Many of the challenges of contemporary health care can be linked to its complexity and the difficulties that patients experience navigating within systems. Unfortunately, the constant evolution of the health care system, coupled with the increasing cost of health care, has not improved patient safety or outcomes. The Institute of Healthcare Improvement Triple Aim initiative addresses the identified gaps of safety, quality, and costs via health care reform (Berwick et al., 2008). The Quadruple Aim, an expansion of that, specifically addresses improving the care experience, improving the health of populations, reducing costs of health care, and improving the work experience of the provider (Bodenheimer & Sinsky, 2014; Merry et al., 2017).
The focus of nursing and medicine on quality, safety, and cost is not new. The Agency for Healthcare Research and Quality, Quality and Safety Education for Nurses (QSEN) Institute, and The Joint Commission on Accreditation of Healthcare Organizations have emphasized the interplay between cost, quality, and safety for years with mixed results (Aiken et al., 2018; Altmiller & Dolansky, 2017). To provide clinical teams that enrich patient care and health care systems, curricular approaches must include opportunities to embed these concepts in professional practice. The restructuring of nursing and medical education to meet these principles remains sluggish (Lawson et al., 2019). To address these continuing challenges, practitioners and educators must embrace a new approach to the delivery and structure of care (Institute of Medicine, 2015). Current literature has shown that interprofessional teamwork and the resulting collaborative approaches to care are key to meeting the challenges of cost, quality, and health (Canadian Interprofessional Health Collaborative, 2010; Institute of Medicine, 2015). Interprofessional education helps underscore and enlighten student appreciation for the roles, responsibilities, and professional values each profession brings to the care environment (Boland et al., 2016). It is logical, and even an imperative, that educational curricula in the professional schools evolve from the traditional immersive, siloed experience, to a more diffuse and collaborative one. Thus, the purpose of this activity was two-fold: to offer medical and nursing students the opportunity to apply new knowledge on safety, quality, and cost, and to do so within an environment requiring interprofessional collaboration.
Advances in simulation and experiential learning techniques have made collaborative and team-based education more accessible to students from different disciplines. Because nurses and physicians form the dyad relationship that most frequently interacts with a patient during their hospitalization, developing curricular activities and courses to improve communication and teamwork within that dyad is essential to patient quality and safety. To date, however, few reports have discussed the integration of patient safety and quality education into medical school education (Lawson et al., 2019; Nie et al., 2011). Giving students opportunities to not only learn about each other's profession but also participate in interprofessional collaborative activities during their early medical and nursing education has the potential to promote trust and strengthen these relationships (Sollami et al., 2018; Visser et al., 2017). The ultimate goal of such educational strategies is to create an effective team that promotes the delivery of safe, affordable, high-quality, individualized care that results in optimal outcomes. This article reports the results of an interprofessional, experiential learning activity with nursing and medical students.
The need for coordinated care has resulted in renewed interest, or a robust argument, for interprofessional education and collaborative practice (IPEC). While interest in IPEC has existed for decades, developing curricula to educate health profession students on the quality and safety standards introduced by Agency for Healthcare Research and Quality and QSEN is relatively new. Professional health care organizations such as the Institute of Medicine (2011), the Joint Commission (2010), the National League for Nursing (2015), and IPEC (2016), which includes the American Association of Colleges of Nursing and Association of American Medical Colleges, have emphasized the importance of interprofessional education, specifically in the areas of teamwork, roles and responsibilities, and communication. The American Association of Colleges of Nursing has included interprofessional collaboration for improving patient and population health outcomes as an essential concept in the preparation of baccalaureate, master's, and doctoral level nursing students (Accreditation Commission for Education in Nursing, 2017; Health Professions Accreditors Collaborative, 2019).
Although professional organizations have agreed on the importance of communication, collaboration, and teamwork, curricular changes have moved at a slower rate. Health professions educators face significant challenges when educating students on the concepts of the Quadruple Aim (Baxley et al., 2016; Lyle-Edrosolo & Waxman, 2016). Although faculty who are also practitioners may be cognizant of the mandates of safety, quality, and collaboration in their own practice, translating that competency to the classroom can be challenging (Krisberg, 2016; Walsh et al., 2019; Wong et al., 2012). Learning about quality and safety has been found to be more impactful when such education is coordinated with clinical initiatives (Farnan et al., 2016). To apply such new knowledge, learning about implementing and measuring change is key (Voss et al., 2008). Educational strategies using small change activities in blended groups can expose future health care professionals to the import of collaborative learning and practice opportunities.
This educational activity took place in a university affiliated with a large academic medical center in rural North Carolina. The main objective was to introduce nursing and medical students to the utility of a collaborative team approach in learning about and applying the concepts of quality, safety, and costs of care. A competitive game-based activity, “Quality Olympics,” provided interprofessional team members with an identified and shared goal. A pre- and postactivity assessment exercise was completed to evaluate for changes in student views of interprofessional education and collaborative practice.
This educational activity was approved by the East Carolina University Division of Research, Economic Development, and Engagement, Office of Research Integrity & Compliance, University and Medical Center Institutional Review Board.
Two cohorts of medical and nursing students participated in a competitive team learning activity during a regularly scheduled course block within their respective curriculums over a 2-year period. Faculty created 63 teams of senior-level nursing students (n = 220) and first-year medical students (n = 163) who were randomly assigned into blended groups of at least six members. In year one, there were 33 blended teams with six members and two teams of seven. Year two was divided into 30 blended teams of six members and three teams of seven. Whenever possible, there was equal representation of medical and nursing students within each team. Each team had at least two members of each profession assigned to their blended group if the total group numbers were unbalanced. Students completed a pre- and posttest to determine their perceptions of interprofessional education and collaborative practice.
The Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) is a 10-item Likert scale self-report survey designed to measure health professions student perceptions of interprofessional education and collaborative practice (Dominguez et al., 2015). The 5-point Likert scale ranges from 1 to 5, where 1 = strongly disagree and 5 = strongly agree (Dominguez et al., 2015, p. 145). According to Fike et al. (2013), “The underlying model for the SPICE-R instrument is based on three factors: interprofessional teamwork and team-based practice (n = 6 items), roles/responsibilities for collaborative practice (n = 2 items) and patient outcomes of collaborative practice (n = 2 items)” (p. 4). Reliability of the SPICE-R was determined by a Cronbach's alpha of .86. The SPICE-R was administered pre- and postactivity to assess student attitudes toward interprofessional health care teams. Data were collected over a 2-year period from 2015 to 2016, with a total of 383 students surveyed.
Students participated in structured icebreakers to launch the learning activity portion of the 3-hour event. The activity occurred in three phases:
- Phase 1: Students completed selected Institute of Healthcare Improvement online modules;
- Phase 2: Lecture bursts lasting approximately 20 minutes covered patient safety, quality improvement, and the plan-do-study-act (PDSA) model; and
- Phase 3: Participation in the Quality Olympics, a game-based team competition, followed by a clinical scenario.
Students applied their newly acquired quality improvement knowledge to a game-based team competition before working on a clinical scenario. The Quality Olympics competition included using materials provided by the faculty to create a package that would prevent an egg from breaking when dropped from a ladder. After their initial attempt, the costs of the materials the teams had selected were provided. Teams then repeated the egg drop process, testing changes in their packaging via repeated PDSA cycles with the goal of designing the safest, highest quality, least expensive package. The teams that constructed the most cost-effective, successful egg drop package were declared the Quality Olympics champion and rewarded with candy. Students were then challenged to apply their cost, safety, and quality knowledge to a catheter-acquired urinary tract infection (CAUTI) scenario. This particular scenario was selected due to the skill level of all participants. Teams were given 20 minutes to discuss treatment options, which were then deliberated within the larger group. Faculty facilitated discussion on the application of quality improvement (QI) principles within an interprofessional team using the gaming (the egg) and CAUTI clinical scenario as examples. Student attitudes toward interprofessional health care teams and the team approach to patient care were assessed via the SPICE-R before and after the activity (Dominguez et al., 2015).
Descriptive statistics were used to analyze the SPICE-R, including response percentages for each question. Pre- and post-test results were compared between professional groups using the Fisher's exact and Cochran-Armitage exact trend tests. The Fisher's exact test was used to test for a significant difference between the responses of the pretest and the responses of the posttest. Significance was set at p < .05. The Fisher's exact and Cochran-Armitage exact trend tests were used to test for trending between cohorts.
In year one, pretest and posttest significance was found for nursing students on all items on the SPICE-R survey (p < .0001 to .003); the same was not true for the medical students (p = .059 to .97). The three factors of interprofessional teamwork and team-based practice, roles and responsibilities for collaborative practice, and patient outcomes from collaborative practice showed significant differences in pretest and posttest in the nursing students and no significant differences in pretest and posttest in the medical students.
In year two, pretest and posttest significance was again noted for the nursing students (p < .0001 to .011). The three factors of interprofessional teamwork and team-based practice, roles and responsibilities for collaborative practice, and patient outcomes from collaborative practice showed significant differences in pre- and posttest associations in the nursing students. Medical student responses reached significance on four questions: (#7) understanding the roles of other professionals within a team (p < .0001), (#8) that clinical rotations within the curriculum are the ideal place for students to interact (p < .0001), (#9) health professionals should collaborate on interprofessional teams (p < .01), and (#10) during their education, health professional students should be involved in teamwork with students from other health professions in order to understand their respective roles (p < .0001). In addition, medical students showed improvement in two factors: interprofessional teamwork and team-based practice, as well as roles and responsibilities for collaborative practice (Table 1).
Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) Pre–Post Significance Comparisons
The purpose of interprofessional education is to demonstrate how collaboration and teamwork between professional disciplines promotes optimal patient outcomes. The results of this learning activity indicate that working together in a structured environment promotes appreciation of other health professional contributions to care. Compared with medical students, nursing students had a more positive attitude toward all three factors, as measured by the SPICE-R: interprofessional teamwork and team-based practice, roles and responsibilities for collaborative practice, and patient outcomes from collaborative practice. Reasons for this difference could be that nursing students were in their senior year, whereas medical students were in their first year of study. Generally, nursing education has prioritized QSEN competencies and modeled their application throughout the didactic and clinical curriculum (Cooper, 2017). The nursing students may also have been advantaged based on their myriad clinical experiences and the application of concepts learned in their undergraduate nursing leadership course. Medical students have expressed a preference for integrating quality and safety experiences into clinical real-life environments and find these settings more useful (Teigland et al., 2013). Medical and nursing students differed in their attitudes toward interprofessional health care teams and team-based approach to patient care at the beginning of the study, with medical students having significantly less positive attitudes. Although results did not reach significance, it is notable that medical student attitudes about collaborative approaches to care changed from year one to year two; they reported an appreciation for the contributions of others to the health care team, and a realization that patient satisfaction was affected when care was shared with other professionals. Reasons for this change are not clear given that the educational activity was the same in year one and year two; however, this could reflect the continual emphasis by faculty linking collaboration to patient quality and safety in the medical student curriculum and within health systems in general. Similar results have been reported where gaps in role perception between medical and nursing students were found (Hylin et al., 2007; Stepney et al., 2011).
This educational activity expanded our understanding of medical and nursing student attitudes toward interprofessional health care teams and the desired team approach to patient care. The contrasts discovered between these professions suggest that students would benefit from early, additional instruction and/or opportunities to link patient safety and outcomes to interprofessional practice. By doing so, educators may ensure that future providers have the attitudes, knowledge, and skills to transform health care systems. Paramount to such seismic change is the ability to work in collaborative teams to deliver what patients and families expect: safe, high-quality, and affordable care. This activity underscores the importance of embedding interprofessional education and QI strategies and their impact on patient outcomes into health professions curricula during the early stages of professional development.
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Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) Pre–Post Significance Comparisons
|Question||Year One||Year Two|
|Nursing (n = 118)||Medicine (n = 82)||Nursing (n = 102)||Medicine (n = 81)|
|1. Working with students from another profession enhances my education.||< .0001***||.92||< .0001 ***||.12|
|2. My role within an interprofessional health care team is clearly defined.||< .0001***||.74||< .0001***||.17|
|3. Health outcomes are improved when patients are treated by a team that consists of individuals from two or more health professions.||.0003**||.97||.011*||.76|
|4. Patient satisfaction is improved when patients are treated by a team that consists of individuals from two or more health professions.||< .0001***||.71||< .0001***||.12|
|5. Participating in education experiences with students from another health profession enhances my future ability to work on an interprofessional team.||< .0001***||.37||.0005**||.52|
|6. All health professional students should be educated to establish collaborative relationships with members of other health professions.||< .0001***||.78||.0010**||.86|
|7. I understand the roles of other professionals within an interprofessional team.||< .0001***||.059||< .0001***||< .0001***|
|8. Clinical rotations are the ideal place within their respective curricula for health profession students to interact.||< .0001***||.070||< .0001***||< .0001***|
|9. Health professionals should collaborate on interprofessional teams.||< .0001***||.89||.0023**||.0023**|
|10. During their education, health professional students should be involved in teamwork with students from other health professions in order to understand their respective roles.||< .0001***||.81||< .0001***||< .0001***|