Interprofessional Teamwork Skills As Predictors of Clinical Outcomes in A Simulated Healthcare Setting
Interprofessional Teamwork Skills As Predictors of Clinical Outcomes in A Simulated Healthcare Setting
Interprofessional Teamwork Skills As Predictors of Clinical Outcomes in A Simulated Healthcare Setting
PURPOSE: Teaching interprofessional teamwork skills is a TEAMWORK SKILLS are essential components of effective
goal of interprofessional education. The purpose of this interprofessional collaboration. Communication failures
study was to examine the relationship between IP team- and break-downs in team functions have been associated
work skills, attitudes and clinical outcomes in a simulated with medical errors.1–3 The Institute of Medicine endorses
clinical setting. METHODS: One hundred-twenty health
effective communication and teamwork as essential com-
professions students (medicine, pharmacy, physician assis-
ponents for the delivery of high quality and safe patient
tant) worked in interprofessional teams to manage a
“patient” in a health care simulation setting. Students com- care.4 Interprofessional competency frameworks developed
pleted the Interdisciplinary Education Perception Scale in Canada and the United States both include teamwork
(IEPS) attitudinal survey instrument. Students’ responses skills as fundamental competencies for successful interpro-
were averaged by team to create an IEPS attitudes score. fessional collaboration.5 Six national associations of schools
Teamwork skills for each team were rated by trained of the health professions formed a collaborative promoting
observers using a checklist to calculate a teamwork score interprofessional education, the Interprofessional Educa-
(TWS). Clinical outcome scores (COS) were determined tion Collaborative (IPEC).6
by summation of completed clinical tasks performed by the Health professions students need opportunities to
team based on an expert developed checklist. Regression acquire and apply teamwork skills suitable for interprofes-
analyses were conducted to determine the relationship of
sional collaborative practice, particularly within patient
IEPS and TWS with COS. RESULTS: IEPS score was not a
care contexts. High-fidelity simulators offer a unique learn-
significant predictor of COS (p=0.054), but TWS was a sig-
nificant predictor (p< 0.001) of COS. Results suggest that ing experience for health professions students. A human
in a simulated clinical setting, students’ interprofessional patient simulator is a mannequin interfaced with a com-
teamwork skills are significant predictors of positive clinical puter program that can produce physiologic responses to
outcomes. CONCLUSION: Interprofessional curricular student actions including changes in the mannequin’s sim-
models that produce effective teamwork skills can improve ulated heart rhythm, blood pressure, respiratory rate, pulse
student performance in clinical environments and likely and heart sounds. Human patient simulators provide a con-
improve teamwork practice to positively affect patient care text for students to assume the responsibility for patient
outcomes. J Allied Health 2013; 42(1):e1–e6. care without compromising the safety of the patient, and to
practice the role of a specific health profession in a patient
care team.7 Furthermore, the simulators present a rich
learning environment for the application of teamwork skills
Dr. Shrader at the time of this project was Associate Professor, South in an interprofessional context. Few interprofessional simu-
Carolina College of Pharmacy, at Medical University of South Carolina, lations that include health professions students are reported
Charleston, and she currently is Associate Professor, University of Kansas in the literature and the majority of results are limited to
School of Pharmacy, Lawrence, Kansas. Dr. Kern is from the Department
of Family Medicine, Dr. Zoller is Professor, College of Health Profes-
pilot data. Reports suggest that health professions students
sions, and Dr. Blue is from the Office of the Provost and Department of learning in interprofessional simulated environments has
Family Medicine, Medical University of South Carolina, Charleston, positive outcomes in that students enjoy the experience,
South Carolina. their attitudes toward interprofessional collaboration
improve, and team communication skills improve.8–12
This study was supported by an AAMC Southern Group on Educational
Affairs (SGEA) Research in Medical Education (RIME) grant.
Team training, including the use of simulations, for
licensed healthcare professionals has been associated with
RN1201—Received Jun 21, 2012; accepted Sept 18, 2012. improvements in patient outcomes and a decrease in
adverse events.13–16 Compared to the data for practicing
Address correspondence to: Sarah Shrader, University of Kansas, KU healthcare teams, student outcomes related to evaluation of
Medical Center, 3901 Rainbow Blvd, MS 4047, Kansas City, KS 66160,
USA. Tel 913-588-9829, fax 913-588-2355. Sshrader2@kumc.edu.
teamwork and clinical outcomes using simulations is lim-
ited. A study of medical students used a simulated health-
© 2013 Association of Schools of Allied Health Professions, Wash., DC. care environment and determined an association between
e1
positive teamwork skills and positive clinical perform- what each profession may contribute to patient care). After
ance.17 Within an interprofessional education context, the orientation, the interprofessional teams were directed to
what might be the clinical performance of students from the patient room where each was provided with the patient’s
different professions working together as a team in a simu- medical record and given 10 minutes to review and begin
lated environment? The purpose of this study was to deter- team discussions. After 10 minutes, the simulation com-
mine if interprofessional teamwork skills, including atti- menced and the team cared for the simulated patient just as
tudes, predict clinical outcomes for the simulated patient they would for an actual patient during hospital rounds.
being cared for by the student interprofessional healthcare They conducted a patient interview and physical examina-
team. The specific hypotheses were: tion, ordered laboratory and diagnostic tests, observed vital
signs on the patient monitor, and ordered medications.
1) Interprofessional teamwork by students will positively Teams were instructed to use a whiteboard serving as the
influence clinical outcomes as measured by team scores on official patient order sheet to record team treatment deci-
observational checklists. sions. Each team encounter was video-recorded. The inter-
2) Positive attitudes toward working with students from differ- professional team was allotted 20 minutes to stabilize and
ent professions will positively influence interprofessional
treat the patient; then course instructors debriefed the team.
teamwork by students as measured by surveys and checklists.
Instructors were guided to debrief the team on both inter-
professional/team communication and clinical skills. The
Methods simulated interprofessional rounding experience was devel-
oped around a case in the medical safety literature where the
The study took place on an academic health science
patient was unstable due to a gastrointestinal bleed caused
campus that is implementing a major interprofessional edu-
by a medical error and medicine interaction.20,21 The patient
cation initiative across its six colleges.18 Students in this
scenario was complex and required expertise from multiple
particular interprofessional activity had participated in the
health professions for the best outcomes.
university’s Interprofessional Day (IP Day) as first and
where applicable, second year students (medical and phar- As part of the study, students were asked at the time of
macy students).19 During first year and second-year student the activity orientation, to individually complete the Inter-
IP Day, students learn more about each other’s profession disciplinary Education Perception Scale (IEPS).22 In addi-
and the importance of interprofessional collaboration in tion to the IEPS items, this instrument also contained items
healthcare; students do not engage in specific teamwork to collect demographic information about the student: age,
activities as part of the event. None had experienced inter- race, and gender. The IEPS instrument was used as a meas-
professional teamwork in a purposeful manner during clini- ure of students’ attitudes toward collaboration since it has
cal rotations, as this requirement similarly was not in place been widely used in the literature to assess learners atti-
during their education. tudes.23,24 It consists of 18 items and measures students’ pro-
One hundred and twenty health professions students fessional perceptions (scale used 1=strongly disagree;
including fourth-year medical students (n=25), third-year 5=strongly agreed)25 relative to their own profession and
pharmacy students (n=76), and first-year physician assis- other health professions through four scales: 1) competence
tant (PA) students (n=19) participated in a high-fidelity and autonomy, 2) perceived need for cooperation, 3) per-
simulation, caring for a patient like they were attending ception of actual cooperation, and 4) understanding others’
hospital rounds. All of the pharmacy students were required values. Since our unit of analysis was the team and the
to participate as part of a required clinical assessment team’s performance, students’ individual responses to items
course; the fourth-year medical students and first-year were grouped by student interprofessional team and then
physician assistant students were required to participate averaged to determine a team IEPS score (IEPS).
depending on what experiential rotation they were com- A clinical outcomes checklist was developed by the
pleting. All students involved were provided with forma- investigators to determine the effectiveness of each team’s
tive evaluations of their performance; no students were for- decision making in the patient care process. The checklist
mally graded on the simulation. The students were divided was validated by interprofessional faculty experts in the
randomly into twenty-four teams consisting of five mem- fields of primary care, cardiology, and emergency medicine
bers (one medicine, one PA, three pharmacy students). using a modified Delphi technique. The patient scenario
Each team was newly formed and members did not have was provided to the faculty experts along with potential
experience working together prior to the simulation. The clinical steps and each expert was asked to rate the impor-
study was approved by the institutional review board. tance of each clinical step for stabilizing the patient. The
The interprofessional teams participated in a 15-minute checklist consisted of 20 items and corresponded to clinical
orientation in which a course instructor explained the steps, including medication administration that would pro-
objectives of the experience and the function of the simula- vide an optimal patient outcome. The clinical items were
tor mannequins. The students also conducted team intro- weighted depending on how critical they were for patient
ductions and discussed potential interprofessional team roles care to acutely stabilize the patient. For example, ordering
(e.g., establish a team leader, recorder for medical orders, intravenous fluids and Vitamin K were weighted more
1=very poor (basically did not occur); 2=poor (occurred minimally); 3=acceptable (occurred throughout but not consistently); 4=good
(occurred majority of time); 5=excellent (occurred consistently).
Team Structure 1 2 3 4 5
Team leader established and evident (ok to shift over course of interview, leader still clear)
Roles and responsibilities established (support member roles clear; pharmacists give drug
recommendations, a member transcribes chart orders, etc.)
All clinical roles represented (e.g. patient interview, medication history/review; diagnostic
exam; treatment plan)
Clinical roles shared among members of the team (e.g. more than one person fulfills roles above)
Actively share information among team members (e.g. shares results of EKG or physical
exam with entire team)
Leadership (the team leader) 1 2 3 4 5
Balances workload with team (team leader not dominating entire encounter)
Delegates tasks, unanswered clinical questions as appropriate (e.g. MD/PA seeks drug
information from pharmacy students)
Conducts briefs, huddles and debriefs throughout the patient encounter (summarizes, team
reviews thoroughly/systematically what has happened, what still needs to be addressed, etc)
Empowers team members to speak freely and ask questions (minimal time spent dominating
encounter and providing one-way orders just coming from leader)
Situation Monitoring 1 2 3 4 5
Includes patient in conversation and the encounter (should occur throughout the scenario)
Cross monitors fellow team members (other team members find out information being
exchanged and decisions being made in side conversations)
Update team members on patient status (e.g. blood pressure is dropping)
Team members share focus on patient problem and outcome (e.g. all focused on bleeding
rather than side issues)
Mutual Support 1 2 3 4 5
Members provide task related support (e.g. PA may do diagnostic checks after MD to see if agree
with findings, pharmacy student may help the order transcriber write appropriate med orders
without using unapproved abbreviations)
Advocates for the patient (e.g. “let’s think about what’s in the patient’s best interest”)
Team members are properly assertive (e.g. willing to participate, speak up, acknowledge
disagreement with team members assessment, actively and openly discuss alternatives)
Collaborates with team members (e.g., discuss things among each other in smaller groups first)
Communication 1 2 3 4 5
Introduction of team members to patient
Members provide brief, clear, specific and timely information/recommendations to other members
Members seek information from all available team members (e.g. ask for help; second set of eyes;
solicit opinions)
Verify information that is communicated is accurate (e.g. clarify when there uncertainty or
disagreement, information is verified and confirmed)
Member side conversations are openly communicated with team as a whole
Overall Total Score