International Journal of Healthcare Simulation

Introduction

The constant evolution and multiple challenges that healthcare systems face advocate for more team-based approaches [1]. Considering that many healthcare incidents are associated with team communication problems and deficient teamwork skills, effective collaboration and communication among healthcare team members are critical components for high-quality patient care [2]. Clinical errors can cause human suffering or even death and are, nonetheless, financially costly [3,4].

Physicians, nurses and other allied healthcare professionals work together on a daily basis at the postgraduate level. Despite this fact, most undergraduate curricula are separate and the training of effective communication strategies and care participation is often postponed to the future professional practice [5]. Traditional medical and nursing education is still based in professional silos, and students have expressed concerns on their insufficient understanding of other healthcare professionals’ roles and responsibilities, materializing the need for undergraduate interprofessional education (IPE) programs [6,7].

IPE is defined by the World Health Organization (WHO) as when ‘students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes’ [8]. Creating a culture that values teamwork and mutual space for students to learn with and from one another paves the way to success in preparing future healthcare professionals [9]. Studies show that IPE increases confidence in health professionals’ identity and appreciation of the roles of other professions, and improves communication, team-working skills [8,10,11] and quality of care [12].

Simulation-based training (SBT) is a well-accepted educational strategy that promotes the development of teamwork skills [13–15], being broadly used in current IPE programs that are slowly arising in medical and nursing schools [16]. This educational strategy can be effective in improving communication and collaboration among healthcare students [17], and its integration with IPE has been extensively recommended by WHO and several scientific societies to enhance IPE outcomes [10,18,19]. Several efforts have been made to create a framework towards a standardized undergraduate interprofessional (IP) intervention [11], including using SBT [20]. Nevertheless, the implementation and sustainability of these interventions are, many times, impaired by the stakeholders involved in the organizational change [21].

In the Portuguese healthcare educational context, simulation-based IPE programs for postgraduate education are emerging and, in specific contexts, have been successfully running for over a decade [22]. Opposed to that, undergraduate IPE in healthcare is barely existent. The Portuguese medical and nursing curricula make little to no reference to IP competencies and challenges and, if addressed, are limited to elective curricular units without a holistic integration in the curricula. Although, during their clinical rotations, students from different professions share the same clinical spaces and patients, no task blending or direct interaction between them occurs.

Considering the emergent educational need and the existent guiding frameworks [11,20,21,23], a collaboration between the Faculty of Medicine of University of Porto (FMUP) and Nursing School of Porto (ESEP), Portugal, was established, and a step-wise approach for the development of an integrative and sustainable IPE undergraduate program is currently being followed. This paper describes the first step towards this goal, namely the implementation and preliminary assessment of the program ‘Lifting INterprofessional Knowledge through Simulation (LINKS)’. LINKS is a simulation-based workshop targeting IP teams of healthcare students (medicine and nursing), aiming the development of IP team practices and behavioural skills to promote effective IP teamwork. To our best knowledge, this is a pioneer initiative that may contribute to a shift in the Portuguese healthcare education paradigm.

With this preliminary study we aim to assess the educational effect of this simulation-based workshop, in medical and nursing undergraduate students’ attitudes towards IP teamwork and collaborative practices, and their perception of roles and competencies within an IP team. A secondary objective is to explore students’ opinion towards the workshop and its curricular integration.

Methods

Design

A pre–post design was used to explore changes in measures through the quantitative surveys completed by medical and nursing students that participated in the simulation-based IP workshop. A follow-up post-workshop questionnaire was used to assessed participants’ opinion. Detailed description of the data collection instruments is given below.

The outcome measurements fit in the first two levels of the extended version of Kirkpatrick’s classic educational outcomes model [24], with the quantitative surveys assessing modifications of attitudes/perceptions (L2A) and the post-workshop questionnaire assessing students’ reactions (L1).

Figure 1 presents a CONSORT flowchart for this single-arm, non-randomized, quasi-experimental study. Appendix 1 (Supplementary file) presents the extended CONSORT checklist for simulation-based research [25], for a comprehensive description of the present study.

Figure 1:

CONSORT flow diagram for a single-arm, non-randomized study of the workshop LINKS (Lifting INterprofessional Knowledge through Simulation).

Setting

Each workshop was conducted between November and December, 2021, with a duration of 4 h, at the Clinical Simulation Centre of Faculty of Medicine of University of Porto. It started with an ice-breaking activity, involving all participants, followed by two clinical simulation scenarios, specifically designed for this workshop, aiming to challenge the clinical team to apply both technical and behavioural skills. Students were not informed of the scenario in advance, and assumed roles close to their professional competencies. In each scenario, the initial assessment was conducted either by nursing students (in the role of nurses) or by a team of one nursing and one medical student (assuming the roles of nurse and doctor). Typically, with patient deterioration, the initial team called the remain element(s) and began the management of the patient. Figure 2 illustrates a simulated scenario, during one of the sessions.

Figure 2:

Illustrative image of a simulation scenario (multi-patient setting) during one session of the workshop.

The first scenario presented a patient with an anaphylactic shock followed by a cardiopulmonary arrest. This scenario explored the critical patient systematic approach and the application of resuscitation maneuvers in cardiopulmonary resuscitation context. It provided a context to reflect on how situational awareness evolved throughout the scenario, how leadership was established and how communication was developed in the various moments of the scenario.

The second scenario presented a multi-patient setting (two patients in a ward): one developing a post-op hypovolemic shock and the other requesting urgent pain control management. This provided a context to reflect on the importance of systematic assessment and re-evaluation, how the cooperation/interaction/support of team members has evolved, how the situational awareness changed throughout the scenario and how the communication of critical information (especially in a noisy environment) was established.

Each scenario took 15–20 min to unfold and was followed by a 40–50 min debriefing, conducted by a pair of experienced faculty members. The program details and approximated timings are summarized in Table 1.

Table 1:

Detailed schedule and activities of the workshop, including the study operational process (pre- and post-tests)

Component	Time	Content
Introduction (all)	20 min	Introduction to the workshop and operational processes; introduction of the study and informed consent obtained; pre-test questionnaires filled
Ice-breaking activity (all)	20 min	‘Tangled’ is an interactive activity that allows the review of team dynamics and concepts
Briefing (all)	15 min	Introduction of ground rules, overall learning objectives, confidentiality and psychological safety; familiarization with the simulation space and simulators
Simulation 1 (team of 3–4 elements)	20–25 min	Scenario: anaphylactic shock with cardiopulmonary arrest
Debriefing 1 (team of 3–4 elements)	40–50 min	Reflective discussion on team performance, based on learning objectives
Coffee break (all)	15 min
Simulation 2 (team of 3–4 elements)	20–25 min	Scenario: multiple patients (hypovolemic shock + pain control management)
Debriefing 2 (team of 3–4 elements)	40–50 min	Reflective discussion on team performance, based on learning objectives
Closing session (all)	20 min	Take-home messages; post-test questionnaires filled

Results

A total of 23 students participated in the workshop. The participants included 14 nursing students (60.9%) with mean age of 21.6 years and 9 medical students (39.1%) with mean age of 23.0 years. There was a clear predominance of the female population with a total of 19 female students (82.6%) and 4 males (17.4%), with the female population being 4.74 times higher. This is in line with the observed gender distribution in Portuguese medical and nursing schools and in health systems in general [29]. Among the participants, 21 (91.3%) reported having previous simulation experience. Of all the participants, only four (17.4%) had previous IPE experience throughout their academic training. All students indicated to be proficient in English (capable to read and understand). The relevant demographic characteristics of the participants are summarized in Table 2.

Table 2:

Participants’ demographic characteristics (n = 23)

	Medical (n = 9)	Nursing (n = 14)
Mean age (years)	23,0	21,6
Gender (n)
Female	7	12
Male	2	2
Previous simulation experience (n)
Yes	9	12
No	0	2
Previous IPE experience (n)
Yes	0	4
No	9	10

ATTITUDES and IPEC Competency scores for medical and nursing students before and after participating in IPE programs are shown in Table 3.

Table 3:

Comparison of pre- and post-simulation mean scores of medical and nursing students

			Medical (n = 9)		Nursing (n = 14)
			M (SD)	P-value	M (SD)	P-value
ATTITUDES [26] (1 to 5 scale)	Relevance of IPE	Pre	4.67 (0.27)	0.018	4.66 (0.24)	0.001
		Post	4.97 (0.06)		4.94 (0.12)
	Relevance of Simulation	Pre	4.82 (0.19)	0.038	4.66 (0.33)	0.007
		Post	5.00 (0.00)		4.89 (0.19)
	Communication	Pre	4.70 (0.31)	0.027	4.62 (0.29)	0.010
		Post	4.96 (0.06)		4.89 (0.21)
	Situation awareness	Pre	4.56 (0.41)	0.026	4.44 (0.41)	0.027
		Post	4.92 (0.18)		4.84 (0.30)
	Roles and responsibility	Pre	4.48 (0.52)	0.027	4.61 (0.32)	0.027
		Post	4.96 (0.07)		4.86 (0.26)
	Total	Pre	4.65 (0.28)	0.012	4.61 (0.21)	0.002
		Post	4.96 (0.05)		4.89 (0.16)
IPEC Competency [27,28] (1 to 5 scale)	IP interaction	Pre	3.35 (0.51)	0.007	3.89 (0.66)	0.003
		Post	4.40 (0.56)		4.64 (0.33)
	IP value*	Pre	4.01 (0.44)	0.011	4.54 (0.33)	0.010
		Post	4.61 (0.43)		4.87 (0.22)
	Total*	Pre	3.68 (0.44)	0.008	4.22 (0.45)	0.003
		Post	4.51 (0.48)		4.75 (0.24)

Scores presented as mean (SD). Pre–post-test differences, Wilcoxon signed-rank test (α = 0.05). Statistically significant results presented in bold. Difference between groups, Mann–Whitney U test (α = 0.05). Intergroup differences were found in the pre-test scores marked with *.

Wilcoxon test was used to analyse the intragroup mean difference between the pre- and post-test results. The overall and subfactors ATTITUDES and IPEC Competency scores increased significantly after IPE, for both medical and nursing students.

Mann–Whitney test was used to analyse intergroup differences, both in pre-test and post-test scores. The only statistically significant difference found was in the pre-test scores of the ‘IP value’ (IPEC questionnaire), with concomitant difference in the pre-test IPEC overall score.

Internal consistency of measures was good (Cronbach 0.8 ≤ α < 0.9) for ATTITUDES scores and excellent (Cronbach α ≥ 0.9) for IPEC scores, showing that both scales present a high reliability for this sample. Table 4 presents the internal consistency values for each scale, for both pre- and post-test.

Table 4:

Cronbach’s alpha for each scale, for both pre- and post-test

	Pre-test	Post-test
ATTITUDES	0.856	0.881
IPEC Competency	0.905	0.919

The follow-up opinion/satisfaction questionnaire had a total of 15 replies, with eight drop-outs. Overall, students agreed or completely agreed that the workshop was well-organized, with a clear and appropriate invitation, adequate bibliography sent in an attractive format (audio-visual) and adequate timing (mean: 4.60; SD: 0.37). All students agreed that this experience should be repeated within few months with different scenarios, and all but two agreed that the final year was the best timing for the workshop.

Similarly, the workshop content was rated high (mean: 4.83; SD: 0.23), with all but one agreeing that the learning objectives were clear, important and adequate (mean: 4.73; SD: 0.26), all agreeing that the scenarios were realistic, with adequate number and time (mean: 4.82; SD: 0.21), all agreeing that debriefing had a constructive approach, allowed reflection on individual and teamwork performance and was open to all contributions (mean: 4.93; SD: 0.14) and all but one agreeing that environment was supportive with psychological safety guaranteed (mean: 4.84; SD: 0.54).

All students agreed (mean: 5.00; SD: 0.00) that the workshop added educational value to their training, and recommended its integration in the formal curriculum (mean: 4.80; SD: 0.41), with a first round in the penultimate year and repeated in the last year. The open questions on ‘positive features’ and ‘needs improvement features’ were aligned with the previous opinions. The positive comments focused mostly in the IP interaction that the workshop offered (eight comments) with a few comments about the importance of debriefing (three comments) and the realism of scenarios (two comments). Possible improvements suggested by students were increasing time and frequency of the workshop (three comments), and provide additional didactics before the workshop (one comment).

Discussion

The present study explored the educational effect of a simulation-based IP workshop (LINKS), in medical and nursing students’ attitudes towards IP teamwork and collaborative practices, and their perception of roles and competencies. This study found that both medical and nursing students increased their awareness on IP practice and changed their perception of roles and competencies within an IP healthcare team. These findings are in line with the results of the studies presented in the scoping review conducted by Langton et al. [16].

ATTITUDES and IPEC Competency scores showed, for both groups and for all subfactors, a statistically significant increase between the pre- and post-test, indicating a more positive attitude towards collaborative practice. Of notice is the IPEC Competency scores prominent increase in the ‘IP interaction’ subfactor, for both students’ group. These results reinforce that ‘working’ together can enhance the individual role and responsibility within the team, and predispose to further interactions.

The analysis of the intergroup differences for ATTITUDES subfactors indicate that, overall, both nursing and medical students had similar perspectives towards IPE, simulation, communication, situational awareness and their roles and responsibilities, at the baseline (pre-intervention) and after the workshop (post-intervention). Medical students’ IPEC mean scores at baseline, for both dimensions, were approximately half-point lower in comparison to nursing students mean scores, with statistically significant differences found in the ‘IP value’ (and, concomitantly, in the overall score). One possible explanation for this result may be that internships of nursing students are, in nature, more team-based than medical students’ internships. Nursing students are involved in various tasks, stimulating their integration within the team (which includes colleagues, tutors, doctors and auxiliary personal) and even with the patient and their families. On the other hand, medical students tend to be focused in technical tasks and engage only in specific activities attributed and oriented by the tutor. Notably, these differences in the baseline become flattened after the intervention, with medical and nursing students presenting higher scores and in the same range, an indicative of reciprocal IP attitudes.

Prior to this study, only four nursing students had IPE experience, even though both groups were in their final year of undergraduate studies and had already started clinical clerkships. The lack of exposure to clinical situations, that require collaboration with other professional groups, can affect students’ perceptions of IP collaboration and practice, and reinforce stereotypes that are prejudicial to effective teamwork.

The behavioural skills imbedded in the scenarios were used to foster open communication, shared information and decision-making, and mutual respect and trust. During debriefings, students reported to have gained: (1) a better understanding of the role of the other healthcare professionals, (2) a more positive attitude towards IP teamwork and (3) confidence in their teamwork skills. Reported examples highlighted the importance of structured communication (e.g. iSBAR – identification, situation, background, assessment and request/recommendation), which allowed the nursing students to share their concerns and provide regular and accurate patient information, and the benefits of summarizations, which stimulated medical students to share information and develop, within the team, a collaborative clinical reasoning and shared mental model.

Considering the pre–post test results and anecdotal comments shared during the session, we may infer that this single IPE event contributed to a clearer understanding of the team dynamic and individual role definition, increased the motivation to engage in collaborative practice between physicians and nurses and potentially challenged pre-existent stereotypes of each professional group. These results are consistent with other studies [30–36].

The majority of the students in this study had previous experience with SBT (with the exception of two nursing students). These findings demonstrate that simulation is a well-accepted educational strategy, commonly integrated in both nursing and medical curricula. On the other hand, the same level of importance and acceptance is not observed towards IPE, marked by separate academic pathways, despite the physical proximity that some nursing and medical schools have. The results of the follow-up satisfaction questionnaire corroborate these findings. It highlighted that students understand the importance of this educational approach, requesting for more opportunities to train and practice their IP skills, especially at the end stage of the undergraduate education. Although there were eight drop-outs, this feedback is a starting point to refine the workshop and understand what should be maintained and what should be improved in future interventions.

IP teamwork training in an educational controlled setting (such as in simulation-based activities) nurtures collaborative practices and develops a clear understanding of the role and contribution of the ‘other’. The educational benefit is observed even in single, short-term IP simulation activities, such as LINKS.

We envision that the results of this study can help to inform future curriculum planning and provide useful insights that can be used within and between institutions to develop a common IP undergraduate program.

Conclusion

Most healthcare educational system focusses mainly on a single-profession scientific learning, with major gaps in collaborative and teamwork-related skills. IPE undergraduate programs can reduce these gaps, promoting a better understanding of teamwork, roles and responsibilities within a team and professional identity. This study presents a pilot approach to this modality in Portugal and identifies the positive effects of simulation-based IPEs, highlighting meaningful information that could guide to future interventions and curricula revisions.

The study findings reinforce that IP interactions in an educational setting are well-received, perceived as relevant and can contribute to demystify students’ preconceived notions or stereotypes of other professions, particularly the hierarchy of decision-making between doctors and nurses.

While a single simulation-based IP session has educational benefits, more sustained opportunities could lead to greater advantages. Including simulation-based IP programs within the clinical practice would expose and challenge undergraduate students, on a regular basis, to actively interact with other professional groups. Although challenging to current healthcare educational programs, such initiatives are needed to foster content and process changes in the healthcare professionals’ curricula, so that these skills are perceived as core elements of good practice and higher quality of care.