Students often do not have the knowledge, skills or practice to communicate, collaborate, or interact within a healthcare team environment (Shafakhah et al, 2015). A clear definition of an individual's role within the care delivery system, and an understanding and respect of the roles of other healthcare team members is critical and necessary (Buring et al, 2009). Interprofessional education (IPE) within healthcare disciplines is a strategy for exploring the roles of self and others within an interdisciplinary team. While IPE has long been identified as the gold standard for healthcare education, roles and responsibilities within teams remain ambiguous for new graduates (Rosen et al, 2018). The purpose of this study was to evaluate nursing students' perceptions of roles and responsibilities following a planned IPE experience.
Background
IPE is defined by the World Health Organization (WHO) as bringing together students from two or more healthcare professions to learn about, from, and with each other (WHO, 2010). Incorporation of IPE is imperative in healthcare education (WHO, 2010; Brashers et al, 2012; National League for Nursing (NLN), 2015). The American Association of Colleges of Nursing (AACN), the National League for Nursing and the Institute of Medicine promote the use of IPE within healthcare curricula (Gunnell et al, 2016). It is an integral addition to nursing education because it aids in transitioning students from the classroom to the practice setting. Nursing students need to be ready to work in interdisciplinary teams upon graduation (WHO, 2010; Watkins, 2016). The more exposure nursing students have to other health professionals, the more socialised they will become to their roles and responsibilities within the profession and within the interdisciplinary team.
IPE has been integrated into nursing and medical education because it promotes high-quality client care and safety; it builds teamwork and communication skills among participants (Cranford and Bates, 2015; Gunnnell et al, 2016; Horsley et al, 2016; Traynor et al, 2016). It helps to improve nursing students' professional development and demonstrates the importance of nursing within the healthcare team (Cranford and Bates, 2015). It also builds respect and collaboration between students in different healthcare professions; students learn more about each other's professions when IPE is used (Cranford and Bates 2015).
AACN (2018) identifies the importance of integrating IPE in baccalaureate and graduate nursing programmes. The Interprofessional Education Collaborative (2016) developed the Core Competencies for Interprofessional Collaborative Practice to support the integration of IPE in curricula. Therefore, it is logical for nursing programmes to implement IPE strategies using these competencies to guide the process (Brashers et al, 2012; Cranford and Bates, 2015; Watkins, 2016). The four interprofessional core competencies are values and ethics for IPE practice, roles and responsibilities, IPE communication, and teams and teamwork (Interprofessional Education Collaborative, 2016). Of these four competencies, the IPE experience discussed in this article focused on Competency Domain 2 related to roles and responsibilities.
Methods
Setting and participants
This study was conducted in a small, private, liberal arts university in a rural area of southeastern USA. Participants in the study were nursing students of an undergraduate baccalaureate degree programme who were enrolled in a nursing leadership and management course. They participated in a two-day IPE grand rounds event with:
While the nursing programme was at undergraduate level, the physician's assistant, physical therapy and pharmacy programmes are all graduate level programmes. All programmes were part of the same university and were deemed appropriate for IPE curricular change through the findings of a university-wide IPE committee. Institutional review board approval was received by the university.
The committee made the decision to focus on the IPE competency of roles and responsibilities within the two-day grand rounds event. Specifically, the focus of the learning outcomes included the roles and responsibilities IPE core competency (Competency Domain 2). Students from these programmes did not have the opportunity to collaborate or interact with each other in the classroom before the two-day event.
The committee decided that the IPE experience would take place over two days, with 11 groups of students participating each day (a total of 22 groups). Each group would consist of two physical therapy students, three physician's assistant students, four pharmacy students, and one nursing student. The nursing students would participate on both days. The university's pharmacy faculty secured 11 rooms for use each day. The physical therapy and physician's assistant students at the other campus location would participate via videoconferencing. A faculty member would be assigned to each group to ensure they remained on task. The faculty were not to offer any guidance or information about the task assigned to each group.
Ethical approval
The authors received Research Review Board approval on 2/1/19 from the university.
Student learning outcomes
The committee and participating faculty from physician's assistant and nursing departments discussed student learning outcomes associated with each programme, and those for nursing leadership were: select effective communication and collaboration techniques to interact with persons and members of interdisciplinary teams to achieve mutually determined health outcomes. These student learning outcomes are based on The Essentials of Baccalaureate Education for Professional Nursing Practice (Essential 6) (American Association of Colleges of Nursing, 2008) and the Quality and Safety Education for Nurses (QSEN) (2017) competencies. All participating programmes identified accreditation standards that indicated the need for implementation of IPE into each programme's curricula (Table 1).
| Programme | Anchor course | Interprofessional education competency | Student semester/year | Accrediting agency | Accreditation standard |
|---|---|---|---|---|---|
| Nursing | Leadership | Roles and responsibility: interprofessional teamwork | Autumn/senior undergraduate year | Accreditation Commission for Education in Nursing (ACEN) |
Standard 4.6
|
| Physician assistant | Summative evaluation | Roles and responsibility: interprofessional teamwork | Autumn/second graduate year | Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) |
Standard B1.08
|
| Pharmacy | Problem-based learning V | Roles and responsibility: interprofessional teamwork | Autumn/third graduate year | Accreditation Council for Pharmacy Education |
Standard 11.1
|
| Physical therapy | Clinical integration III | Roles and responsibility: interprofessional teamwork | Autumn/second graduate year | Commission on Accreditation for Physical Therapy Education** | ** The standard that includes interprofessional education as part of the curriculum was not put in place until January 2018 |
Group task and goal
The pharmacy faculty created a chart loosely based on a case the students had experienced in the hospital. The goal for the students was to discuss the case and to determine the best discharge plan for the client and the client's family. There was no right or wrong answer. The purpose was to get the students to begin communicating and collaborating with each other, and to learn more about each healthcare profession's roles and responsibilities.
A week before the event, the faculty provided students with access to the patient's chart through the university's learning platform. The faculty expected students to review the chart and become familiar with the case before the IPE experience. Students were given the background and rationale for the IPE meeting; the pre-work instructions for all disciplines; the post-meeting instructions for all disciplines; the timeline for the meeting; and the specific instructions for each discipline, as well as the names of each student and the meeting room location. A link to a YouTube video, demonstrating a grand rounds process, was also provided. Students were expected to contribute at least one comment/intervention during their discipline's turn in the grand rounds.
The day of the grand rounds, the students reported directly to their assigned room. All student participants discussed the case for 30 minutes. After all groups had reached a conclusion, everyone came together in a lecture hall for a debriefing session, which lasted 35 minutes. During the debriefing, students were asked about their discharge plan and how they had come to that decision; what they had learnt from the other disciplines; whether there had been disagreement among the group about the outcomes; and whether the students had found the exercise beneficial. Following this experience, nursing students were given a journal to complete. Nursing was the only discipline to attend both days as it was a small cohort of 11 students. Nursing students were given a journal with prompts to submit in their leadership and management course.
Data analysis
Colaizzi's (1978) strategy for analysis of phenomenological data was used to analyse journal entries. This descriptive data analysis method promotes trustworthiness and credibility of findings. An independent qualitative methodologist, expert in qualitative research, was also consulted to peer review the themes and subthemes. The findings are described using excerpts from the students' responses; all names have been replaced with pseudonyms.
Results
While the focus of the interprofessional experience was primarily for interdisciplinary training, it became apparent that roles and responsibilities were vague and often misunderstood.
The responses were reviewed and related themes were extracted. Themes were classified into major constructs related to reflections of the undergraduate nursing students and what they perceived about the phenomenon of roles and responsibilities..
In addition to the analysis of the written responses to the journal prompts, participants were asked to select five words to describe their experiences during this IPE programme. Self-perception and perception of others emerged as two key themes in the journal entries (see Table 2). From the five words identified by all participants, four themes emerged (see Table 3).
| Self-perception |
|---|
|
|
| Perception of others |
|
|
| Emerging theme | Number of participants identifying theme |
|---|---|
| Challenges the learner and allows for insight and growth | 8 |
| Teaches collaboration and team skills | 9 |
| Develops professionalism and leadership | 4 |
| Positive learning experience that promotes motivation and critical thinking | 8 |
Self-perception
Throughout the journals, the undergraduate students wrote about various observations of self. Multiple subthemes of self-perception emerged during the analysis, including confidence, feeling of belittlement, feeling as others belittle you, preparedness, intimidation, respect, advocacy, and uncertainty of when to talk.
Confidence
Seven of the 11 nursing student journals highlighted this theme. Comments included:
‘This experience helps us to see how vital our roles are into patient care.’
‘… but it made me step up as a leader. My confidence as an individual was tested, but I loved the challenge.’
‘My favourite experience today was being more confident being the only nurse in the room and getting to give a better report this time.’
‘One of the [physician's assistant] students on Tuesday told me that a nurse literally saved him from nearly killing a patient, when she noticed that something was different in the chart. He thanked me for doing what I do and that was a huge confidence boost for me.’
Feeling of belittlement
Four of the 11 nursing students referred to this. Their comments included:
‘They were not really engaged in what I had to say as the nurse.’
‘My least favourite experience about the second day was the condescending nature of a few people in my group. I was looked at and felt as though I didn't belong and was not needed. I am not the type to care about how much people make per year or how much education they have, so it was stereotypical to me. It is a bit arrogant, in my own opinion. We are taught to not be judgemental, and that should include other healthcare professionals. No healthcare professional can function without the other, so it was disappointing. Nobody should act as though they are above anyone else.’
‘It shocked me because we hear so many horror stories about [physician's assistants] and how they think that nurses are beneath them.’
‘There is a stigma centred around nurses just cleaning people, or not having authority to do many things, but I think that stigma deserves to be addressed and eliminated.’
‘Really the only thing was that I felt like I was being attacked at one point, but I explained what I said and why, and I felt they had a better understanding of my point of view as a patient advocate.’
‘I assume the [physician's assistant] has the most power in this setting.’
Preparedness
Three of the students mentioned this theme. Statements included:
‘In the future, I will be more prepared to collaborate at my job because of this experience.’
‘It has also given me the experience of an interdisciplinary meeting before I actually have to do one in real life.’
Intimidation
This theme emerged in nine of the student journals. Their comments included:
‘I was uncomfortable at first because sometimes I feel that graduate students are not as accepting to nurses and that sometimes they do not understand our role.’
‘My least favourite experience today was how I didn't get to put in as much of my input as I would have liked. I felt like the other students covered most of the material.’
‘I think initially being the sole representative nurse was intimidating …’
Respect
Six of the students wrote about this in their journals and their comments included:
‘She was very complimentary of the nursing profession. This was a surprise because I had a preconceived notion that the other professions were not really aware of our role.’
‘One of the [physician's assistants] actually said at the end, which was surprising to me, that some nurses know more about the patients and their families and things than the [physician's assistants] typically do. It shocked me because we hear so many horror stories about [physician's assistants] and how they think that nurses are beneath them. It was nice to hear from a future [physician's assistant] that they are aware of the value of nurses.’
Advocacy
Four of the journals touched on this theme and statements included:
‘The only thing I really felt uncomfortable with was voicing my opinion because I did not want to be wrong and them to think badly of the nursing profession or nursing programme. I eventually got over that because I wanted to do what was best for the patient regardless of what they felt was right. I explained to them that we were the ones with the patient most of the day, therefore it was important for nurses to be patient advocates.’
‘… work as a team in generating the best possible outcomes for the patient.’
‘It felt almost uncomfortable to ask the meaning of some words because the [physical therapy] students used them so effortlessly. But of course, we have to take into consideration the best care for the patient so I asked.’
‘The biggest thing I noticed that nurses are truly the main patient advocates.’
Uncertainty of when to talk
This theme was evident in six of the student journals. Comments included:
‘At times I was unaware when it would be appropriate to talk.’
‘I didn't really know during the conversation where I should intervene at. I didn't know if I was over-stepping my boundaries today when I kind of took charge when the [physician's assistant] student didn't know what to say or ask.’
‘I kept waiting for a chance to talk but the opportunity took a while.’
Perception of others
In addition to the students' perception of self, the perception of others clearly emerged from the data. Themes related to perception of others included values of others; skills of others; knowledge of others; realistic simulation; roles; and others as advocates.
Value of others
Seven students highlighted this issue. Some of the comments included:
‘I always assumed the pharmacist had one mission to find the right medication for the patient but in fact, they consider the costs and look at the patient more holistically than I could have ever imagined.’
‘Each profession brought something different to the experience and it was neat to see the level of professionalism in each participant.’
Skills of others
Seven of the students commented on this, stating:
‘It's good practice to work on our team skills.’
‘I think I have learned more of what each healthcare professional does and the different things that I can ask and expect of them.’
‘This experience will help me in clinical practice because I know what is the focus of each discipline and how each discipline can help each other.’
Knowledge of others
This was a theme mentioned in six of the 11 nursing student journals, and their statements included:
‘It was interesting to see that we all have very different focuses, but working together we can figure out an appropriate discharge plan that encompasses all aspects of the patient's needs.’
‘Talking with other disciplines is vital because each discipline has important information regarding the patient.’
Realistic simulation
Four of the students cited this. Their comments included:
‘I was surprised at how well the experience mimicked the treatment plan meetings.’
‘It sounded very much like the treatment plans that I have been able to observe during clinicals.’
‘I will have a clearer understanding of what roles other healthcare professions have to offer and where I fit in as a nurse.’
‘The overall experience was very life-like.’
Roles
Most of the students wrote about this, with 10 of them mentioning this. Statements related to roles included:
‘Each profession brought something different to the experience and it was neat to see the level of professionalism in each participant.’
‘This experience would allow us to understand the nursing role more in depth and understand the importance of collaboration. Future nursing students would be able to see how important your input can be and how important it is to have effective communication with other team members.’
‘All members of the healthcare team truly make a difference.’
‘Before the experience, I was never fully aware of the roles for each person involved.’
‘I have learned more of what each healthcare professional does and the different things that I can ask and expect of them. It has also given me the experience of an interdisciplinary meeting before I actually have to do one in real life.’
Others as advocates
Five students referred to this with comments including:
‘The biggest thing I noticed [was] that nurses are truly the main patient advocates. Yes, the other professions want what's best for the patient, but sometimes that is compromised when they are trying to treat them. They also don't care too much about social history and personal history and those things can play a huge role in the care and treatment that is provided. I also realised that nurses are looked to for pretty much all the answers.’
‘This experience was able to help me get a feel for my role as a nurse in a team meeting. I was able to give input based on what I know, and also ask questions to the other professions to help expand my knowledge.’
‘Seeing the different course of actions between people in the same discipline was surprising.’
Discussion
Roles and responsibilities within interdisciplinary teams have previously been described in the literature. Students from various disciplines participating in IPE events recognise that learning about roles and responsibilities of all healthcare professions is a valuable outcome of IPE (Brashers et al, 2012; Cranford and Bates, 2015; Murphy and Nimmagadda, 2015). Through an IPE simulation, Traynor et al (2016) demonstrated that role perceptions of others held by graduate nursing students and physicians can hinder collaboration and communication between the two groups. Brashers et al (2012) described the integration of IPE in nursing and medical school. Strategic planning, initiatives and buy-in to the IPE curriculum by the university heightened the integration of IPE at all levels of healthcare education.
However, it is important to note that for the nursing participants, attending the IPE event was mandatory and was 5% of their grade for the nursing leadership class. The only discipline that did not attach a grade to the experience was the physician's assistant faculty, as the event occurred during the students' final exams. It is possible that the lack of mandatory participation could provide some explanation for the comments that physician's assistant students were less engaged or did not put a lot of effort into the IPE event.
A barrier to IPE involves the concept of power. Engel et al (2017) reported on a phenomenological study related to interprofessional collaboration between nursing students and medical students. The authors reported that the nursing students in the study transferred power to the medical students due to the perception that the medical students had more knowledge related to complex health issues (Engel et al, 2017). Due to this perception, the medical students reported that the nursing students seemed uneasy during the IPE scenario; the nursing students revealed that intimidation influenced their behaviour during the learning experience, which resulted in decreased communication with the medical students (Engel et al, 2017), which was consistent with the findings of the study presented in this paper. The medical students stated that they valued the nurses and nursing students for their practical knowledge in the clinical setting, but they noted that there were deficits in nursing students' knowledge compared with their own knowledge base (Engel et al, 2017). The study found that power in the form of intimidation was present in IPE involving these two disciplines; this barrier has the potential to lead to adverse learning experiences (Engel et al, 2017).
Similar to our findings, Lawlis et al (2014) reported that some of the barriers related to the integration of IPE in medical education include disrespect by some for other professions, limited faculty support, increased faculty workload, lack of time, and lack of financial support. As noted by some of the participants in this study, the lack of respect from some healthcare students toward other students was identified as a negative influence on learning from IPE activities (Lawlis et al, 2014). Ren and Kim (2017) reported that nursing students felt that medical students believed nurses were not able to fully provide care for patients and, therefore, they were not able to gain an appropriate learning experience. This theme is also documented in the literature related to clinical practice; Friend et al (2016) stated that nursing students felt powerless and belittled by physicians in the healthcare setting. The authors recommended emphasising equality of all healthcare students involved in IPE, regardless of level (Lawlis et al, 2014).
Based on the findings of the study presented in this article, there seems to be a clear power dichotomy as perceived by the nursing students in the IPE experience. Research demonstrates that power has a direct impact on the patient safety climate (Brandis et al, 2017) and healthcare provider choices about whether to collaborate, with whom, and to what level (McDonald et al, 2012). Sepasi et al (2016) explored nurses' perception of power. They found that nurses identify power as an inner sense and the basis of professional communication, resulting in outcomes such as improved quality of care and professional excellence. In an article by Rainer (2015), the choice for nurses to speak up or remain silent is multifactorial, including differences in generations, culture and organisations, as well as oppressed group theory, safety cultures and moral distress.
Ineffective communication among members of the healthcare team remains in the top three root causes of sentinel events, directly affecting the quality and safety of patient care (National Association for Healthcare Quality, 2012; Scott et al, 2017; The Joint Commission 2015a; 2015b; 2016). Rainer (2015) identified that one avenue to improving nurses' ability to speak up involves role-playing activities. These are fundamental to IPE educational designs and allow each healthcare team member the opportunity to further understand roles and responsibilities. Faculty modelling of effective communication techniques may reduce the perception of power imbalance. Including role-play among healthcare providers is fundamental to IPE designs.
IPE provides an opportunity to decrease the power dichotomies in practice by highlighting the roles and responsibilities of healthcare providers before students become professional caregivers. However, IPE must be developed and implemented with this focus in mind. The literature indicates that students lack exposure to communicating with other healthcare providers in the clinical setting and in simulation (Friend et al, 2016; Sollami et al, 2018). Power disparities can result in poor communication efforts between healthcare providers which have been linked to poor health outcomes for clients (Friend et al, 2016). According to Engel et al (2017) where these disparities exist between nursing and medical students they can negatively impact learning in interprofessional education activities. As experienced by nursing students they can also influence their future practice, as already reported. Engel et al (2017) stated that the disparities existed because nursing students considered the medical students as smarter and more valuable due to their more rigorous education and the entrance requirements for medical school (Engel et al, 2017). These power disparities led to discomfort and fear when nursing students and medical students participated in IPE (Engel et al, 2017).
Faculties involved in developing interprofessional education simulations should incorporate measures to decrease these power dichotomies in learning events (Engel et al, 2017). The role of nursing within the healthcare team should be developed within the simulations to address some of the power disparities found in interprofessional education and the healthcare environment (Engel et al, 2017).
IPE outcomes typically include the development of teamwork to enhance health outcomes. Another critical goal of all IPE experiences is the element of levelling power among healthcare team members. Practising and role-playing situations requiring communication, and discussing power dynamics among healthcare students can be effective in changing the perceptions of power levels. Future research needs to focus on how IPE can be developed further to help all students to be ‘level’ in the team. An element of concern is the level of entry to practice. Many healthcare disciplines have graduate entry, but for nursing it occurs at undergraduate level. Does this difference contribute to the perceived power issues and lack of perceived voice? Also, based on the intimidation that was indicated by our participants, how do we prevent perceived victimisation in future IPE events? Do we, as a faculty, perpetuate the negative stereotype of nursing? If not, then which factors do contribute to the perceived negative stereotypes?
Nursing implications
The findings of this study identify that there is a still a clear need to address roles and responsibilities within the healthcare team. Increased IPE experiences will provide students with the opportunity to learn about roles and responsibilities in a reality-based environment. In addition, accreditation agencies have put more focus on IPE experiences within curricula which may positively impact students' understanding of the roles of self and others within the healthcare team. Research has demonstrated students have enhanced development of leadership roles and responsibilities using reality-focused IPE simulated experiences (Hutchinson et al, 2011; Martin et al, 2016) and IPE-based curriculum (Furr et al, 2015). Much like any activity, practice increases confidence and proficiency. Single event IPE experiences are valuable, but in order to create consistent outcomes for students, IPE experiences must be threaded throughout the curricula. The movement towards health sciences-based colleges may be one of the first steps in moving education out of silos and into the same sandbox.
Nursing students must understand their own worth and value to the team, and be able to clearly articulate their own role to others. Historically, nursing as a profession has not been successful in communicating nurses' roles within the healthcare environment. Advocacy for the nursing profession and for asserting the voice of nursing can be achieved in many ways. Assignments could include presentation of elevator speeches (clear, brief messages about yourself or on a topic that take 30 seconds or less) throughout the curricula, conversations with legislators, or opportunities for students to participate in local discussions that impact community health. In community-based courses, students could participate on community boards or boards within the university in order to understand their role and develop confidence and comfort in the role of advocacy and communication.
Tools such as TeamSTEPPS (Agency for Healthcare Research and Quality, 2018) and Situation-Background-Assessment-Recommendation (SBAR) are often used to help teach nursing students about communication and approaches to working with other disciplines in a healthcare setting. The SBAR technique provides a framework for communication between members of the healthcare team (Institute for Healthcare Improvement, 2018) while TeamSTEPPS is a set of tools aimed at optimising patient outcomes through communication and teamwork skills. However, it does not fully address the issues identified by participants in this study, such as confidence in communication and power dichotomies, or the perception of power dichotomies, that may exist. A simple tool that combined all of these elements could provide a consistent platform for students to begin to learn and practice the communication process.
As healthcare providers, communication is one of the most important factors in the provision of safe quality healthcare (Institute of Healthcare Communication (IHC), 2011). ‘Extensive research has shown that no matter how knowledgeable a clinician might be, if he or she is not able to open good communication with the patient, he or she may be of no help’ (IHC, 2011). Moreover, if a clinician cannot communicate with his/her teammates, how many errors or near misses might occur? Communication skills must be a fundamental competency for all providers, and must also be threaded throughout the curricula.
Conclusion
Healthcare does not occur in a silo, and effective teamwork among health professionals is fundamental to the delivery of safe, quality healthcare provision. Educators in all disciplines must provide due diligence in educating the future healthcare workforce on role expectations and responsibilities within the individual's own profession and that of others. Additionally, each profession must be skilled in confidently articulating their own roles and responsibilities. Just as inclusive excellence is a core underpinning of today's educational institutions, recognising that success is dependent on how well the organisation values, engages and includes the rich diversity of all constituents, we must focus on inclusive excellence and inclusive education in our healthcare teams. This education must start in the foundations of each discipline's educational curricula.