For more than four decades, interprofessionalism has been strongly advocated as a means to provide better coordinated, efficient, and effective care to clients (Reeves, Tassone, Parker, Wagner, & Simmons, 2012). The World Health Organization strongly advocates the use of interprofessional education to develop a collaborative practice-ready workforce to address the global health workforce crisis, strengthen health care systems, and improve health care outcomes (World Health Organization, 2010). Similarly, the U.S. National Center for Interprofessional Practice and Education (2017a) suggests that interprofessional education is an important part of achieving the triple aim of improving the patient's experience of care, improving heath, and reducing the per capita cost of health care. In response to these goals, accreditation bodies for professional schools are now promoting and requiring interprofessional education initiatives (Zorek & Raehl, 2013).
Despite decades of efforts to improve education to promote interprofessionalism, we have not achieved these ideals in practice. Moyers and Metzler (2014) advocated for an acceleration of the design, implementation, and evaluation of interprofessional efforts in occupational therapy to foster better collaborative practices. To meet these goals, four key student competencies identified by the U.S. National Center for Interprofessional Practice and Education as critical to interprofessional practice must be addressed by our profession: interprofessional team communication, teamwork, values and ethics, and roles and responsibilities. Many have argued that preservice education is the best place to start to develop these core interprofessional practice skills (American Occupational Therapy Association, 2015; Barr, Koppel, Reeves, Hammick, & Freeth, 2005; Begley, 2009; Solomon & Salfi, 2011).
Within academia, each profession's curriculum is driven by its standards for accreditation. In occupational therapy, a standard for interprofessional education was added in 2013 (Moyers & Metzler, 2014). This standard stated that preservice students should “effectively communicate and work interprofessionally with those who provide services to individuals, organizations, and/or populations to clarify each member's responsibility in executing an intervention plan” (Moyers & Metzler, 2014, p. 27). An analysis of interprofessional content in accreditation standards and practices for health professions conducted by Zorek and Raehl (2013) found that most U.S. health professions have at least one interprofessional accreditation standard that their accrediting body may hold the institution responsible for as an “accountable” learner outcome. However, their analysis showed that the statements for only two professions, which did not include occupational therapy, were comprehensive in addressing all four interprofessional competencies. These authors concluded that “there is a lack of a collective mandate for interprofessional education which is regrettable given that academic institutions must respond to accreditation requirements” (Zorek & Raehl, 2013, p. 5).
In preservice preparation, a professional “tribalism” is often created as students are inculcated into an “insider” identity; this identity may serve as a barrier to cooperation and create turf battles in practice. Therefore, interprofessional practice must create a bridge between divergent cognitive professional maps (Hall, 2005; Pecukonis, Doyle, & Bliss, 2008). Effective interprofessional education requires wrestling with one's own discipline's epistemology, practice domain, declarative and tacit knowledge, professional jargon, stereotypes, rivalries, and power relationships to reach mutual interpretations of the client's issues in a shared language and determine common goals for treatment (Manathunga, Lant, & Mellick, 2006). Interprofessional education must provide a learning context that teaches mutually identified core skills and builds the trust, communication, and conflict management skills that are necessary for interprofessional practice within health care settings (Oandasan & Reeves, 2005; Solomon & Salfi, 2011; Suter et al., 2009).
Common models for interprofessional education have focused on different approaches to preservice training: short case-based interprofessional workshops lasting hours or days, virtual interprofessional case studies, series of two to four modules completed over the span of a year, week-long clinical interprofessional education ward experiences, preservice short elective interprofessional classes, and combined interprofessional courses and clinical placement experiences (Arenson et al., 2015; Bondoc & Wall, 2015; Cooper, MacMillan, Beck, & Patterson, 2009; Derbyshire & Machin, 2011; Forte & Fowler, 2009; Gunaldo et al., 2015; Hallin, Kiessling, Waldner & Henriksson, 2009; Howell, Wittman, & Bundy, 2012: Jorm et al., 2016; Kraft, Wise, Jacques, & Burik, 2013; Lawlis, Wicks, Jamieson, Haughey, & Grealish, 2016; Lumague et al., 2006; Sheldon et al., 2012; Shepard et al., 2015; Shoemaker, Platko, Cleghorn, & Booth, 2014; Solomon & Salfi, 2011; Wilhelmssson et al., 2009). Most interprofessional education experiences were one-time pre-service programs that lasted 1 to 5 days (Reeves et al., 2012). Case-based workshops have been advocated as scalable approaches to educating large multiple-profession groups in a short period. Interestingly, in some of these programs, students reported an improved understanding of the role of other professions but noted less clarity about their own professional role (Bondoc & Wall, 2015; Gunaldo et al., 2015; Kraft et al., 2013; Ponzer et al., 2004). Qualitative comments suggest that pitfalls of short case-based workshop experiences include logistical issues, poor group dynamics and communication, and pressure to produce a result (often a mutually developed discharge plan) in a short time (Bondoc & Wall, 2015). In addition, these experiences may not create sustainable changes in skills.
Reviews of interprofessional education studies have not consistently noted positive outcomes (Hammick, Freeth, Koppel, Reeves, & Barr, 2007; Kent & Keating, 2015; Lapkin, Levett-Jones, & Gilligan, 2013; Reeves et al., 2008). A review of 21 interprofessional education studies assessing mostly high-quality preservice programs showed more positive than mixed results for attitudes toward collaboration and teamwork and addressing professional stereotypes and hierarchies (Hammick et al., 2007). A systematic review of clinic-based experiences by Kent and Keating (2015) found that students began to learn team skills and developed a greater understanding of others' roles. However, they did not report changes in attitudes toward other professions or evidence of greater effectiveness in care delivered after interprofessional education (Kent & Keating, 2015). Current approaches to interprofessional education have shown improvements in teamwork but less success in developing skills that overcome professional tribalism.
More recent findings confirmed that students learned from each other in interprofessional clinical experiences and reported that the experience would improve later relationships with health care teams (Lawlis et al., 2016). A review by Lapkin et al. (2013) examined the best evidence available, including all randomized controlled trials and quasi-experimental studies on interprofessional education, for a total of 14 studies. They concluded that health care students showed increased positivity toward interprofessional education and enhanced perceptions of their clinical decision-making skills. However, these studies did not show enhanced communication or clinical skills (Lapkin et al., 2013).
In general, given the mixed outcomes of studies reported in reviews, better measures of quality outcomes have been strongly recommended to strengthen the evaluation of interprofessional education programs and, in turn, develop more effective interprofessional education (Begley, 2009; Reeves et al., 2008). There may be shortcomings in the design of current programs for interprofessional education, including insufficient time to build the critical skills necessary for successful teamwork in health care settings, failure to design the experience to sufficiently address professional tribalism, and inadequate program evaluation of interprofessional education learning outcomes.
With uneven earlier successes, the focus in interprofessional education has turned to identifying the most essential elements for collaborative practice. Suter et al. (2009) suggested that understanding and appreciating professional roles and effective communication are two such essential competencies. In a qualitative study, Croker, Fisher, and Smith (2015) identified the following essential features that are needed to build rapport effectively in interprofessional education: a set of contextual qualities (balance of students in professions, shared space, and sufficient time) and interpersonal qualities (interest, openness to inclusion, respect for other professions, a sense of one's own profession, development of interprofessional bonds, and patient-centered practice).
It appears that effective interprofessional education must facilitate boundary crossing between professions using effective communication strategies. Some have identified this as learning about, with, and from other professions (Bainbridge & Wood, 2012; Barr, 2002). Therefore, the goal of interprofessional education is not simply to teach students to be better team members but rather to develop higher-level cognitive skills to enable students to move in and out of many teams beyond their professional tribalism, deal effectively with discord within teams, and work in teams to discern the meaning of illness, needs, and treatment for clients. Our objective was to design, implement, and evaluate an interprofessional motivational interviewing course rooted in patient-centered practice and focused on fostering communication principles for participating health professional students.
Interprofessional Course Development and Design
Faculty from counseling psychology, nursing, occupational therapy, pharmacy, and social work programs collaborated to design this interprofessional course. The group's interests and research coalesced around client- or patient-centered practice, cultural sensitivity and diversity, and wellness and lifestyle changes. Thus, the course content focused on teaching motivational interviewing skills, a strongly evidence-based approach that emphasizes development of a skill set to evoke and support client-driven change (Miller & Rollnick, 2013). This same set of skills fosters the ability to ascertain meaning, address unclear circumstances, and negotiate conflict.
Core faculty designed the interprofessional education course to maximize in-class student-to-student interactions. Preclass preparation required completion of readings, workbook exercises, and videos reviewing the week's key content. Classes opened with mini-lectures, followed by brief discussions, with most of the time dedicated to the practice of motivational interviewing skills. Motivational interviewing skills that were taught included listening intently, using body language to suggest openness and acceptance, asking open-ended questions to elicit the client's meaning, responding to discord and ambivalence, and evoking change talk.
Motivational interviewing skills practice sessions were followed by peer debriefings that identified strengths and areas for improvement. Students addressed authentic, personally meaningful questions, alternately taking the role of practitioner and client in these conversations. Debriefing sessions allowed students to develop the skills needed to negotiate discord and build consensus in teams through giving accurate and respectful feedback. Student groups also were assigned to develop a treatment plan for case scenarios that addressed disciplinary foci. In this way, students moved in and out of their disciplinary identities to apply the course content with uni- and interprofessional approaches. Another feature of this course was the inclusion of content on cultural sensitivity through readings, discussions, and assignments.
We planned the features and structure of the class to facilitate a supportive, balanced interprofessional learning environment. This began by creating balanced enrollment of professions, allocating equal slots for each group. Although we were successful in selecting a time and a central campus location that allowed almost all professions to participate, social work students had a conflict with the course schedule. In class, faculty modeled nonjudgmental interactions with each other and supported this behavior in all interactions. As noted previously, students and instructors moved in and out of the practitioner and client roles within practice sessions. This first-person learning allowed students to build greater insight and empathy for client struggles and challenges in creating life change as they considered how they might address their own wellness and time management issues. Learning activities that included ethical dilemmas or other practice quandaries shared by students and faculty during class were discussed openly, without encouraging pursuit of a single “right” solution but instead considering the complexity and conflicts of each case.
Finally, in designing the evaluation of course outcomes, we selected the best available assessments of empathy, competence in motivational interviewing, and perceptions of interprofessional practice. For this analysis, we reported outcomes from the Jefferson Scale of Physician Empathy: Health provider—student version (Fields et al., 2011) and the Student Perceptions of Interprofessional Clinical Education—Revised (SPICE-R; Dominguez et al., 2015). To assess motivational interviewing skills, we used a performance-based assessment, with two simulated patient encounters that were videorecorded and rated with the Motivational Interviewing Treatment Integrity instrument, version 4.1 (Moyers, Manuel, & Ernst, 2014), by a trained motivational interviewing practitioner, and a self-rated measure of confidence in motivational interviewing skills; the findings are reported elsewhere (Larson & Martin, 2017).
Table 1 describes how this course uses the best practices recommended for interprofessional education in content, contextual qualities, infrastructure and evaluation of outcomes, and learning activities or course strategies.
This project was awarded an exemption by the institutional review board. Therefore, participants were anonymous and student grades were not linkable to survey data.
Students from the course faculty's affiliated professional schools were eligible to enroll. Because of classroom size and the desired interactive learning environment, enrollment was limited to 15 students. Students were enrolled on a first-come, first-served basis. Two student cohorts completed this interprofessional course, for a total of 27 students (25 female and 2 male). Across professions, 33.3% of students were from occupational therapy, 33.3% were from counseling or school psychology, 8% were from nursing, and 26% were from pharmacy. Because nearly all (99.6%) were in the final year of didactic professional training, most students had some beginning clinical training.
Students completed two measures to assess the course outcomes of empathy and attitudes toward interprofessional education. Students were sent e-mails requesting that they complete the online surveys before the course and after grades were posted. To preserve anonymity, students entered three text strings at the start of the survey to allow matching of their pre- and postcourse responses for analysis.
Jefferson Scale of Physician Empathy: Health Provider—Student Version. Empathy is believed to be essential to the development of high-quality client-practitioner relationships (Hojat et al., 2002). Motivational interviewing focuses on fostering a deeper capacity to communicate “hearing” and reflecting on the client's meanings, values, and beliefs. Interprofessional collaboration is enhanced by the ability to demonstrate this skill with clients and other professionals.
At the time of this project, the Jefferson Scale of Physician Empathy was the only empathy measure validated for an interprofessional health professions group. This 20-item measure uses a 7-point rating scale (strongly agree = 7 to strongly disagree = 1) and has good internal consistency (Cronbach's coefficient alpha = 0.78) and test-retest reliability of 0.58 within a 3-month period. Sample items include the following: “Attention to patients' emotions is not important in a patient interview” (reverse coded) and “Patients feel better when their health care providers understand their feelings.” No differences were noted on the scale for college degree or ethnicity; however, women and those older than 40 years had significantly higher empathy scores (Fields et al., 2011).
Student Perceptions of Interprofessional Clinical Education—Revised (SPICE-R). The 10-item self-report measure SPICE-R is recommended to examine changes in students' perceptions of interprofessional education and collaborative practice over time as well as perceptions of interprofessional teamwork, roles and responsibilities, and patient outcomes from collaborative practice (Fike et al., 2013; Zorek et al., 2016). Items are rated on a 5-point scale from strongly disagree (1) to strongly agree (5). The reliability of this measure is reported as very good (Cronbach's alpha = 0.84; Fike et al., 2013).
Survey response rates pre- and postinstruction were 100% (N = 27) and 52% (n = 14), respectively. Because of institutional review board restrictions, students could not be required to complete the survey for course points. Despite multiple reminders, some students did not complete the postcourse surveys. Using baseline student responses, the empathy scale exhibited Cronbach's alpha of 0.63, and the interprofessional perceptions survey exhibited Cronbach's alpha of 0.70. These values were calculated with the statistical software Psych, version 1.6.9 (Revelle, 2016). All preand postcourse responses were perfect and fuzzy matched with text strings provided by students; fuzzy matches were used when the three text strings created did not match 100%.
After reverse coding was performed for 8 items, summed scores and paired t tests for the Jefferson Scale of Physician Empathy were calculated with R (R, version 3.3.2; R, 2016), which was also used for the other analyses. Students rated themselves high overall on empathy, with the highest agreements found with items relating to paying attention to patients' emotions and feelings and how this positively affects treatment outcomes. No significant difference was observed for the summed empathy scale scores (p = .58) from pre- to postcourse (precourse = 118.37 ± 7.35; postcourse = 120.43 ± 5.57).
On the SPICE-R, a significant difference was noted for students' attitudes in pre- and postcourse overall summative scores (p ≥ .000; Table 2). Of the 10 items, 5 were also statistically significant pre- and postcourse. Students expressed greater agreement that it was important for teams to collaborate, reported that they had a better grasp of their role on collaborative teams, expressed stronger beliefs that teamwork would increase patient satisfaction, and believed more strongly that this interprofessional education enhanced their future teamwork (p ≥ .03-.000). Students also highly valued their clinical rotations as a forum for using interprofessional collaborative skills, expressing even stronger agreement by the end of the course. These students appeared to desire further training on clinical teams to advance their newly developed motivational interviewing and teamwork skills.
Summary of Means and Paired t Test Results for Student Perceptions of Interprofessional Clinical Education—Revised
On several items where students had initially high levels of agreement (the belief that working with students from other professions enhances one's education, the clarity of other professions' roles on the team, and the importance of opportunities to work on teams with other professionals during education), no significant change in ratings was noted after the course. This is not surprising, given the initial high ratings and thus the potential ceiling effects.
Through a year's collaboration, our faculty team built an interprofessional course that used training in motivational interviewing, a strongly evidence-based approach for promoting behavior change, to foster key skills that professional students need to achieve competence in interprofessional communication and teamwork. This course successfully addressed several interprofessional competencies, including developing better communication skills, which fostered better teamwork, problem-solving skills, and management of difficult situations, and the use of case-based exercises to promote students' discernment of their own and others' roles in working with clients. The success of the course was evident in our findings. After the class, these preservice multiprofessional students rated themselves on the SPICE-R as having a greater understanding of their own roles on teams, were more strongly invested in the importance of collaborative teamwork, rated themselves as having more teamwork skills, and believed that teamwork enhanced patient satisfaction. In addition, the findings suggest that students developed beginning or advanced competencies in motivational interviewing skills (Larson & Martin, 2017). Although we were initially surprised by the lack of increase in self-rated empathy, there is likely a self-selection bias (i.e., students pursuing careers in the health professions already may possess highly empathic beliefs and values).
Similar to other studies, our students rated themselves as showing greater appreciation of interprofessional education and practice. However, unlike previous studies, our students retained a strong professional identity after this interdisciplinary experience. Based on our findings, this course both supported students' understanding of their own identities and bridged the tribal divides between professions. It is likely that the sustained class interactions over a semester fostered the students' communication skills, building their teamwork skills during class exercises and developing their capacities to discern team roles, unlike the shorter interprofessional education programs that led to valuing interprofessional education but also role diffusion and confusion (Bondoc & Wall, 2015; Gunaldo et al., 2015; Kraft et al., 2013; Ponzer et al., 2004). Shorter experiences in preservice education may not provide sufficient in-depth experiences to build trust, create understanding of the professional scope of practice, or develop the communication skills necessary to deal with discord and disagreements effectively.
The National Center for Interprofessional Practice and Education (2017b) noted that “a very real and substantial gap exists between health professions education and health care delivery in the United States.” This gap also may be the result of institutional and social barriers in our professions and preservice education, such as the uniprofessional regulatory and accreditation standards that determine curricular content and in turn faculty teaching, the fragmented nature of preservice programs that make it difficult to match schedules and learning priorities and share resources; and current professional socialization practices and turf issues within academic and health care systems (VanKuiken, Schaefer, Hall, & Browne, 2016). In creating this elective course, we overcame some of these barriers—including matching schedules and learning priorities and addressing turf issues—but not larger organizational issues (e.g., creating a required interprofessional course). Creating, coordinating, and teaching curricula in the health professions are complex endeavors. Adding required and intentional interprofessional elements that are integrated across multiple health care programs requires an organizational restructuring of teaching resources and schedules and a commitment of resources (Paul & Peterson, 2002). Leadership and committed champions within the university are needed to navigate these issues and sustain these curriculum changes over time (Ho et al., 2008).
This study had limitations. First, although all students completed precourse surveys, fewer participated in post-course surveys. Other limitations included the potential for students to respond in socially desirable ways on measures and the use of peers rather than clients in practice sessions, although these peer conversations were authentic in discussing real-life issues. However, our study went beyond previous work in fully articulating course instruction and design, using current best practice guidelines for interprofessional education, and using well-validated instruments to assess outcomes. Further projects need to discern best practices in interprofessional education course design and the efficiency of training models to prepare students for interprofessional practice. Given the high priority of developing high-quality interprofessional practice in health care, we must not only use the best available assessment tools but also engage in long-term follow-up to answer these questions.
Recognition of the need to create a more coordinated effort in interprofessional education has led to the development of guidelines (Spelt, Biemans, Tobi, Luning, & Mulder, 2009; World Health Organization, 2010). World Health Organization guidelines and a recent systematic review of teaching in interdisciplinary higher education offer insights into best practices for designing interprofessional education courses; these include the use of adult learning strategies, such as problem-based learning; the use of authentic and real-world application of knowledge; and the promotion of student-to-student interactions (Rosenfield, Oandasan, & Reeves, 2011; Solomon & Salfi, 2011; World Health Organization, 2010). We have developed a course that uses these strategies through teaching an evidence-based, client-centered empathetic clinical approach that enhances communication, even when there is a lack of clarity or when disputes occur. Given the importance of communication in the collaboration of health care teams in service with and for their clients, a motivational interviewing course is an ideal interdisciplinary course for universities to offer. Designing, offering, and sustaining this type of course requires commitment and cooperation among the university professional programs. Our course may serve as a beginning model for universities that are intent on designing courses to improve health collaboration among professional students. Such an effort seems long overdue—the calls for interprofessional education are nearly 40 years old—but the good news is that there appears to be a growing determination and mandate to provide resources and support for such initiatives in the United States and around the world.
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|Curriculum elements||Course strategy/learning activities|
| Active student-to-student engagement|
Weekly peer-to-peer practice of motivational interviewing skills
Peer debriefing of in-class practice, with feedback provided with a motivational interviewing approach
Peer review of video motivational interviewing interviews
| Authentic experiences|
Weekly motivational interviewing practice with questions relevant to the student's life and practice (e.g., What would make you a better practitioner? How could you change your daily routine to improve your quality of life?)
Videotaped motivational interviewing interview assignment
Performance-based midterm and final assessment with simulated patients
Faculty team-taught sessions, modeled collaboration, and supplemented student discussions with additional interdisciplinary perspectives on case studies
Discipline-specific solutions to case studies developed by student teams and presented to the class for feedback
Collaboration of cross-discipline dyads of students to develop motivational interviewing approaches to case studies
Skills training (use of open-ended questions, affirmations, reflections, and summarizing) to elicit meaning, responding to discord and ambivalence, and evoking change talk
| Cultural competence|
Cultural interview of someone who identifies strongly with a particular identity that the student does not share
Cultural competency readings and discussions to increase cultural awareness and sensitivity
Case study discussion with Kleinman's (1988) Illness questions and The Spirit Catches You and You Fall Down (Fadiman, 1997) to understand the meaning of the disability to the family
| Interdisciplinary content and valuing the other's knowledge base|
Faculty team discipline/research presentations of the use of motivational interviewing
Presentation and examination of motivational interviewing research within the student's area of focus
Cross-disciplinary course readings
Student discussion of ethical dilemmas from practice
The Spirit Catches You and You Fall Down case study: discussion of approaches to fostering collaboration with the family to develop a plan to address outcomes in each discipline's area of practice
| Balance of professions|
An equal number of slots in the course reserved for each profession
| Nonjudgmental, supportive environment|
Mini-lecture and skills training on developing the spirit of motivational interviewing (presence, interest, curiosity, and respect)
Faculty modeled/supported “spirit of motivational interviewing” in all course interactions
| Tolerance of diversity|
Mini-lecture: effect of practitioner traits on the therapeutic alliance
Cultural competence assignments (as noted earlier)
| Equal status for all learners|
Students engaged in practitioner and client roles during motivational interviewing practice
Conducted at a time when most professions did not have opposing courses scheduled
| Team taught|
Two lead instructors and four discipline-specific course collaborators representing counseling psychology, nursing, occupational therapy, pharmacy, and social work
In-person course taught at an accessible campus location
|Evaluation of learning outcomes|
| Direct observation, indirect assessments|
Performance-based midterm and final simulated patient motivational interviewing interview
Pre- and postcourse surveys: Jefferson Scale of Physician Empathy: Health provider—student version, the Motivational Interviewing Confidence Scale (Martin & Larson, 2015), the Student Perceptions of Interprofessional Clinical Education—Revised (SPICE-R)
Summary of Means and Paired t Test Results for Student Perceptions of Interprofessional Clinical Education—Revised
|Survey item||Preinstruction, mean (N = 27)||Postinstruction, mean (n = 14)||t||Paired t test p (n = 14)|
|1. Working with students from another health profession enhances my education||4.59||4.93||−1.88||.08|
|2. My role within an interprofessional health care team is clearly defined||3.41||3.86||−2.46||.03*|
|3. Health outcomes are improved when patients are treated by a team that consists of individuals from two or more health professions||4.33||4.71||−1.47||.16|
|4. Patient satisfaction is improved when patients are treated by a team that consists of individuals from two or more health professions||4.63||4.86||−2.28||.04*|
|5. Participating in educational experiences with students from another health profession enhances my future ability to work on an interprofessional team||2.81||3.57||−4.19||.00**|
|6. All health professional students should be educated to establish collaborative relationships with members of other health professions||3.85||4.36||−1.88||.08|
|7. I understand the roles of other health professionals within an interprofessional team||4.81||4.79||0.56||.58|
|8. Clinical rotations are the ideal place within their respective curricula for health professional students to interact||3.37||4.21||−4.77||.00**|
|9. Health professionals should collaborate on interprofessional teams||4.07||4.64||−2.86||.01**|
|10. During their education, health professional students should be involved in teamwork with students from other health professions to understand their respective roles||4.70||4.71||0.43||.67|