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INTRODUCTION
The importance of interprofessional collaborative practice (IPCP) in health care is now being emphasized more than ever. IPCP has been shown to improve patient outcomes such as blood pressure and glucose and cholesterol control, and thus reduce mortality. This change in health care delivery accelerated the introduction of interprofessional education (IPE) courses for physicians, nurses, pharmacists, and social workers.12345
IPE is a collaborative approach for teaching and learning that fosters teamwork among two or more health-care professionals from different educational backgrounds.678 If students from different health-care professions learn together, they might be prepared to collaborate more efficiently and effectively in practice.91011 However, many undergraduate students of medicine, nursing, and other professions still have only limited opportunities to learn how to collaborate with other members of the health-care team and continue to be educated in isolation.1213
Recently, in countries such as Canada, Australia, the United States, and Europe, many schools for the health professions and academic health centers have made great efforts to implement IPE. The accreditation bodies for health science programs in Canada and the United States require the inclusion of IPE in curricula.141516 Although growing amount of research have described various types of IPE programs with diverse curriculum content, course duration, participating group and outcomes and studies have provided evidence of a long-term impact of IPE on IPCP,171819 we have limited experience of IPE program in Korea.
In fact, although an IPE program with active interactions among various health professionals would be ideal, implementing it has various practical limitations. This study thus aimed to develop an IPE program that can be implemented in medical schools that afraid to implement IPE due to various obstacles. In this study, we describe the process of developing and implementing an IPE program and evaluate the IPE curriculum based on Kirkpatrick's model.
METHODS
We developed and implemented an IPE curriculum for third- and fourth-year medical students before they started clinical practice.
The curriculum development and implementation
In early 2017, we developed an IPE curriculum to prepare health professionals for IPCP. We focused on third- or fourth-year medical students because we believe that students should learn interprofessional collaboration and communication during their clinical clerkships and before working as medical interns, as team members providing health care.
We invited experts from various fields to constitute an organizing committee for the IPE curriculum. They were from medical education, internal medicine, emergency medicine, nursing, and so on. Through consecutive meetings, discussions, and a workshop, we came to agreement on the core values and desired course outcome for IPE (Supplementary Data 1). The 2-week IPE curriculum was designed based on the core competencies for IPCP guidelines.20 (Tables 1 and 2) Learning objectives and curriculum components were developed and coordinated. The contents of the IPE curriculum are as follows:
Table 1
Two-week schedule of the IPE program in 2018
Table 2
Two-week schedule of the IPE program in 2019
- Human centeredness/Patient centeredness
- Patient experience
- Patient safety
- Values/Ethics for Interprofessional Practice
- Roles/Responsibilities
- Communication with patients
- Communication with other professionals
- Teams and teamwork
- Respect
These topics were taught using appropriate teaching methods such as interactive lectures, discussions, shadowing, small-group discussions, simulation, role playing, etc. (Tables 1 and 2). To assess student performance, we used multiple approaches including essays, performance in role play, video clips, and attitude toward participation.
Subjects
The subjects of the study were third or fourth-year medical students at the Chung-Ang University College of Medicine (Republic of Korea) from 2018 to 2019. In its first year, we launched the IPE program for fourth-year medical students. We subsequently switched it to the third year, thinking that earlier exposure to IPE is required before entering clinical clerkship. In the first year of implementing IPE, the main curriculum participants were medical students only (fourth-year medical students, n = 72). But in 2019, the second year, we added simulation sessions for medical and nursing students (third-year medical students (n = 94) and fourth-year nursing students). Seventy-five fourth-year nursing students from the Sung-Shin University College of Nursing participated in this class.
Outcome measures
For IPE course evaluation, we used Kirkpatrick's educational outcome model. We evaluated the participants' reactions, modification of attitudes and perception, acquisition of knowledge and skills, behavioral change, and change in organizational practice based on Kirkpatrick model.
Level 1 – Reaction: After the training, we asked all students to describe their satisfaction with the IPE program. We asked them to each write a reflection paper and to make a video clip describing their experiences, lessons learned, and feelings during the program.
Level 2 – Modification of attitudes/perceptions & acquisition of knowledge/skills: To analyze perceptual changes of students related to readiness for interprofessional learning, we asked all students to complete a readiness for interprofessional learning scale (RIPLS) 19-item questionnaire (see Table 3 for items) before, immediately after, and 4 months after the training. The RIPLS is a commonly used tool for evaluating attitudes and perceptions of students regarding IPE that was developed by Parsell and Bligh.21 We used the 2009 version of the RIPLS that was adapted by Latrobe Health Service and the Health & Social Care Interprofessional Network and consists of 19 questions and 4 subscales including teamwork and collaboration, negative professional identity, positive professional identity, and roles and responsibilities.222324 In order to help students understand it, the questionnaire was written in both Korean and English. Students gave responses to the statements using a five-point scale (5 = strongly agree; 1 = strongly disagree).
Table 3
Results of the RIPLS surveys before and after IPE training in 2018 and 2019
Levels 3 and 4 – Behavioral change and change in organizational practice & benefit to patients: By the end of the medical internships of the medical graduates who first participated in the IPE program, we obtained 360° evaluation by diverse health professionals during the medical internships one year after the training. During 1 year of their internship, we received feedback repeatedly from senior doctors and nurses. At the end of each year, nurses have scored satisfaction with interns as team members using 5-point Likert scale (5 = very satisfied, 1 = very dissatisfied), and we compared satisfaction scores before and after IPE training. As for improvement of patient outcome and benefit to patients, we are planning a long-term follow-up comparative investigation to see if there was any change in patient outcomes after the IPE training.
Data analysis
Statistical analysis was performed using the SPSS (version 23) statistical package (SPSS, Chicago, IL, USA). Changes in RIPLS score after the IPE program were analyzed using a paired t-test and overall satisfaction score with working with interns P values of < 0.05 were taken to indicate statistically significant differences.
RESULTS
Participant satisfaction with the education program
A total of 166 medical students in 2018 and 2019 (72 and 94, respectively) and 75 nursing students in 2019 participated in the curriculum. The reflection papers showed that students had learned and felt a lot during the training. The video clips that the students made in small groups showed that they also had a chance to think deeply, considering different perspectives.
At the end of the program, students were asked to give descriptive feedback about the curriculum. Most participants answered that they were fully satisfied with the program. They said that shadowing and interaction with other professionals helped them to understand and acknowledge other health professionals in the hospital and that they could understand the common situation of conflict among diverse health professionals. Comments about the educational program included the following:
- I'm glad I could participate in this curriculum before my clinical clerkship.
- I was surprised to see that there are so many different jobs in the hospital that I had not heard of before.
- It was only a few days' program, but as I toured various facilities in wards and hospitals, I realized that hospitals could never be run by doctors alone.
- It was good chance for me to see the system of the hospital as a whole before my clinical clerkship.
- I really enjoyed shadowing. After visiting various departments and experiencing other jobs indirectly through friends' presentations, I could feel that so many people were working together in the hospital. When I asked my seniors who are currently in practice, they said they didn't know there was such a department in the hospital after a year of practice.
- I now understand that the hospital needs a wide variety of other jobs besides doctor or nurse to function.
- It was an opportunity to feel how hard nurses were working and realize that patient care is not something that doctors can do without their cooperation.
- The simulation session with nursing students was so fun, and I couldn't help but admire the professionalism of the nursing students.
Reliability of the English with the Korean version of the RIPLS
The internal consistency of the RIPLS was overall good (α = 0.849). Cronbach's α estimating the internal consistency of the four factors ‘teamwork and collaboration,’ ‘negative professional identity,’ ‘positive professional identity,’ and ‘roles and responsibilities’ were 0.819, 0.710, 0.828, and 0.371, respectively.
Students' perceptual change following the IPE program
We used the RIPLS to survey students to find out whether the IPE course had influenced students' attitudes or perceptions about interprofessional learning and collaborative care. All 166 students (72 for 2018 and 94 for 2019) answered the RIPLS questionnaire on the first day of the course, at the completion of the planned curriculum, and again 4 months later.
In 2018, there was no noticeable significant change in RIPLS scores immediately after the training (Table 3). But 4 months after the IPE program, students' RIPLS scores changed to be significantly more favorable to interprofessional learning (IPL). However, in 2019, all RIPLS scores changed to be significantly more favorable toward IPL immediately after the students completed the IPE program, and the changed scores were still valid 4 months later (Table 3). When we compared the 2018 with the 2019 RIPLS scores, there were no differences in the initial scores (before the IPE program). Immediately after the program, the average RIPLS score in 2018 was significantly less favorable to IPL compared with 2019, but 4 months after the program, most of these gaps had diminished (Supplementary Table 1).
The curriculum in 2019 is not significantly different from 2018 in terms of learning objectives or learning activities, but the order of lectures and practice was changed slightly and more participatory practice was reinforced. Above all, the biggest difference in the curriculum between 2018 and 2019 was the participation of nursing students and interaction with them during a simulation. The direct interaction with nursing students might have influenced medical students' attitudes toward IPL. Considering that there were no obvious differences between 2018 and 2019 in the responses before the training, direct interaction between medical and nursing students might have caused the difference.
Behavioral change one year after the IPE curriculum
The next outcome measurement was behavioral change, the third level of Kirkpatrick's model. We followed up on the IPCP-related performance of students who had participated in the IPE curriculum in 2018 and worked as medical interns in 2019. An assessment by a nurse was carried out as part of a 360° evaluation. The number of complaints related to interns decreased significantly compared with the prior consecutive 2 years, from 34 cases per year to 17 cases per year. And overall satisfaction score with working with interns improved significantly, from 3.1 out of 5 points (a total 799 out of 975 nurses had answered) to 3.4 out of 5 points (a total 778 out of 982 nurses had answered) after IPE training (P < 0.05).
DISCUSSION
In this study, we introduced an IPE curriculum for training prior to medical internship and found that students' attitude toward IPCP improved after participating in the 2-week IPE program. Their positive attitudes toward IPL were still valid at 4 months and at 1 year after the training.
In spite of the significance of IPCP and the recognized need for IPE, there are some obstacles to developing and sustaining IPE. Common obstacles include institutional leadership, physical distance between different disciplines' institutions, student diversity, and pre-existing diverse curricula for different health professionals. The IPE concept and lack of an accredited, efficient teaching method are also common barriers.252627 We intended to create an interactive IPE program in which students in diverse health professions would learn about, from and with each other, but it was difficult to gather them due to the geographically distant locations of their different disciplines' institutions and their diverse undergraduate curricula. As the curriculum for undergraduate students was already overwhelming, making space for IPE was not easy. In spite of these difficulties, we did start a 2-week IPE program and were able to add a simulation session with nursing students in the second year of the program.
As there is no gold standard for teaching interprofessional skills, we made an effort to match learning activities to each objective. A recently published review paper reported that didactic, small group discussion, patient case analysis, simulation, and shadowing are major educational strategies currently available for IPE.28 We started various educational tools for IPE and focused on experiential learning because we thought IPE skills could be acquired through experience. In our curriculum, we minimized one-way teaching such as lectures, and maximized interactive learning, self-directed learning, and diverse experiences by which students could discover the importance of IPE and interaction with other professionals. Among diverse learning activities, a majority of students rated the simulation session with nursing students as the most satisfactory class, and the nursing students were also satisfied with the class. We concluded that real interaction with diverse health professionals is the most effective way to learn IPCP. The more favorable change in students' attitudes toward IPCP at their completion of the training in the second year compared with the first year might have been caused by their direct interaction with nursing students in the second year. Besides adding the simulation session with nursing students, in that year we also added various learning activities such as a team building game or communication game, while small group discussions were the main activity in the first year. Insufficient inter-professional interaction in 2018 might be the cause of the insignificant RIPLS score change right after IPE course. But 2-week IPE training would have influenced students' attitudes resulting in change in RIPLS scores after 4 months.
A favorable view of IPE by hospital leadership is necessary for IPE implementation, not just for implementing IPCP in the hospital, but also for introducing an IPE curriculum in medical school. We need support from other health professionals and cooperative hospital leadership for shadowing programs and creating a collaborative culture in hospitals. Thus, successfully implementing IPE is a kind of IPCP process itself. However, IPE program leadership is the most important factor in IPE implementation and maintenance. Persuading the health care community of the importance of IPCP, appealing to other professions and hospital leadership to elicit cooperation, and operating IPE courses using various educational methods are possible only when the IPE program leader has a strong will and drive.
Interprofessional learning is known to help prepare students for team-based practice, but the appropriate time for intervention is not well understood. In our study, we introduced IPE in the third or fourth year of medical school, before the medical internship. Traditionally, curricula for doctors and medical students have more focused on clinical skills such as diagnosis or treatment of disease and paid little attention to teamwork, communication, or cooperation with other health professionals. But nowadays these skills are more emphasized than clinical skills and are known to be proven, effective ways of improving patient outcomes. Therefore, all undergraduate medical students should have the necessary competence to be good team players.2930313233 The critical period for IPE might be before students work with other professionals, because teams do not function well without practice. An IPE program at the prelicensure level has been shown to produce positive outcomes in patient satisfaction, collaborative team behavior, and reduced medical error.34 Hence, gradual implementation of IPE is recommended for undergraduate students.
IPE's learning outcomes are not simple knowledge or skills, but contextual knowledge and performance skills in collaborations among different professions, so the curriculum should be designed not only at the individual level but also at the organizational level, and an inter-organizational learning process should be arranged. Our results support these lessons. We included interactions with other professionals through shadowing in the first year of IPE when medical students were the only participants in the program, and then added a multi-profession simulation session in the second year. Students' satisfaction increased in the second year when direct interaction was present.
Despite debate about the validity and reliability of the RIPLS, a number of studies have reported that RIPLS is a reliable and valid tool.3536 Our results revealed the weak internal consistency (0.371) in the roles and responsibilities subscale that has already been reported.2237 We used a bilingual version of the RIPLS questionnaire because we did not have previous data from the Korean version of RIPLS and medical students are very good at English.
Our study has several limitations. First, we started the IPE program at a small institution and the number of participants was limited, so it is hard to generalize our results to other institutions. Second, nursing students participated only in the simulation session and were not included in the rest of the IPE training. The curriculum was designed mainly by medical doctors for medical students. Because we still do not have a curriculum that involves multiple professions from the start, we need to develop and apply an IPE curriculum that includes diverse professions throughout the program. Third, the validity of measuring students' attitudinal changes using RIPLS is still debated, and multi-faceted evaluation using various tools could be a better option for assessing students' attitudinal change. Fourth, as the internship period was one year after the IPE course and various factors could affect the intern's performance in addition to IPE training, it may be difficult to conclude that the improvement of intern' performance as teammates was only achieved by IPE training. And last, although the final outcome measure for the IPE program was improvement in patient outcomes and benefits to patients, the fourth level of Kirkpatrick's model, we do not have data regarding any change in patient outcomes or benefits to patients. A long-term follow-up study will provide it.
In conclusion, the IPE curriculum was satisfactory in that it changed students' attitudes to be more favorable to IPCP and these changes were maintained until the end of the medical internship. This study shows that even a single, short IPE program with limited interaction with other health professionals can change medical students' attitudes about IPCP. We also found that students enjoy interaction with students in other health care professions and that this interaction increases IPE effectiveness. The program should be extended to more diverse groups of health professionals and students.
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