they might do differently in the future as a member of an IPE team. These focus groups were de- signed to produce qualitative data grounded in the students’ experience during the study and are the focus of this report.

Data Analysis Qualitative content analysis was used to analyze the initial focus group data. This is a dynamic form of analysis for focus groups, which is subjective in nature and includes summa- rizing the information contents of those data through visual and verbal documentation.17 Hsieh and Shannon18 defined qualitative content analysis as a method that provides a sys- tem of coding leading to themes or patterns as a result of subjective interpretation.

Data across both focus groups were synthesized and coded, with significant statements extracted, categorized, and analyzed for content. A table was created including all initial codes in both focus groups for a comparison of commonalities across the groups. The transcripts were re- viewed an additional time for specific statements that related to the codes, which were highlighted in the table for each focus group. The statements were made into a list and labeled to correspond to each code.

Qualitative content analysis of the data was achieved through repeated iterative discussions with the research team. The team consisted of 2 faculty with qualitative experience, both with knowledge of nursing leadership and IPE, 1 physician with experience in IPE research, and 2 master’s degree–prepared students, 1 with IPE and public health experience and 1 with a focus on statistical analysis and data management. All have had experience and knowledge in the aspects of comparison of the data with past and current research results.

Findings The findings discuss the focus group qualitative data rep- resentative of the students’ experience of participating in an IPE team. Analysis resulted in identification of 2 conceptual categories, challenges of working on an IPE team and team communication, each with 7 distinct codes, and definitions (Table).

Challenges of Working on an IPE Team The 7 codes identified in this category were relative to the challenges or lack of components the students experienced throughout the project: effectiveness, research, resources, changes, emotional, holistic, and accountable (see Table for definitions). Students discussed their feelings of a lack of effectiveness. One student stated, ‘‘I think I would have been more effective as an individual if I would have been more familiar with the technique of how to communicate with a participant in a team setting.’’ Another said, ‘‘I was excited initially, but I thought we would be much more effective than we were.’’ It appeared that students were expressing their feelings of frustration and not being as prepared as they thought they would be to work in a team setting with patients.

Another challenge for the students was their lack of knowledge of how to do the research needed to provide resources for patients to make the necessary changes over time to improve their health. One student stated: ‘‘I wish I would have done more to actually follow up on education things for her. There was room for improvement on doing

Table. Focus Group Categories, Codes, and Definitions

Challenges of Working on an IPE Team Team Communication

Effectiveness: capacity to persuade Listen: to hear something with thoughtful attention Research: getting information about a subject Focusing: a state or condition permitting clear perception or understanding Resources: something used to accomplish an end Goals: the end toward which effort is directed Changes: process of making something different Roles: a part that someone has in group Emotional: expressing depth of feeling Motivational interviewing: a technique in which you become the helper in the change process Holistic: relating to treating both the mind and body Health coaching: a supportive mentor who motivates individuals to cultivate positive health choices Accountable: required to be responsible for something Supporting: educating patients to achieve their health goals through lifestyle and behavior adjustments

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more outside research.’’ Another one stated, ‘‘I think we held back a little bit on some things that I wish I would have referred her to or found other resources.’’ The lack of these skills influenced the amount of change that oc- curred with the patient, expressed through statements, such as ‘‘I think at the last meeting we really focused on her as a person, but we could have given so much more than that, so I don’t think she was ready to make the changes we wanted her to make yet.’’ Another student stated, ‘‘At the start, my focus was definitely medical, just trying to figure out tiny ways she could change her habits, but she got more relief from talking about her problems.’’

In addition, students expressed not feeling adequate in their abilities to meet the emotional needs of the patient by stating, ‘‘I remember from the very beginning we talked about her need for emotional support, but you can’t even do that with a patient whom you’ve seen for many years.’’ Another student said, ‘‘I think that we could have contacted her a little bit more and given more emotional support to gain her trust.’’

Students described their ability to use a holistic ap- proach with patients by attempting to identify all of the areas that contributed to the patient’s health. One student com- mented, ‘‘I think we worked really well together and tried to look at her holistically.’’ Yet, students did not refer to addressing the mind as well as the body. At times they expressed a level of frustration with not being prepared to deal with the emotional needs of the patients. Another student said, ‘‘Psych is such an ‘off thing’ you can’t discuss, so I guess I would be more forthcoming and more honest with future patients.’’ If students were not comfortable with addressing all of the patient’s concerns, were they taking a holistic approach and holding the patients accountable for their actions and behaviors? One student summarized her feelings by saying, ‘‘We brought something up, and she was able to elaborate on that, and then from there, the meeting took a turn to wherever she was concerned or whatever she wanted to talk about. I think it was good because it focused on her.’’ However, by allowing the patient to change the focus of the conversation, it appeared that the students were not keeping the patients on task and therefore not holding them accountable for following through on their personal behaviors and goals.

Team Communication Both of the focus groups discussed what it was like for them to be part of a team and the importance of communication with the patient and each other. This category had 7 codes related to the process of team communication: listening, focusing, goals, roles, motivational interviewing, health coaching, and supporting (see Table for definitions).

The codes were identified through the students’ discus- sion about the need for all members of the group to actively listen to the patient and to each other. One comment was: ‘‘I think we were not only listening to her but also respecting each other’s turn to talk and give their input.’’ This statement indicated the students realized the importance of focusing on the patients’ needs and allowing them to set their own goals. One student discussed how attentive the team was to the patient: ‘‘One thing we did well was listening to her and letting her speak whatever was on her mind and using an

open-ended question so she could talk about what she wanted.’’ On the other hand, another student described the difficulties experienced with their patient: ‘‘We couldn’t actually work on the goals that she wanted because there were so many barriers for her, more than just things like weight or blood pressure.’’

Furthermore, the students discussed learning about the roles of others on their team. For example, 1 student said, ‘‘We weren’t in the roles defined in the hospital, we were working together, and I think that was the best part about it.’’ In addition to learning about their roles, students discussed using motivational interviewing as a means to provide health coaching by supporting the patient as an individual and a team member. A comment reflective of concerns with the process by 1 student was: ‘‘It seemed like she had the information, but she wasn’t doing the right thing with it. I think our biggest challenge was to get her to identify the motivation versus having us directly coach her all the time.’’ Yet another student stated, ‘‘It was hard to motivationally interview her; she seemed to want more coaching than accountability, which was a hard thing for us to deal with.’’

Students’ comments suggested they needed more training on motivational interviewing and coaching. While they were given a strong background and expert coaches as resources, the teams did not often reach out to those resources. Therefore, they seemed to do well with listening and focusing on the patient’s needs, but struggled with keeping the patient on task and moving toward the es- tablished goals.

Discussion Based on the results of the focus groups with students, overall responses were positive. These results indicated the IPE project appeared to accomplish our main goals of increased communication skills among nursing and med- ical students on an individual and team basis, increased awareness of the roles of other health care professions, and increased comfort levels with developing health care plans. However, students requested additional education and training on motivational interviewing and coaching.

Students involved in the IPE project indicated that this experience of working together to solve health care issues helped them learn how to approach patients in a differ- ent manner. Students acknowledged they were more con- fident in their abilities to work with other health care professionals and increased their skills and knowledge of patient-centered care. They believed that as a team they would have a stronger impact on the patient than working alone. However, students acknowledged the work was challenging at first, as they were not accustomed to par- ticipating in IPE teams and addressing a patient together. Not only were they being asked to use a new style of communication with motivational interviewing, but they also were in a setting that was unfamiliar to them. Therefore, it took several meetings as a team with the patient to become more comfortable and work as a collaborative group.

Overall, the patients were highly satisfied with the experience of working with students in IPE teams. When asked if the team fully understood their goal for participating in the program, all of the patients strongly agreed. They also were in agreement that the IPE team valued them as an equal

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participant and addressed them with respect, professional- ism, and compassion. All of the patients noted improvement in the goals they set with the team, in areas such as blood pressure, glucose levels, reduced stress, improved nutrition, and achieving a healthier weight.

The implications of an IPE project such as this one are significant as educators and health care providers seek out ways to not only educate students about IPE in classroom and simulation settings, but also provide them with a means of practicing interprofessional care to patients while they are still students. This type of opportunity allows students to increase their communication and coaching skills and their awareness of other’s roles and responsibilities in an en- vironment where faculty are present to provide guidance. This project could be implemented with other types of students working together in an IPE environment to become skilled providers and coaches to patients.

Limitations The primary limitations of this study are the size of the sam- ple and IPE teams, nature of self-reporting, and use of focus groups with the potential for groupthink. The sample size was limited to the available number of third-year medical students, which also limited the number of nursing students involved in the project. Self-reporting by the students may not have provided an entire description of their IPE ex- perience. The faculty encouraged open inquiry by providing each member of the group an opportunity to share his/her viewpoint and used separate focus groups instead of 1 large group to help prevent groupthink.19

Conclusion Providing students with a direct-care IPE experience con- tributes to the development of IPEC competencies. The faculty found that students were capable of developing key teamwork skills while collaborating with each other and patients. Many lessons were learned concerning the logistics of combining clinical objectives, outcomes, and requirements of 2 programs together into 1 project. Because the team meetings occurred outside the traditional classroom setting, a major challenge for the students was to work around the patient’s schedule. This also created a need for flexibility with the faculty who were required to be at each meeting. While faculty and students found the experience to be highly posi- tive and beneficial to all involved, there were challenges to establishing an IPE curriculum, particularly with scheduling. The results of this study provide a clearer picture of the benefits and challenges from the student perspective that can assist faculty in strengthening the IPE experience for similar projects in the future.

References 1. Masten Y, Acton C, Ashcraft A, Esperat C. Interprofessional

education development: a road map for getting there. Open J Nurs. 2013;3:232<329.

2. Centre for the Advancement of Interprofessional Educa- tion. Interprofessional Education. http://www.caipe.org.uk/ resources/. Published 2002. Accessed October 13, 2013.

3. Interprofessional Education Collaborative. About Interprofessional Education Collaboration (IPEC). https://ipecollaborative.org. Published 2009. Accessed February 28, 2012.

4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

5. Institute of Medicine. Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century? Washington, DC: National Academy of Sciences; 2002.

6. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. www.iom.edu/~/media/Files/Report% 20Files/2010/TheFuture-of-Nursing/Future%20of%20Nursing% 202010%20Recommendations.pdf. Published 2010. Accessed May 20, 2013.

7. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Re- port of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011.

8. Department of Human Resources for Health. Framework for Action on Interprofessional Education & Collaborative Prac- tice. Health Professions Network Nursing and Midwifery Office, Department of Human Resources for Health. http://www. who.int/hrh/nursing_midwifery/en/. Published 2010. Accessed June 5, 2012.

9. Stone JA, Haas BA, Harmer-Beem MJ, Baker DL. Utilization of research methodology in designing and developing an inter- disciplinary course in ethics. J Interprof Care. 2004;18(1):57<62.

10. Sullivan DT, Godfrey NS. Preparing nursing students to be effective health team partners through interprofessional edu- cation. Creat Nurs. 2012;18(2):57<63.

11. Fiddes PJ, Brooks PM, Komesaroff P. The patient is the teacher: ambulatory patient-centred student-based interprofessional education where the patient is the teacher who improves patient care outcomes. Intern Med J. 2013;43(7):747<750.

12. Reeves S, Hean S. Why we need theory to help us better understand the nature of interprofessional education, practice and care. J Interprof Care. 2013;27(1):1<3.

13. TeamSTEPPS: national implementation. http://teamstepps.ahrq. gov. Accessed September 20, 2015.

14. Hudson CE, Sanders MK, Pepper C. Interprofessional education and prelicensure baccalaureate nursing students: an integrative review. Nurse Educ. 2013;38(2):76<80.

15. Gordon MA, Lasater K, Brunett P, Dieckmann NF. Inter- professional education: finding a place to start. Nurse Educ. 2015;40(5):249<253.

16. Office of Research Integrity. Research Design. http://ori.hhs. gov/education/products/sdsu/res_des1.htm. Published 2013. Accessed January 12, 2014.

17. Sandelowski M. Whatever happened to qualitative descrip- tion? Res Nurs Health. 2000;23(4):334<340.

18. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277<1288.

19. Sullivan E, Decker P. Thinking critically, making decisions, solving problems. In: Connor M, ed. Effective Leadership and Management in Nursing. Upper Saddle River, NJ: Pearson Education, Inc; 2009:117<118.

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http://www.caipe.org.uk/resources/

https://ipecollaborative.org

http://www.iom.edu/~/media/Files/Report%20Files/2010/TheFuture-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf

http://www.who.int/hrh/nursing_midwifery/en/

http://teamstepps.ahrq.gov

http://ori.hhs.gov/education/products/sdsu/res_des1.htm