Nursing and medical students’ experiences of interprofessional education during clinical training in psychiatry

ABSTRACT

The aim of the study was to describe nursing and medical students’ experiences of participation in an interprofessional education (IPE) activity, “round school,” during their clinical rotations in psychiatric care. Data were collected in six focus groups with 32 students from nursing and medical programs, focusing on their experiences of the IPE activity and their reflections on interprofessional collaboration. The students considered the round school to be meaningful and true-to-life. Important conditions for learning were well-informed staff, sufficient time for preparation and feedback, clear routines, instructions, and an open climate. Non-explicit instructions and limited preunderstanding of psychiatric care left the students feeling uncertain. Students’ reflections regarding interprofessional competences encompassed both similarities and differences in roles, responsibilities, and collaboration. Evidence of hierarchical and stereotypical images of the nurse-physician relationship was identified. Round school is an example of how IPE can be integrated into the units’ regular ward rounds. However, if the clinical everyday work is not based on collaboration between different professions, it can be arduous to implement IPE. Well-planned preparations are necessary, both in the clinic and at the faculty.

KEYWORDS:

• Interprofessional education
• interprofessional collaboration
• psychiatric care
• focus groups

Introduction

Interprofessional collaboration (IPC) can be described using four dimensions: values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork (Interprofessional Education Collaborative, 2016). IPC can be taught and learned (Vogt & Vogt, 2017) and extends beyond the roles of the specific professions (Vogt & Vogt, 2017; Wilhelmsson et al., 2012). For promotion of IPC, a curriculum for health profession students has to incorporate learning activities in which students work together and improve their understanding of their respective professions thus preparing them for their coming professional life (Vogt & Vogt, 2017). Interprofessional education (IPE) is an activity through which two or more students from different professions learn with, from and about each other, with the specific goals of improving the ability to collaborate and in that way contribute to the improvement of quality of care (CAIPE. Centre for the Advancement of Interprofessional Education, 2002). There is currently little evidence regarding which methods within IPE are most effective for teaching interprofessional skills to students from different health professions (Fox et al., 2018; Reeves et al., 2017).

Background

In previous research, students have emphasized that IPE should be true-to-life and relevant, rather than theoretical (Derbyshire & Machin, 2011; Hilton & Morris, 2001; Morison et al., 2003, 2010). However, IPE is often conducted outside the clinical setting in simulations, problem-based learning, skills training, and scenarios; few authors have reported on IPE in regular clinical care (Fox et al., 2018). In psychiatric care, IPE is generally organized as simulations or workshops (Marcussen, Nørgaard, Arnfred et al., 2019).

Ward rounds have generally included education from senior physicians to junior physicians and medical students, and are traditionally the physicians’ arena (Lakshminarayana et al., 2015; Walton et al., 2016). In recent years, “round schools” with a focus on training medical students in ward rounds have been reported (Gray et al., 2020; Krautter et al., 2014). Today, the use of ward rounds for training of IPC has become more common. The training is often performed in the form of simulations held outside the clinic and has been well-received by students of both nursing and medicine (Nikendei et al., 2016; Pedersen et al., 2006; Wershofen et al., 2016). However, students have reported that the training can be artificial and idealized (Nikendei et al., 2016). Reasons for lack of clinic-based IPE can be diverse, including prioritizing profession-specific training, under-resourcing in health care, and/or a lack of clinical teachers (Fox et al., 2018; Murdoch et al., 2017). Common challenges have also been described: timetabling across multiple professional programs, lack of faculty willing to participate, and concerns over equitable distribution of resources (Fox et al., 2018; Lawlis et al., 2014; Sundberg et al., 2019).

Round school is an example of how IPE can be integrated into the units’ regular ward rounds. An important aspect of IPC during rounds is the ability to prepare, organize, communicate, teach, and work in a team (Lakshminarayana et al., 2015; Vietz et al., 2019). Integration of IPE activities into clinical training, such as ward rounds, requires clearly articulated teaching points and feedback on interactions in the team (Walton et al., 2016).

Several different professionals are involved in psychiatric care, and a collaborative practice and training in teamwork has been identified as beneficial for patients in psychiatric care (Marcussen et al., 2020). In hospital inpatient care, interprofessional teamwork is often organized in ward rounds (Walton et al., 2016). In both medical and psychiatric specialties, competences necessary for collaboration in ward rounds have been identified to be the same (Vietz et al., 2019).

In summary, IPC is important in health care today, but little is known about adequate methods for IPE, and there is a lack of clinic-based IPE activities for students during placements in psychiatric care. The aim of this study was to describe medical and nursing students’ experiences of participation in the IPE activity “round school” and their reflections on IPC.

Method

Design

This was an explorative study with qualitative analysis of data from focus groups.

Setting

At Uppsala University in Sweden, students from both nursing and medical programs participate in psychiatric clinical training. Because of differences in the curricula for the two programs, round school could not be offered to all students at all times. During 6 weeks of each semester, there were both nursing and medical students at the inpatient wards. Students in clinical practice during these weeks were offered round schools as an IPE activity. Participation was recommended but voluntary.

The round school is conducted in collaboration between a nursing student and a medical student. The learning objectives, provided in the ward round instruction were: To learn with, from, and about each other during ward rounds to raise awareness of the different professions’ assignments, responsibilities, and factors important to enable effective collaboration during rounds. The learning activity, as presented below, presumes a person-centered perspective.

All clinical supervisors had been given information about the IPE activity. Clinical supervisors were responsible for informing students about the routines for rounds and about which patients were willing to take part. The students prepared by accessing relevant information and discussing what is important from their different professional perspectives. The students meet the patient and should, in partnership with one another, suggest what to report at the ward round and suitable interventions. Their plan should include interventions based on both nursing and medical care, and the students should discuss the differences. Thereafter, during the regular ward round, the students present relevant information and suggest appropriate interventions. Afterward, students and supervisors use a guide to share their reflections regarding preparation for and execution of the round school. The focus of feedback from the supervisors (who can be nurses, physicians, or both) should be communication and collaboration between the students. The interventions proposed by the students are also evaluated.

Participants

Nursing and medical students during fall 2018 and spring 2019 who participated in the round school were invited. A total of 32 students were enrolled in the study: 13 nursing students (11 females) and 19 medical students (15 females).

Data Collection

Data were collected in six interprofessional focus groups (Kitzinger, 1994; Kreuger, 2001) from January to May 2019, led by the three authors in alternation. The number of students in each group varied between 3 and 10. A focus group protocol with open-ended questions was used. Questions corresponded to the two study aims, and encouraged students to discuss their experiences of participation in round school and their reflections on interprofessional teamwork. Probing questions were used to clarify the students’ reflections and to encourage detailed descriptions. The focus groups, lasting between 32 and 51 minutes, were audio recorded and transcribed verbatim. The transcripts were read through with simultaneous playback of the recordings to correct any inaccuracies or misunderstandings.

Data analysis

Qualitative content analysis, as described by Elo and Kyngas (2008), was used. All three authors had extensive experience teaching in the nursing (JS, CÖ) or medical programs (MR), and broad clinical competence in psychiatric care. These experiences enriched the analysis with more than one professional perspective.

First, all authors read the entire text to get a sense of whole. The analysis was based on two distinct domains from the study aims: “Experiences of participation in the IPE activity round school” and “Reflections regarding interprofessional teamwork.” Two of the authors continued the analysis separately. Through open coding, parts of the text related to the study aims were highlighted, and preliminary headings were noted in the margin. The headings were abstracted into codes and collected onto two coding sheets, one for each domain. Codes were then grouped into categories, and the two authors compared their groupings. After discussion and consensus, the coding sheets contained 6 categories. As quality control, the third author grouped all codes into the previously defined categories, without having seen the previous groupings. This step in the analysis highlighted ambiguities in the previous steps, and, after joint discussions, some codes were moved and some categories were renamed.

Ethical considerations

Approval was obtained from the Regional Ethical Review Board, Dnr 2018:176. Participants were informed that participation was voluntary and anonymous and that they could withdraw at any time without giving a reason or suffering any consequences. Written consent was given before participation. The focus group facilitators had no direct involvement in the students’ clinical education. The transcribed material was coded; no personal data beyond sex and program of study were collected, and individual participants could not be identified. The focus groups were conducted during students’ lunch time, and all participants were offered a light meal and a movie ticket for their participation.

Findings

In the analysis, three categories with subcategories were identified in each of the two domains. The findings are described in text below and presented with quotations illustrating the two domains in Table 1.

Table 1. Result of analysis, presented in domains, categories, and subcategories. Verbatim quotes in each domain highlight the link between data, interpretation, and conclusion.

Domain with quotes	Category	Subcategory
Experiences of round school as a learning activity So, I think it’s important for the staff also to have an idea of what is supposed to be done and some … we should have some rules too “should we meet the patient before this or not?”, we didn’t get any clear details on how to perform this task. #6 And that’s the main thing, that we could bounce ideas off each other, and of course we didn’t know the answers to everything, but it still helps if you can reason with one another and think aloud, so I think that was almost the best thing actually about round school, that you got a chance to do that. #6 I agree with you there, that it’s good to … for … for everyone at the ward, too, so they knew that “now there’ll be a medical student and a nursing student doing the rounds” to there was more time and so on, that maybe we were given a bit more space than what you get during regular rounds, because then it can often be sometimes that maybe you get to start and then someone else will take over. #1	Learning
	Performance
	Conditions for learning	Favorable
		Unfavorable
Reflections regarding interprofessional competence Yeah, but we can like recommend that maybe “this person needs this” and then it’s the physician who prescribes it, if it’s necessary. #2 The nurse maybe thought that “No, I don’t really agree with that prioritization,” but then they’ve made that decision and then that’s how things will be. #3 Yeah, so what I’m thinking is that … that the nurse, with the help of aides or nursing assistants, is in closest contact with the patient and kind of has … the main part of the patient contact, I mean if we compare with the physician who is maybe not out on the ward to the same extent, that you can help the patient, act as support for the patient, and help out in communicating things to the physician, who makes decisions on investigations and so on. #2 So that’s closer to how I have perceived it, that the nurse’s role together with the aide, is to speak for the patient and kind of focus on the care of the patient and “how have things been today, socially?”, what do we see that the physician can’t see in their conversation, when we see them in a different environment. #2	Responsibilities	Independent
		Assisting
		Non-explicit
	The professional relationship	Caring
		Formal
		Overlapping
	Working together	Different perspectives
		Collaboration

Experiences of round school as a learning activity

The domain, with its categories and subcategories, include the students’ experiences of participation in ward round school during their clinical training.

Learning

The students appreciated the opportunity to practice together with another student. It allowed them to have an open forum where they could discuss relevant areas from both perspectives: nursing and medicine. The learning activity was considered both a process of learning and a confirmation of their current knowledge. They stated that they attained new insights regarding both patient issues and the other profession.

Performance

The students’ statements regarding round school were mostly positive, although some of the students were uncertain if they had completed the activity in the proper way. A few students described their round school as confusing. On the positive side, they said that the learning activity was meaningful, serious, that they were challenged, and that it was fun and true-to-life. One student said that the learning activity had been somewhat exaggerated beforehand, but that it was straightforward when carried out.

Conditions for learning

A large part of the students’ discussions was about round school as a teaching activity, especially regarding the conditions for learning. They described the experienced and desired conditions, here grouped as favorable and unfavorable.

Favorable

A situation in which the staff were fully informed about the round school activity and appreciated the value of carrying it out in line with the intentions, was described as a prerequisite for the open climate where students are given space to explore their professional roles on equal terms. The possibility to support each other during the process was experienced as positive. Well-functioning routines and use of communication tools for transfer of information were facilitating factors. Providing the time and opportunity for necessary preparation, as well as later feedback, were regarded as important conditions for learning.

Unfavorable

Lack of time and insufficient routines were mentioned as hindering performance of round school in the desired way. Conditions directly connected to the students’ education included feeling they had a lack of knowledge and preunderstanding of psychiatry, psychiatric care, and their future roles, because of the limited time available to them for clinical psychiatric training. Negative factors for the round school were non-explicit written instructions and uncertainty about whether staff in the wards, especially their clinical supervisors, lacked knowledge of this learning activity. The students reported a discrepancy between the two programs, where medical students’ supervisors were considered to promote round schools more, and medical students were therefore more likely than nursing students to take part in the round schools.

Reflections regarding interprofessional competence

The domain, with its categories and subcategories, include descriptions of how the students reflected upon IPC after their participation in ward round school. Students’ reflections were mostly focused on how different professions worked together and acted during interprofessional teamwork.

Responsibilities

The discussions regarding responsibilities for different professions focused on both nurses and physicians’ respective responsibilities, as well as the responsibility for supporting or even assisting the other profession. The students thought that the responsibilities were sometimes non-specific.

The independent role

The students often described the physician as the decision maker with the overall responsibility for patient care. Some students described nurses as having professional responsibility for nursing care at the ward, especially autonomous nursing interventions, and for the individual patient. Some students did not describe the nursing profession as independent.

The assisting role

Nurses were often described as assistants, in the sense that they guided the patients’ treatment and the physicians’ decisions by being providers of information and suggestions. Students said that nurses needed to ask the physicians to get interventions delegated to them – not only medical interventions, but also nursing interventions.

Non-explicit roles

Students reported difficulties in defining and delimiting the different professions’ responsibilities. Students perceived nurses’ and physicians’ responsibilities as different from one another, but not explicitly defined. They stressed the importance of taking responsibility for their work.

The professional relationship

Students reflected on professional health care workers’ relationships with the persons being cared for. Their reflections focused on the care relationship and the formal relationship, as they experienced them.

Caring

Students stated that they felt nurses could build a caring relationship with patients more easily. This was related to their way of working and their more holistic perspective. Nurses were perceived as spending more time with patients and having a more personal knowledge of each patient. Nurses were also regarded as advocates for patients, as care needs were often identified by nurses.

Formal

According to the students’ reflections, physicians had a more formal relationship with patients. They generally had less direct contact with patients and were seen as distancing themselves from them. Students perceived that the physicians’ main goal when meeting a patient was to evaluate facts.

Overlapping

Students perceived that nurses and physicians’ care relationships (with the persons being cared for) differed. However, they experienced their roles in relationship to the patient as not being explicitly defined and to overlap somewhat. One student mentioned that physicians acted more like nurses when a patient was in the room.

Working together

Students’ interprofessional reflections concerned the round as a clinical work situation where different perspectives met and strived toward the same goal. Certain prerequisites for teamwork were also discussed.

Different perspectives

According to students, the focus of psychiatric in-patient care was predominantly medical. However, they said that other perspectives, such as nursing, were equally important, though somewhat more unnoticed in the workplace. The different perspectives were considered to be complementary, and the students reflected that these perspectives were valued and respected.

Collaboration

Students discussed IPC as an important factor in psychiatric care, covering inclusion of different competencies and the ability to reach consensus. Students’ reflections showed that they experienced that all staff had a common goal and that the different knowledge areas combine into a holistic or general picture of the patient.

Discussion

Participation in round schools at psychiatric wards was considered a meaningful and true-to-life IPE activity. Important conditions for learning were well-informed staff, sufficient time for preparation and feedback, routines, clarity regarding instructions, and an open climate. Non-explicit instructions and limited preunderstanding of psychiatric care left the students feeling uncertain. Students’ reflections regarding interprofessional competences encompassed both similarities and differences in roles, responsibilities, and collaboration.

Round school training in the form of simulations has previous been experienced as artificial and idealized (Nikendei et al., 2016). This round school was part of the units’ regular ward rounds, which was appreciated by the students who experienced the round school as being part of the clinical work. Being “one in the team,” as a student, and being accepted in the practical community have previously been identified as valuable (Hägg-Martinell et al., 2014), as role identification and interpersonal skills can be practiced.

Ward round training, where the participating professions collaborate on equal terms, requires not only education of supervisors but also information to all personnel in the ward, to clarify the aim and goals of IPE. In the focus groups, the students emphasized the importance of an open climate where they could learn with, from and about each other. If the clinical everyday work is not based on collaboration between different professions, it can be arduous to implement IPE through round schools (Tang et al., 2013; Thörne et al., 2017; Vietz et al., 2019).

The students mentioned the unfavorable situation when their clinical supervisor lacked knowledge of the learning activity, eliminating the benefits of fully informed staff and supervisors. In the focus groups, it was evident that information and support to nursing students’ supervisors was insufficient, which led to less participation of nursing students in the round schools. Implementation of IPE in the clinical context often requires additional resources and can be challenging due to timetabling between programs, and to hierarchical structures and cultural traditions both in the faculty and at the clinic (Fox et al., 2018; Lawlis et al., 2014; Murdoch et al., 2017; Sundberg et al., 2019).

The students did not talk about feedback to the expected extent, although feedback was described as favorable for learning. There was a guide for clinical teachers to use in giving comments, in particular on students’ collaboration and communication with each other, but also regarding their professional assessments. The guide was not discussed at all. One possible reason can be that supervisors were not well-informed and not accustomed to round schools. Another reason may be that some supervisors had difficulties giving constructive feedback on performance, even though there was a feedback tool (Nasir et al., 2020).

Our results indicate that students who have undergone IPE during clinical education in psychiatric care discuss IPC in terms of responsibilities, the professional relationship, and teamwork. Parallels can be drawn to the four core competences of IPC described by the Interprofessional Education Collaborative Expert Panel (Interprofessional Education Collaborative, 2016): values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork.

Although responsibilities were considered to be less than explicit, physicians were, to a large extent, regarded as decision makers and nurses as assistants. Students’ perceptions of this hierarchical distribution of power and stereotypes of nurses and physicians have been identified in research on IPC (Price et al., 2014; Reeves et al., 2017; Zuzelo, 2019).

Both medical and nursing students described the professional area of nursing as unclear and unseen, reflections corresponding to research where nursing is discussed as being inferior to medicine and struggling to frame its own area (Fewster-Thuente, 2015; Price et al., 2014). The lack of clarity is further supported by results from a recent study, which found that nursing can be understood in qualitatively different ways, even within a group of nursing staff working at the same psychiatric clinic (Salberg et al., 2019). This inferior view of nurses and the hierarchical structure was obviously evident for students.

Reflection and assessment of professional roles is an important part of IPE activities. These are important aspects to consider when formulating future activities for IPE, aiming at strengthening students’ IPC. Students’ reflections on the professional relationship indicated that physicians were seen as having a more formal relationship, whereas nurses were more caring toward patients. These findings are in line with the social positioning of nursing as having a monopoly on caring and being morally superior with regard to the care relationship (Price et al., 2014), and previous reports of the imbalance regarding time spent with the patients (Fewster-Thuente, 2015). Students described nurses as having more knowledge about and knowing the patients better than physicians. This parallels a study that concluded nurses need to make recommendations, because they spend more time with the patients and consequently hold a lot of important information (Fewster-Thuente, 2015).

Students reflected on teamwork as encompassing different perspectives with the same goal, coming together in agreement. The common goal was expressed as “what is best for the patient.” Working together in health care teams that understand how to optimize the skills of all members leads to improved health services to patients and the community (World Health Organization, 2010). However, according to the students, the overarching focus of the care was medical, even though other perspectives were considered as important contributions. When designing IPE activities, this “common goal” needs to be critically reflected on, in the light of the hierarchical dominance of physicians’ medical perspective in health care, which has been described in the context of both psychiatric care and other areas of the health care system (Bladon, 2017; Price et al., 2014; Zuzelo, 2019).

We recommend that IPE should be integrated in curricula for health professions education, as the students should be ready for IPC in their work life upon graduation (World Health Organization, 2010). Results from this study on IPE in psychiatric care inform us that students, after completion of round school, reflected on key aspects of IPC. A review on the effects of IPE (Reeves et al., 2017) highlighted that students responded well, (e.g., showed improvement in attitudes, perceptions, collaborative knowledge, and skills). In addition, results from a recent review in mental health care indicated that IPE interventions had an effect, resulting in both more positive attitudes toward other professions and improved skills in collaboration compared with conventional education (Marcussen, Nørgaard, Borgnakke et al., 2019). In addition, improved patient-reported outcomes related to interprofessional training in mental health have been described (Marcussen et al., 2020).

Limitations

Differences on the wards (e.g., team collaboration, routines, and availability of clinical teachers) affected round schools. Thus, students did not participate in exactly the same learning activity; on the other hand, the differences gave rich material for focus group discussions. The students’ experiences of what they learned from participating and what they noted as important prerequisites became clear. In focus groups the students interacted irrespective of their future professions. Some students were more prominent in some of the focus groups, but all students contributed actively in the discussions.

Another limitation was that only nursing and medical students were included. The IPE activity could have been designed to include more categories of students, such as physiotherapists, social counselors, and occupational therapists, professions usually participating in ward rounds. Although nurses and physicians are the professionals usually working in closer proximity in psychiatric wards, it is arguably beneficial to also train for collaboration with a wider group of professions.

To increase trustworthiness, all authors, three teachers who had long experience from psychiatric care – one psychiatrist and two specialist nurses in psychiatry – conducted the focus groups, and read all of the text after transcription. During the analysis, the authors’ different perspectives contributed to discussions on possible interpretations, the search for negative cases, and formulation of subcategories and categories.

Conclusions

Students described round school with a focus on collaboration and communication as valuable for IPE. In implementation of round schools as IPE, it is essential to have clear instructions for both students and supervisors, which the students underlined. Considering the evident hierarchical and stereotypical images of the nurse-physician relationship, in both the current study and previous research, it is important to design IPE that supports students’ development of IPC. It should be possible to introduce more IPE activities during clinical education in psychiatric care, in addition to round schools; however, well-planned preparations in the faculty and at the clinic are necessary.

Disclosure of potential conflicts of interest

There are no relevant financial or non-financial competing interests to report.

Acknowledgments

We thank all participating students and Madeleine Bergstedt Nelson for valuable contribution during the first part of the project. The research was financially supported by the Committee for the Medical Program at Uppsala University.

Additional information

Notes on contributors

Johanna Salberg

Johanna Salberg is a specialist nurse and a PhD student in caring science. She has extensive experience in teaching and designing courses in nursing programmes both at the bachelor and advanced level and specialized in care for people with psychosis.

Mia Ramklint

Mia Ramklint is a physician specializing in psychiatry and a professor of child and adolescent psychiatry. She has extensive experience in designing and teaching courses foremost in psychiatry for medical students and she is also teaching professional development.

Caisa Öster

Caisa Öster is a specialist nurse and associate professor in caring science. She has extensive experience in teaching and designing courses in nursing programmes both at the bachelor and advanced level and specialized in the management of the organization of care.