Call the On-Call: a study of student learning on an interprofessional training ward

ABSTRACT

Interprofessional training wards are designed to train students’ team and communication competences. Such wards are generally highly valued clinical placements by undergraduate students; however, evidence in the literature suggests that medical students experience a lack of profession-specific tasks on these wards. Moreover, students lack structured training in the complexities of everyday communication where different health professions rarely are present together in stable teams. This paper reviews one strategy to train students in interprofessional communication while letting students perform profession-specific tasks. A qualitative study with ethnographically-collected data was conducted among three interprofessional student teams over three two-week periods, mixing field observations (75 h), interviews (n = 16), and field notes (45 pages). The findings show that students gained insights into new aspects of their professional roles and an appreciation of clear and open interprofessional communication over the telephone. Learning was facilitated through being confronted with new situations and discussing these experiences with each other over time. Call the On-Call as a pedagogic activity provided not just medical students, but also nursing students with new types of profession-specific tasks on the interprofessional training ward.

KEYWORDS:

• Interprofessional training
• interprofessional communication
• learning activity
• ethnography

Introduction

Over the last few decades there has been a growing recognition that students of the health professions need to get training in interprofessional collaboration already at the undergraduate level (Reeves, Tassone, Parker, Wagner, & Simmons, 2012). One major reason for this is that the traditional approach of educating health professionals in uniprofessional silos has been found to cultivate a culture of ineffective interprofessional collaboration with direct negative consequences for patient safety (World Health Organization, 2010). Therefore, a wide variety of interprofessional educational (IPE) programs have been created at medical schools across the world in the last 20 years (Thistlethwaite, 2012). The aim of IPE is to enable students to develop collaborative competences, the ability to understand and appreciate the role of one’s own as well as other health professionals in providing quality patient care, and to collaborate with other professions. A key skill to develop collaborative competences is good communication skills (Freeth, Hammick, Reeves, Koppel, & Barr, 2005; Suter et al., 2009). In this paper we explore how the Call the On-Call activity generated interprofessional learning. .

Interprofessional learning environments are designed to promote a safe space for students to work in a process-based manner with realistic tasks. A non-threatening learning environment is thus seen as a cornerstone for creating successful IPE. There is also widespread consensus that IPE needs to give students the opportunities to interact in realistic clinical environments while encountering “real world” situations of collaboration (Clark, 2009; Hammick, Freeth, Koppel, Reeves, & Barr, 2007; Reeves, Freeth, McCrorie, & Perry, 2002). Moreover, IPE is commonly conceptualized as process-based, and it is the process itself of trying to collaborate with other professions around clinical cases that constitutes the learning. This process is often understood as some variant of a learning cycle whereby students alternate between experiencing collaboration and subsequently reflecting upon those experiences, and thus students are learning the meaning of teamwork while also experiencing it (Kolb, 1984). Additionally, the reflective component involves stepping back and analyzing new experiences, reflecting upon and observing these experiences from different perspectives, and then integrating these reflections into abstract understandings that eventually can be used to solve the problems better next time (Clark, 2009). Reflection is often seen as an important aspect not just of interprofessional learning, but also of well functioning teams in clinical practice (Freeth et al., 2005).

Interprofessional training wards (IPTWs) are clinical placements where students from various health professions learn collaboration skills by working together under supervision to take care of real patients on a hospital ward. Although varying slightly in structure and patient populations, IPTWs have certain features in common. On these wards, students from the later parts of undergraduate training in various health professions – for example, medicine, nursing, physiotherapy, and occupational therapy – typically spend a two-week clinical placement together. This educational design is explicitly informed by the core concepts of IPE as outlined above – that learning is an experiential and social process that is most effectively enabled in realistic learning situations (Clark, 2009; Freeth et al., 2005; Oandasan & Reeves, 2005). A core idea behind IPTWs is that “the best way of learning to work together is by doing it” (Carpenter & Hewstone, 1996, p. 240; see also Wilhelmsson et al., 2009).

IPTWs were first designed and pioneered at University Hospital Linköping in Sweden in 1996 (Wahlström, Sandén, & Hammar, 1997; Wilhelmsson et al., 2009). Since then, several hospitals and nursing homes have been inspired to set up similar units elsewhere in Sweden (Ponzer et al., 2004), Denmark (Jakobsen, Hansen, & Eika, 2011), England (Reeves et al., 2002), and Australia (Brewer & Stewart-Wynne, 2013). In addition to the term IPTW, as used here, these wards can go by several names, including Interprofessional Training Units and Clinical Education Wards.

Background

Studies on IPTWs show that most students report having a clearer picture of their own and other students’ professional roles after the placement (e.g. Ericson, Masiello, & Bolinder, 2012; Hallin, Kiessling, Waldner, & Henriksson, 2009). Most students also report that they appreciate the team training (Ericson et al., 2012) and that they feel that they have improved skills for interprofessional collaboration after the placement (Hallin et al., 2009; Jacobsen, Fink, Marcussen, Larsen, & Bæk Hansen, 2009).

Other aspects of the clinical learning environment that have been described in previous studies on IPTWs include the importance of a safe learning environment and status equality among students (Jakobsen, Larsen, & Hansen, 2010) as well as the importance of physical proximity among the students “rubbing shoulders during a fortnight” (Pelling et al., 2011). The fact that students spend time together in the same place is seen as crucial for their collaborative work – they constantly have each other close at hand, which facilitates an ongoing dialogue (Falk, Hult, Hammar, Hopwood, & Dahlgren, 2013; Reeves et al., 2002).

The critique of research on interprofessional collaboration and education is that “complexities such as team membership fluidity, rotation, and multiple forms of communication are generally overlooked”(p.576) (Varpio, Hall, Lingard, & Schryer, 2008). For example, on surgical wards it is common that junior and senior physicians move “across multiple spaces – from wards, operating rooms, emergency departments, and call rooms”(p. 569) – and that there is a rapid turnover of junior physicians whereas nurse teams remain more stable and anchored to a specific ward (Fernando et al., 2016). Interprofessional communication not only happens face-to-face in planned and spontaneous encounters, but also through various information technology devices. Such everyday temporal and spatial factors affect the formation of interprofessional trust and role understanding, but are seldom acknowledged in IPE programs, which tend instead to teach interprofessional collaboration in stable teams with clear definitions of tasks and roles (Fernando et al., 2016; Oandasan et al., 2009).

Because students of different health care professions are socialized into different learning cultures (Liljedahl, Björck, Kalén, Ponzer, & Bolander Laksov, 2016; Liljedahl, Björck, Ponzer, & Bolander Laksov, 2017), it could be argued that their experiences in IPTWs might differ in authenticity. This problem is recurrently identified in IPTW studies showing that students report feeling frustrated if they feel the training is not realistic or relevant for them (Lidskog, Löfmark, & Ahlström, 2008). Notably, several studies have reported on medical students’ dissatisfaction due to a perceived lack of profession-specific tasks and supervision, especially in the evenings when there is no supervising physician present on the IPTW (Falk et al., 2013; Hylin, Nyholm, Mattiasson, & Ponzer, 2007; Jensen et al., 2012; Reeves et al., 2002).

In order to address some of these problems at their particular IPTW, an interprofessional faculty at the academic hospital in question decided to develop a new pedagogic activity in 2016. The activity was named “Call the On-Call”. Specifically, Call the On-Call sought to address both the long-standing dissatisfaction among medical students about too few profession-specific activities on the evening shifts and a general lack of training in interprofessional communication over the telephone.

Aim

The aim of this study was to conduct a contextually grounded exploration of what interprofessional learning the new activity Call the On-Call generated on the IPTW and how it did this.

Methods

To explore what learning activities actually took place in everyday interactions among students in relation to Call the On-Call, we decided to conduct a study inspired by ethnography. Ethnography uses observations, interviews, and documentary data to provide detailed descriptions of what actually happens in a specific setting instead of merely what people say happens (Hammersley & Atkinson, 2007; Leslie, Paradis, Gropper, Reeves, & Kitto, 2014). The ethnographic research is inductive, which means that the researcher learns about the phenomenon under study as the data are gathered. Themes and theory emerge from the data, and this is seen as “a valuable outcome of, not a precondition for, research” (Hammersley, 1990, p. 9). Often the researcher spends considerable time (months or even years) in the field. A focused ethnographic approach, which inspired the current study, uses ethnographic methods but makes shorter field visits, relies on researchers with contextual knowledge, and focuses on specific research questions (Reeves, Peller, Goldman, & Kitto, 2013), which was the case in the present study. Ethical permission was obtained by the regional ethics board (2016/1425-31).

Context of the study

The IPTW in question is an orthopedic ward where students from programs in nursing, medicine, physiotherapy, and occupational therapy share a two-week placement. On their introductory day, students are placed into teams to which they belong during the entire two-week placement. Each two-week period, three student teams rotate on daytime and evening shifts during weekdays and the weekend (07.00–16.00 and 13.30–21.00, respectively). Regular staff run the ward during the nights. Each student team consists of a maximum of eight students, including four nursing students, one physiotherapy student, one occupational therapy student, and one or two medical students. All student categories except the medical students are in their sixth and last semester before graduation, but the intended learning outcomes for the course are the same – to learn with, from, and about each other. The medical students are in the seventh (surgical) semester after which they have two years left until graduation. During daytime shifts, supervisors from each health profession category are present on the ward, i.e. a physiotherapist, occupational therapist, medical doctor, and two or three nurses, of which one is the team leader. During evening shifts, only nursing supervisors are present on the ward – the on-call orthopedic surgeon can be reached by telephone with urgent questions. All patients are elective, meaning that they have preplanned surgeries such as a knee or hip replacement. Patients that are severely ill or have cognitive impairments are excluded from the IPTW. All patients have been informed that the ward is an IPTW and are given the choice between the IPTW and a regular ward.

The Call the On-Call activity

The new learning activity Call the On-Call on the IPTW was designed as a result of having identified the dissatisfaction of medical students with the evening shifts. It was designed as follows. During some evening shifts, after afternoon rounds on the IPTW, one medical student left the IPTW to join the on-call orthopedic surgeon. At some point during the evening shift, one of the nursing students made a phone call regarding a real or simulated clinical situation demanding a consultation with the on-call medical student, which was supervised by the orthopedic surgeon. Although the phone call involved clinical reasoning, the focus was on the interprofessional communication over the telephone and not on the medical situation per se. A paper with seven possible clinical emergency scenarios was constructed, for example, fever, urine retention, and sudden difficulty breathing. These short scenarios were brief and general, and if possible could be linked to actual patients admitted to the IPTW in order to increase the authenticity of the dialogue around the case. At the end of the evening shift, the on-call medical student returned to the student team on the IPTW to join a concluding reflective seminar. The activity had been piloted during one semester and was thus running in its second semester when this study was conducted.

Data collection

The observations were made by the first author (JI) in the course of three different teams’ placements at the IPTW during the first months of the spring semester in 2017, and this consisted in total of 75 hours of observations with field notes taken on the IPTW and 16 audio-recorded interviews with students. Throughout the observations, an observer-participant stance was taken (Hammersley & Atkinson, 2007). This involved closely following the students during their activities but not actively taking part in any clinical work. JI, who was medical student of a higher course at the time, wore the same clinical gown as the students and staff. When the students were busy doing clinical work, JI mainly remained silent, observing the talk among students. Over coffee breaks and lunch, JI either listened quietly or talked with students to build rapport and elicit their spontaneous reflections about what they were experiencing on the IPTW. When there was time as the students’ had clinical work, JI held shorter conversations and informal interviews with students to clarify what had been observed and to capture their spontaneous reflections and experiences of Call the On-Call.

Oral and written information about the research project was given to students and clinical supervisors. Patients were orally informed by the observer that she was a medical student doing research aiming to explore the students’ learning on the IPTW. Oral consent was obtained from those patients whom JI came in contact with when observing the students.

A brief thematic guide had been developed for the observations, focusing the observations on what the students said and did in relation to the activity Call the On-Call (see Online Appendix). Observations, including informal interviews, were recorded with anonymized hand-written notes about what was done and said by whom and when. JI’s reflections regarding what was observed were also noted down during and after the observations. After each observation, the notes were transcribed into field notes for analysis (Hammersley & Atkinson, 2007), amounting to 45 pages. Pseudonyms were given to students, and all names in the results are thus fictional.

In addition to observations, 16 audio-recorded semi-structured interviews were made with students in a private room on the IPTW. An interview guide was prepared with certain themes and key questions that were probed during each interview (Patton, 2002). The interview guide consisted of questions about the students’ overall impression of the IPTW, how they experienced Call the On-Call, and what they thought they had learned from Call the On-Call (see Online Appendix). Interviewees were purposefully selected so that all nursing students who had performed Call the On-Call were interviewed and so that two or more nursing students who had not themselves performed the activity were interviewed. All medical students in the three teams that were followed were interviewed. In total 10 nursing students (all female), five medical students (two female, three male), and one occupational therapy student (female) were interviewed. The interviews lasted between 10 and 25 minutes and were transcribed verbatim within a few weeks of their completion.

Finally, documentary data were gathered, such as written information about the IPTW in general and Call the On-Call in particular.

Data analysis

The data analysis was an iterative process meaning that it took place alongside the data collection, but also that we went back and back again to the original data during the analysis process (Hammersley & Atkinson, 2007). All notes and audio-recorded interviews were transcribed. By reading and re-reading the entire data set, emerging patterns were condensed into codes and themes by two of the authors (KBL and JI). Meetings were held on several occasions with the research team to discuss and reach agreement on the developing of codes and themes. Finally, all data were reviewed in relation to the final codes so that all instances of a particular theme could be identified.

Given the nature of this research, it is important to note the researchers’ backgrounds (Reeves et al., 2013). KBL is an educationalist who has an expert in qualitative research, and she has been researching healthcare since 2003. JI was a medical student at the time and also has a master’s degree in organization studies. LZ is a nurse by training and was involved in developing the activity together with ES and AS, both of whom are physicians responsible for the educational program for medical students at the hospital of the IPTW.

Findings

Call the On-Call can be said to consist of two parts – as an exercise in interprofessional communication over the telephone and as an activity where a medical student leaves the student team on the IPTW for a few hours to shadow the on-call surgeon. Both parts of Call the On-Call generated interprofessional learning among the students. The second part of the research aim, namely how Call the On Call generated interprofessional learning among the students, will be addressed in the Discussion because it requires taking a step back from the results.

New aspects of professional roles made visible

The fact that a medical student left the IPTW to join an on-call surgeon, leaving the student team with no or just one medical student had several consequences. First, it made visible new aspects of the professional roles of doctors and nurses in hospitals that were not otherwise visible in the IPTW learning space. Secondly, aside from learning new aspects of the professional role of doctors by observing and talking to the on-call surgeon, the medical students also had to face various practical aspects of on-call work themselves. On the day that they were assigned to leave the ward to go with the on-call orthopedic surgeon, one of the new profession-specific activities for the medical students became planning to leave the ward. The medical students had to plan when their profession-specific tasks were to be done and whether some of them should be delegated or postponed. For example, one medical student described during an interview how he learned from his mistake of putting his mobile phone in an unreachable pocket in his trousers underneath the sterile surgical gowns during his first surgery with the on-call:

Markus:

“But before the next surgery I thought, ‘Oh right, I have to get my cell phone out – and when can I do that? Can I scrub in first?’ There are a lot of such little practical things that one has to learn.”

During all but one observation of Call the On-Call, it became an event in itself when the medical student returned to the student team after having shadowed the on-call surgeon. This event consisted of a welcoming back followed by curious questioning by the other students and storytelling on behalf of the medical student about how it had been to join the on-call (which in most cases meant having assisted the on-call surgeon in the operating theater). This “home-coming” can be illustrated by the following observation:

A few minutes before the evening reflection is supposed to start, medical student Anna arrives short of breath to the IPTW office room, dressed in surgical gowns. Nursing students Frida, Karin, Sofia, and Malin and medical student William are in the room. They turn toward her.

Frida:

Hi Anna!

Anna:

Sorry I’m late!

Karin:

How was it?

Malin:

How did it go?

Anna tells them about the hip surgery she assisted – how “brutal” it was and how they drilled deep into the patient’s bones – by dramatically mimicking the sounds and movements of the drill. The others respond with “wow” and ask about how this and that works in the operating theater. Anna tells them about a question she got from the surgeon about a fascia in the thigh and how she had not known the answer. She gets out Sobotta’s Atlas of Anatomy from a shelf. Karin asks if a fascia is like a muscle. Anna tries to explain the difference. She points to a page in the atlas with muscles of the thigh. Sofia points to her own thigh and asks, “There or what?” They continue talking.

This observation is just one of many examples of students talking about what an on-call surgeon does, for example, conducting emergency hip surgery in the operating theater. The fact that a medical student left the ward, shadowed the on-call surgeon, and returned back to the team with stories from their experiences made visible various new aspects of the doctor’s professional role on call not only for the medical student, but for the students of other professional roles too and thus contributed to enhanced professional learning on their part.

During the hours that the medical student was gone from the ward, the situation for the nursing students changed. Several nursing students highlighted how the absence of a medical student in the team meant that they had to prioritize their questions to the medical student in a different way. In this way they got to experience the role the nurse has on the ward when the doctor is not there and having to make decisions about when to call and not to call the doctor. One nursing student describes it in the following way:

Lotta:

“When it comes to making priorities, it was actually a good thing [that the medical student was absent from the ward] – because that is how it usually works on the wards in the evenings. The doctor isn’t there. So we couldn’t have that usual fast lane of just being able to catch him/her in the corridor and quickly ask a question … Instead I really had to think. So I had to trust my own feeling about what sorts of questions I should call him/her about, and what could wait.”

Both medical and nursing students reflected on the role of the nurses in deciding when to call the on-call because the activity made visible the medical knowledge needed by nursing students in order to handle clinical situations where patients deteriorate. As one nursing student said:

Karin:

“I also learned things like … Confusion, okay, it can be due to stroke so one should check for that … and is there a dip stick taken, otherwise I should take one. Medically speaking, I learn what I should do. It is not at all obvious to me what I should do. Okay, the patient is confused – but what is it? What should I measure, what should I look for? More such exercises would be good, because this sort of thing happens all the time, that patients all of a sudden get worse … ”

Call the On-Call made new aspects of the professional roles visible to students and also made medical students more aware of practical aspects of preparing for being on call, and nursing students more aware of the needs to prioritize questions in telephone communication.

Appreciation of clear and open interprofessional communication

Call the On-Call generated greater appreciation for the importance of clear and open interprofessional communication. First, the activity made visible various difficulties of interprofessional telephone communication. Second, it made visible to students the importance of structuring reports with SBAR and the importance of an open dialogue following the SBAR report (SBAR is an acronym for Situation, Background, Assessment, Recommendation, and this is a widely used technique to structure communication in health care). Finally, Call the On-Call was accompanied by a notable curiosity and perspective-taking among the students about how others had experienced the telephone communication.

Appreciation of the difficulties of talking on the phone

When performing the phone call, the students ran into and subsequently reflected on three kinds of difficulties of having telephone conversations about medical emergencies – firstly, difficulties in making a good report, secondly, difficulties in receiving the report and deciding what to do, and thirdly, a general nervousness about communicating over the phone.

When preparing to make the phone call to the medical student on-call, and right after having made the call, nursing students spontaneously reflected upon the difficulties of delivering a clear verbal report over the phone. One nursing student described how calling the medical student on-call made her realize some of the difficulties and responsibilities of making the report:

Sara:

“The doctor wants information from us in order to be able to help the patient. It’s not like it’s just them [the doctors] who have responsibility. They want information from us so they can know what situation the patient is in. So as a nurse, I really became aware that I must know my patient.”

Other nursing and medical students reflected upon the difficulties of “knowing everything” and the risks posed to patient safety if nurses just report certain aspects of a patient’s medical situation and forget other aspects that might be essential information in the current situation.

Students also commented on the difficulties of being at the other end of the telephone, i.e. answering questions in the role of the on-call surgeon. “Hey … how does he see the patient’s medications and such things? When he’s in the middle of a surgery?” Such comments were made several times during observations and came from all four student categories. During evening reflections and coffee breaks, several medical students were observed confessing to their team members their sense of inadequacy at being able to correctly handle emergency situations in general, and over the telephone in particular. Knowing specific medications and doses, for example, was seen as difficult to remember. Also, several nurses spontaneously reflected during interviews upon the difficulties for the medical student receiving the phone calls. One nurse put it thus:

Tom:

“One realizes how hard it is to just describe some symptoms and then expect someone to decide upon what is to be done. Really difficult! So that gives one a sense of respect, and one understands how important it is to practice communicating over the phone, because it’s actually quite difficult.”

A third difficulty of calling the on-call doctor was the strong sense of nervousness about having to make phone calls to both doctors and nurses that several nursing students expressed. This nervousness seemed to be related to the situation of having to call someone that one does not know and cannot see. Having to call another health professional was described by several students as “really difficult,” “scary”, and something that made them nervous. “I hate having to make phone calls”, one nursing student said.

During observations on the ward, both nursing and medical students expressed a sense of nervousness prior to doing the Call the On-Call exercise. Then, after actually having made or received the phone call, there was often a sense of relief that it was not as difficult as they thought it would have been. Students made sense of this in terms of them knowing who the other person on the line was.

Appreciation of the role of structured communication

One of the most common reflections about interprofessional communication over the phone generated by Call the On-Call was an appreciation by medical and nursing students alike, of the function of SBAR. For example, students reflected that the situation usually was much clearer when doctors and nurses were speaking face to face on a ward because then they already know what kind of ward they are on and what their roles are. However, when a doctor answers a phone call, she/he has no idea who the nurse is or what ward the nurse is calling from. Several students said that the telephone exercise made them realize the importance of following a pre-determined structure (SBAR) so as not to forget to present important aspects of the patient’s history or current condition. Students also frequently discussed the importance of having an open dialogue over the phone. Several students emphasized that they had understood that effective telephone communication is not about the nurse reporting a situation to the doctor who then decides on the best course of action, but about being able to discuss things together.

The following conversation between nursing students Karin, Sofia, and Malin and medical student Karl upon his return to the training ward after his shadowing of the on-call illustrates what many students talked about:

Karin:

So, did you get a phone call? I missed it!

Sofia:

It felt natural [to Karl, whom she called.]

Karl:

It felt like I didn’t really help with anything.

Sofia:

No, you did. It was great.

Malin:

Oftentimes one just wants the help to think aloud together.

Call the On-Call seemed to deepen the students’ appreciation of interprofessional communication through a sort of heightened curiosity about how others had experienced the telephone conversation. A recurrent pattern of interaction among the students was that they asked and told each other about how the phone call went. This happened in spontaneous interactions in the office room, lunchroom, and corridors of the ward both on the day of the exercise and the days following the exercise and in the structured evening reflections about the exercise. In this way, even students that neither made nor received the phone call still commented at length about what experiences they had heard other students reporting and what conclusions they had drawn from having heard this.

Discussion

The aim of this study was to conduct a contextually grounded exploration of what interprofessional learning the new activity Call the On-Call generated at the IPTW, and how it did so. The main findings are that Call the On-Call generated learning among students about new aspects of the professional roles of nurses and doctors in hospitals as well as the importance of clear and open interprofessional communication over the phone. In this section, these results will be discussed in relation to previous research on IPTWs. Thereafter, how this learning happened will be discussed. Finally, strengths, limitations, and applications of this study will be discussed, as well as possible future studies.

Several previous studies of IPTWs have shown that most students report an enhanced understanding of their own role and other professions’ role after their IPTW placement (e.g. Ericson et al., 2012; Hallin et al., 2009). Enhanced role understanding was one of the main findings of this study, too. However, Call the On-Call made visible new aspects of the professional roles of nurses and doctors that the students otherwise were not experiencing or discussing on the IPTW. For the nursing students, the absence of the medical student made visible their responsibilities when being alone on the ward, e.g. how to decide when to call a doctor. This placed new demands on the nursing students, and for a few hours they could not spontaneously ask the medical student questions in the corridor but had to work more independently. For the medical student, joining the on-call surgeon for a few hours generated insights into several practicalities of on-call work, such as having to plan to leave the ward, as well as the medical knowledge needed by an on-call orthopedic surgeon.

A cornerstone of the educational design of IPTWs is that interprofessional learning best takes place in realistic settings (Hammick et al., 2007; Reeves et al., 2002). The idea is that students together should face “real problems in an everyday health-care environment” (Fallsberg & Hammar, 2000, p. 339). On an IPTW, the patients and the ward are real. However, the presence of a stable team of nurses, doctors, physiotherapists, and occupational therapists over a two-week period is far from clinical reality. In reality, it is primarily nurses that are continually present on any given ward. Doctors, physiotherapists, and occupational therapists commonly come and go in and out of the ward. This built-in lack of realistic context for interprofessional collaboration is seldom addressed in the literature. What this study adds is the description of a new pedagogic activity, during which the medical student – albeit just for a few hours – leaves the ward. The findings suggest that this, in fact, adds an opportunity for “students to act as representatives of their own profession in realistic collaborative work” (Lidskog et al., 2008, p. 495). The activity adds an opportunity for students to make visible – for themselves and each other – realistic aspects of nurses’ and doctors’ professional roles. They get to practice a situation they recognize will happen “all the time.”

In the two studies we have found on interprofessional telephone communication exercises, students report an enhanced understanding for the importance of organizing one’s thoughts before delivering an SBAR over the phone (Kostoff, Burkhardt, Winter, & Shrader, 2016; Shrader et al., 2016). Our findings also demonstrate that Call the On-Call elicited appreciation on behalf of the students for clearly describing the situation one is calling about and using SBAR systematically. In addition to this, our study found that the students do not just seem to appreciate the structure that SBAR gives. They also reflect on the importance of having an open dialogue over the phone; of daring to make suggestions to each other, of “thinking together”. Next we turn to a discussion of how Call the On Call generated interprofessional learning among the students.

Being placed in concrete situations prompted reflections and questions on behalf of the students, such as the nursing student wondering, “Hey … how does he see the patient’s medications and such things when he’s in the middle of a surgery?” Having to solve problems themselves, such as receiving a phone call, geared the students’ attention to specific practicalities, such as the medical students’ attentiveness to how the on-call surgeon handled incoming phone calls in the operating theater. These findings support previous studies and theoretical frameworks that emphasize learning as an experiential process involving “direct encounter” (Kolb, 1984, p. 5) with various situations in the world (Clark, 2009; Oandasan & Reeves, 2005). What “direct encounters” or experiences a learning environment provides thus seems to be of key importance for what the students actually learn.

Students learned together by sharing and discussing these new, concrete experiences with each other. In this way they engaged in several steps of Kolb’s (1984) learning cycle – the concrete experience, and shared reflection. In the results, we see how Call the On-Call becomes an event that the students talk about, curiously asking about each other’s experiences, recounting their own experiences, and imagining and discussing each other’s point of view and thus engage in what Kolb calls abstract conceptualization to identify what their experiences meant and how they could learn from them for future active experimentation. In this context, active experimentation would mean trying out other, new or innovative ways of solving problems in the clinical environment generally, and in communicating of the phone in future on-call situations specifically.

It seemed that being separated from each other generated a heightened curiosity about what the other had experienced when away. We see here how the learning generated by the specific activity Call the On-Call was intimately intertwined with the overall learning space on the IPTW. The learning cycle they engaged in does not, however, only focus on their individual learning, but on learning as a team, and thus they also show how they develop into a functioning team (Freeth et al., 2005). The students had developed relationships, and a sense of community with each other over time by sharing the same tasks, space, and patients. It was against this backdrop of sustained co-presence that they explored interprofessional communication at a distance, without a face-to-face encounter. For example, we saw that several students expressed that they usually feel nervous about making phone calls, but felt less nervous doing Call the On-Call because this time they knew the other person, and it was like “calling a friend”.

This talk among the students about Call the On-Call could not have been possible in the same way had they not been returning to their stable teams and meeting their team again the next day to carry on the conversations. Moreover, in the findings we saw examples of students daring to share shortcomings and difficulties with each other, enabling themselves and one another to learn from what they did not know or what they had done wrong. These aspects of the wider learning space on the IPTW echo previous findings and theorizing about the role of a safe learning environment for interprofessional learning processes to take place (Clark, 2009; Jakobsen et al., 2010). It also relates to previous research on IPTWs about the value of students “rubbing shoulders during a fortnight” (Pelling et al., 2011). Indeed, this on-going talk about Call the On-Call among the students can in itself be understood as an experience – as, as several students commented, an atmosphere of daring to talk to each other over the phone and in person. Call the On-Call can thus be understood to generate both concrete experiences of new aspects of professional roles and concrete experiences of being curious about and talking about each other’s professional roles, i.e. experiences of interprofessional communication per se.

Methodological considerations

A methodological strength of this study is that by using observations and interviews and by describing some concrete student interactions and reflections at length it adds more in-depth descriptions to the previous findings in questionnaires and interviews in the literature on IPTWs (Fallsberg & Hammar, 2000; Ponzer et al., 2004).

There are also several limitations of this study. By letting a former student do the observations there was a risk that her background as a medical student would provide a biased view. However, her familiarity with the context also enabled a focus on this particular activity and the ability to pick up the dialogue generated by it instead of being overwhelmed by other aspects of the context, which might have been the case had a non-health care professional carried out the observations. We do acknowledge that she was influenced by her own experiences and perspective on health care, and more so probably by being a medical student and not, for example, a nursing student. Therefore, the research team was constructed of researchers with different professional backgrounds. JI’s background in qualitative research from doing a master’s degree in organizational studies we believe helped in her ability to make observations.

Significance

The findings both reinforce and challenge taken-for-granted assumptions in the current literature on IPTWs, namely that IPTW students (should) share the same space at all times and that this is the best thing. The findings reinforce this assumption by highlighting how crucial the contextual grounding of being together over time is for the way the students experience and talk about Call the On-Call. However, the findings also challenge this assumption because the activity Call the On-Call illuminates new aspects of professional roles and interprofessional communication precisely by the students not being in the same space all the time and instead having to communicate over the phone. This study thus sheds light on a new type of learning activity that potentially could partly alter the way IPTWs are designed.

Conclusion

The learning activity Call the On-Call generated new insights into the professional roles of doctors and nurses as well as the importance of clear and open interprofessional communication over the phone. The activity did so by exposing students to a range of new and concrete situations that they could reflect upon because they had developed relationships with each other and had the time and space for formal and informal sharing of experiences. Thus, Call the On-Call provided not just medical students, but also nursing students with new sorts of profession-specific tasks on the IPTW. The activity provided students with experiential learning opportunities around everyday complexities in interprofessional communication that are generally overlooked in the literature on IPTWs, namely that doctors seldom are present on wards in the evenings.

Declaration of interest

The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Acknowledgments

We want to thank all the staff and students at the IPTW who so generously allowed access to their educational practice.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website.

Additional information

Notes on contributors

Josefin Ivarson

Josefin Ivarson is a junior doctor currently working in child and adolescent psychiatry. She also holds a MSc in organization studies.

Lana Zelic

Lana Zelic is a PhD candidate in medical education and works as nurse and clinical teacher at an interprofessional training ward.

Anders Sondén

Anders Sondén is an Associate Professor of Surgery and Education at Karolinska Institutet, and Senior Consultant of the Upper Gastrointestinal Unit at the Department of Surgery at Södersjukhuset, Stockholm, Sweden.  He is responsible for the Post Graduate Program of Surgery at Södersjukhuset and the course Clinical Medicine-Surgery since 2008.

Eva Samnegård

Eva Samnegård is orthopaedic surgeon with particular interest in medical education, osteoporosis and knee surgery. She is affiliated to Karolinska Institutet.

Klara Bolander Laksov

Klara Bolander Laksov is a Professor of Higher Education at Stockholm University and affiliated to Karolinska Institutet. She leads a research group that explores the interaction between system factors and individuals in the clinical learning environment and its impact on educational development and learning.