Interprofessional education in the clinical learning environment: a mixed-methods evaluation of a longitudinal experience in the primary care setting

ABSTRACT

Team collaboration in our healthcare workforce is necessary to effectively address multifaceted medical and social needs, especially for those impacted by systemic inequities. Effective interprofessional practice and education models including curricula are needed to prepare a practice ready healthcare workforce for team collaboration. Most healthcare trainee interprofessional experiences take place episodically in classroom settings. However, creating a culture that supports team-based learning and interprofessional clinical practice requires teaching skills (e.g., communication, collaboration, shared decision-making, coordination of care) longitudinally in the clinical setting. A weekly interprofessional clinic for patients/clients with chronic health conditions was organized in three primary care practices. Trainees from nutrition, social work, medicine, and physician assistant programs worked with supervising clinicians from each field. Surveys, interviews, and focus groups assessed the effects of interprofessional education and training in the primary care setting. Results show the longitudinal experiential IPE program significantly improved knowledge, attitudes, skills, and values addressing key interprofessional competencies. Qualitative results complement survey data and highlight key themes addressing patient-centered care and team dynamics. These findings demonstrate the importance of longitudinal, immersive team-based interprofessional training in the clinical learning environment.

KEYWORDS:

• Interprofessional education
• longitudinal curriculum
• primary care
• clinical learning environment
• mixed-methods evaluation

Introduction

The Institute of Medicine’s (IOM) report, Academic Health Centers: Leading Change in the 21st Century, (2004) recommended that academic health centers provide learning environments that exemplify health care delivery systems of the future. Preparing a healthcare workforce that is collaborative and ready to work in teams to address the needs of a growing population with complex medical and social needs requires effective training in interprofessional education (IPE) (Gilbert et al., 2010). Evidence continues to demonstrate the positive effects of IPE on the professional practice of health care providers, including improvements in collaborative care (Reeves et al., 2016, 2013), patient/client-centered communication (Reeves et al., 2013), shared leadership (Forsyth & Mason, 2017), continuity of care (Soones et al., 2015), perceptions of interprofessional colleagues (Reeves et al., 2016), and health system error rates (Reeves et al., 2016). As such, interprofessional care teams have been identified as a critical component for the provision of whole-person, integrated, accessible, and equitable high-quality primary care (National Academies of Sciences Engineering and Medicine, 2021). In response to the demonstrated benefits of interprofessional practice, national accreditors from a variety of disciplines have defined interprofessional competencies for programs. Health profession educational leaders have expanded IPE opportunities, recognizing the importance of having trainees learn to work together on interprofessional teams while training in their own individual disciplines.

The majority of existing IPE experiences requiring trainees to learn from, with, and about each other to collaboratively improve health outcomes (Ghorob & Bodenheimer, 2012) occur in the classroom/seminar setting (Abu-Rish et al., 2012). To best prepare the future healthcare workforce for collaboration, IPE must transition to the clinical environment. The goal of this paper is to report on a study of the impact of IPE in longitudinal primary care practices on trainees’ interprofessional knowledge, attitudes, skills, and behaviors. We utilized a mixed-methods evaluation to study our model of care and to understand its impacts on trainees.

Background

Training in a supervised interprofessional clinical environment addressing the care needs of a patient/family allows learners to practice discipline-specific skills while sharing knowledge and building trust and skills as a team. Furthermore, designing experiences that are longitudinal in nature affords the opportunity for trainees to assess the impact of their collaboration on their own and their team’s professional growth over time.

Boston University Community Health Alliance of Medical Professionals (BU CHAMPs), established in 2016 with HRSA Primary Care Training and Enhancement funds, provides a longitudinal interprofessional team-based experience to health profession trainees in ambulatory primary care settings.

Drawing on the Interprofessional Learning Continuum (IPLC) (Committee on Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes, 2015) model as a conceptual framework, our model accounts for an understanding of where the learner is on their education continuum, assesses learning over time, and evaluates outcomes at the level of the learner, patient, and healthcare system. We provide trainees with experiential patient-centered and team-based learning with the purpose to facilitate discipline-specific and cross-discipline growth along with collaborative practice.

Development was facilitated by support from Deans of the participating healthcare programs at BU and the program was implemented by an interprofessional leadership team that was formed at its inception. The team of faculty members from different health professions training programs (medicine, family medicine, physician assistant, nutrition and dietetics, social work) collaborated on overarching program goals and objectives. Support was obtained from leadership at participating clinical sites. Each site identified a core group of healthcare professionals (social worker, registered dietitian, and physician) who provided the clinical supervision as the primary clinical “preceptors” and, along with select leadership team members, education for the trainee teams at each respective site. The patient visits were conducted by interprofessional trainee teams consisting of medical and physician assistant students, a master’s level social work intern, and a master’s level dietetic intern. Figure 1 details the BU CHAMPs practice model.

Figure 1. BU CHAMPs Practice Model

Methods

Intervention

The interventional component of BU CHAMPs was a longitudinal curricular and patient care experience called the Interprofessional Care Clinic (ICC). The ICC provided workplace learning for trainees and preceptors alike and consisted of a four-hour block of time (Table 1) once per week at each clinical site (see “Training Settings and Supervision” below). The experience combines direct patient care, team huddles, and debriefings with a two semester curriculum facilitated by interprofessional faculty and preceptors.

Table 1. Structure of the interprofessional care clinic.

Activity	Time	Description
Case-Based Didactic	40 min	Utilize skills learned in prep-work to practice and work through cases as a team. May include standardized patients for in-depth practice.
Team Huddle	20 min	Trainees review scheduled patients, create an agenda for each visit as a team, set roles and learning goals. Faculty facilitation provided.
Patient Visits	2 hrs	Up to 3 patient visits of 40 min each. All student providers in the room with the patient at once. Faculty supervision provided.
Debrief	30 min	Facilitated discussion & reflection on team-based collaboration and patient-centered care with faculty facilitation to identify best practices and areas for improvement.
EHR Documentation	30 min	Care plan documented in EHR with faculty supervision. Time permitting, outreach to patients who no showed/scrub chart for following week.

Each weekly ICC session began with an interactive case-based didactic that asked learners to apply skills from assigned pre-work and which focused on team-based care. Direct patient care involved the student team seeing selected patients (and their families when appropriate) together as a team for a scheduled 40 minute visit. All student providers remained in the room together with the patient for the visit.

The curriculum was developed and piloted in year one of the program. Learning objectives for each session were aligned with the four core domains of the 2016 Interprofessional Education Collaborative (IPEC) Core Competencies (Interprofessional Education Collaborative, 2016) -values & ethics, team-based collaboration, interprofessional communication, and roles & responsibilities. The order of didactics was structured around the Dreyfus Model of Skills Acquisition (Dreyfus, 2004) accounting for learners at different stages in their education continuum. Supervising preceptors facilitated the case-based learning which included use of role plays, standardized patients, and regular reflection. The initial curriculum was iteratively adapted each year by faculty based on trainee feedback.

Participants

Trainees included first year medical and physician assistant students, second year master’s level social work interns, and master’s level dietetic interns. Social work interns and medical and physician assistant students participated in the program for two semesters and the majority of dietetic interns participated for one semester. Medical and physician assistant students were chosen from a pool of volunteer candidates. Social work and dietetic interns received educational credit for their experience. Completion of the intervention required trainees to attend a minimum of 70% of the four-hour sessions including participation in direct patient care. Presented in this paper are results from program years two and three for trainees who met these criteria.

Training settings and supervision

Trainees were placed at participating family medicine clinics in Boston, including two at community health centers and one located at a large safety net hospital. All three sites are certified National Committee for Quality Assurance (NCQA) Patient-Centered Medical Homes (National Committee for Quality Assurance, 2021). Clinical preceptors, the majority of which worked as licensed providers at their respective site, provided education and supervision to the interprofessional learner teams.

Patients seen in the ICC

Patients were identified by their primary care providers or clinical site patient registry and invited to participate in the ICC if they had two or more of the following chronic conditions: diabetes, hypertension, chronic obstructive pulmonary disease, heart failure, chronic pain, substance use, depression, or anxiety. Housing, financial, and/or food insecurity were also qualifying conditions along with at least one chronic medical condition.

Data collection

This study used a longitudinal mixed-methods design with both qualitative and quantitative inquiry to gather and assess trainee, preceptor, and patient experiences.

Surveys

Trainees received surveys at baseline and at the end of each semester of participation (Figure 2). Results from three surveys are presented in this paper including the validated Interprofessional Collaborative Competency Attainment Survey (ICCAS) (Archibald et al., 2014) and the Interprofessional Socialization and Valuing Scale (ISVS) (King et al., 2016) which were administered to trainees in program years two and three at post-semester time points, and the Review of Interprofessional Competencies (RIPC), a survey created internally by our leadership team and administered in program year three at baseline and post-semester time points.

Figure 2. Data Collection Time Points Abbreviations: ISVS: Interprofessional Socialization & Valuing Scale; ICCAS: Interprofessional Collaborative Competency Attainment Scale; II: Individual Interview; RIPC: Review of Interprofessional Competencies; TBFG: Team-Based Focus Group (the IP trainee team(s) at each site); DSFG: Discipline-Specific Focus Group (uniprofessional groups of trainees from across all sites)

The ICCAS has a retrospective-pre/post design, allowing for change calculations despite being administered only at post-semester time points. This survey measures change in the Canadian competencies of interprofessional care: communication, collaboration, roles & responsibilities, patient/family-centered approach, conflict management, and team functioning (Archibald et al., 2014; Orchard et al., 2010). The ISVS measures socialization among trainees and their readiness to function in interprofessional teams and has been demonstrated to be valid in measuring outcomes of IPE and collaborative practice (King et al., 2016). The RIPC (Attachment 1) was developed to measure trainee self-assessment of proficiency on IPEC sub-competencies that correlate with the four IPEC core domains of communication, roles & responsibilities, teams & teamwork, and values & ethics (Interprofessional Education Collaborative, 2016). Trainees rated proficiency on a 5-point Likert scale drawn from Dreyfus’ Model of Adult Skill Acquisition (Dreyfus, 2004) – Novice, Advanced Beginner, Competent, Proficient, and Expert. Definitions of each level of proficiency were provided that were both descriptive and behavior-based.

Trainees had the option to opt-out of having their survey responses used for research purposes. Ethical approval was granted by the Boston University Medical Campus Institutional Review Board under protocol H-35639.

Interviews and focus groups

In program year two, trainees were invited to participate in virtual or in-person individual interviews. In program year three, trainees were invited to participate in both in-person team-based focus groups as well as virtual or in-person discipline-specific focus groups (e.g., social work interns from the three sites; Figure 2). Individual interviews were offered to program year three trainees if they were unable to participate in a focus group or the interviewer wanted to follow up on comments made.

Interviews and focus groups were facilitated by an experienced qualitative researcher who was a member of the leadership team. Web conferencing technology was offered as it has been found to be an acceptable data collection method especially with geographically dispersed participants (Tuttas, 2015).

Interviews and focus groups ranged from 45–60 minutes with in-person meetings audio recorded and virtual meetings video recorded using the Zoom web conferencing platform (Zoom video Communications, Inc, 2016). Recordings were transcribed verbatim by a professional transcription service and deleted when transcription review was complete.

Preliminary findings from individual interviews were presented during team-based focus groups as a means of member checking (Saldaña, 2013). Team-based focus groups allowed participants to reflect on shared ICC experiences and expand each other’s responses. Discipline-specific focus groups, which involved learners of the same discipline from different clinical teams, captured site differences and any perspectives perhaps not shared during team-based focus groups.

Semi-structured interview guides for individual interviews and focus groups were developed based on documented facilitators and barriers to interprofessional education (Visser et al., 2017), 2016 IPEC Core Competencies (Interprofessional Education Collaborative, 2016), findings from the ICCAS survey, and findings from the Interprofessional Education Perception Scale (IEPS), another validated measure of IPE that some trainees completed in program year two (Luecht et al., 1990; McFadyen et al., 2007). Questions focused on trainees’ role and responsibilities within the team, perceived benefits and challenges of learning and collaborating within the ICC environment, team communication, and recommendations for future iterations of the CHAMPs program. Interview and focus group participants received a $25 gift card for their participation.

Data analysis

Surveys

Demographics of study participants and all other quantitative data were described with means and standard deviations (SD) for continuous variables and frequencies and proportions for categorical variables. Quantitative data were analyzed descriptively with a focus on longitudinal intergroup and overall score comparisons at earliest and latest time points and for change in score (using ANOVA) as well as intragroup/within-discipline significance testing of change in score (using paired t-tests). Exploratory analysis on ICCAS and ISVS data were conducted by examining effect size calculated as Hedge’s g, classified as small (<0.5), moderate (0.5-<0.8), and large (≥0.8). Statistical significance was defined as p < .05 for all tests. All quantitative data analyses for this paper were generated using SAS/STAT software, Version 9.4 of the SAS System for Microsoft Windows (SAS Institute Inc, 2016).

Interviews and focus groups

Individual interview and focus group transcripts were reviewed for accuracy and de-identified to maintain participant confidentiality. The interviewer and a trained research assistant individually coded all transcripts using initial and descriptive coding methods (Saldaña, 2016) and each developed a coding dictionary. Each pair of coded transcripts and the coding dictionaries were collaboratively reviewed to reconcile differences. The reconciled coding dictionary was iteratively refined and used by both research team members to independently code the remaining transcripts. Coding decisions were continuously reviewed by referring to the refined coding dictionary and the segment of the transcript in question.

Dedoose (Dedoose Version 8.2.14, Web Application for Managing, Analyzing and Presenting Qualitative and Mixed Method Research Data, 2021) was used to manage the coded data and quantify how many times each code was applied within and across transcripts. Codes most frequently used and appearing in at least two interview or focus group transcripts were selected for structural analysis (Saldaña, 2016). During this secondary analysis, similar codes were merged into categories and related categories were combined into larger themes. The themes aligned with the primary aims of this manuscript and provide context for interpreting the quantitative data reported here.

Results

Trainees

A total of 35 trainees representing four disciplines (nutrition, social work, medicine, physician assistant) participated in the full four hour intervention for at least one semester in program years two and/or three. A mean of 26 four hour sessions occurred in each program year, with mean attendance rates of 85.0% (SD 7.7%) and 89.8% (SD 8.1%) in program years two and three, respectively. Twenty two trainees (62.9%) participated for two semesters, with the remainder participating for one.

Clinical preceptors

A total of 15 preceptors with clinical practices in social work, nutrition, and family medicine participated in program years two and three. Twelve of these were regular weekly preceptors and the other three acted as substitutes.

Patients

A total of 42 individual patients were seen by the ICC teams during the study period, with a mean of 3 visits per patient.

Trainee, preceptor, and patient demographics were similar across program years in regards to race, gender, ethnicity, and age. See Table 2 for full demographic data.

Table 2. Demographic data – trainees, preceptors, patients.

	N	Age		Gender		Race*														Ethnicity
				Female		American Indian/Native Alaskan		Asian		Black/African American		Native Hawaiian/ Pacific Islander		White		Other		Not Reported		Hispanic
		Mean(SD)	Range	N	%	N	%	N	%	N	%	N	%	N	%	N	%	N	%	N	%
Trainees	35	25.3(3.4)	22–40	25	71.4%	2	5.7%	6	17.1%	0	0.0%	0	0.0%	30	85.7%	0	0.0%	0	0.0%	3	8.6%
Preceptors	15	41.1(9.2)	29–62	13	86.7%	0	0.0%	1	6.7%	1	6.7%	0	0.0%	12	80.0%	1	6.7%	0	0.0%	1	6.7%
Patients	42	50.7(11.1)	26–74	30	71.4%	0	0.0%	0	0.0%	28	66.7%	2	4.8%	10	23.3%	0	0.0%	2	4.8%	7	16.3%

*Persons who identify as multiracial were counted more than once

Surveys

Response rates for the ICCAS, ISVS, and RIPC surveys were 100%, with all trainees completing one baseline and one or two post-semester measurements. The RIPC survey was introduced to the 17 trainees in program year three. One trainee opted out of having their responses used for research purposes, leaving 16 trainees whose RIPC responses could be analyzed. The ISVS was administered to all 35 trainees after the first and second semester of the longitudinal curriculum. Dietetic interns (n = 14) participated for one semester and therefore a mean change score was calculated for the remaining 21 trainees who had two post-semester measurements.

ICCAS

As shown in Table 3, there was a significant increase in trainee growth in interprofessional skills addressing communication, roles and responsibilities, conflict management, and team collaboration for all trainees combined, as well as within each individual discipline (p < .01). Statistically significant differences (p < .05) were also observed between disciplines in their retrospective-pre scores. No significant differences were observed among disciplines in their post scores.

Table 3. ICCAS scores – all trainees & by discipline.

	All			Dietetic Interns			Medical Students			Physician Assistant Students			Social Work Interns			P-value†
Time Point	N	Mean	SD	N	Mean	SD	N	Mean	SD	N	Mean	SD	N	Mean	SD
Retrospective-Pre	35	4.46	0.98	14	4.43	1.01	7	3.71	1.09	7	5.23	0.56	7	4.51	0.58	0.028
Post	35	6.41	0.54	14	6.46	0.36	7	6.23	0.95	7	6.68	0.36	7	6.25	0.40	0.358
Change	35	1.96*	0.95	14	2.03*	0.97	7	2.52*	1.17	7	1.45*	0.67	7	1.74*	0.69	0.175

*P < 0.01 by paired t-test.

^†By ANOVA.

Medical students had the lowest mean retrospective-pre score (3.71) and the greatest mean change in score (2.52, p < .01). Physician assistant (PA) trainees had the highest mean retrospective-pre and post scores of 5.23 and 6.68, respectively (1.45, p < .01). After PA students, social work interns (SWIs) had the second lowest mean change in score (1.74, p < .01), but their retrospective-pre scores were much closer to that of the overall group (SWIs: 4.51, Overall: 4.46). Dietetic interns had the second highest increase in mean score (2.03, p < .01).

An exploratory analysis was performed looking at individual effect sizes for each of the 20 ICCAS items. For all trainees there was statistically significant (p < .0001) improvement in every item on the ICCAS with large Hedge’s g effect sizes ranging from 1.0 to 2.7. The largest effect sizes were seen in trainees’ reported abilities to “use an interprofessional team approach with the patient to assess the health situation and provide whole person care” (ICCAS questions 13 and 14, Hedge’s g effect sizes 2.7 and 2.5, respectively).

ISVS-21

Mean scores and SDs for all trainees on the ISVS-21 are presented in Table 4. Change was calculated for the 21 students who completed the survey twice using data from the two post-semester time points categorized as ‘earliest’ (post-one semester of participation) and ‘latest’ (post-two semesters of participation) (ISVS not administered at baseline). Overall, mean ISVS scores increased significantly (p < .01) by 0.47, from 5.37 to 5.81 on a 7 point scale (1-“not at all” to 7-“very great extent”). While the overall mean score increased, this effect was differentially driven by the disciplines. When analyzed separately, medical students and social work interns had significant increases in mean score (0.74 and 0.53 respectively, p < .05). No significant change was observed within physician assistant students. Change in socialization could not be analyzed for nutrition students as their dietetic internships were one semester long.

Table 4. ISVS-21 scores – all trainees & by discipline.

	All			Dietetic Interns*			Medical Students			Physician Assistant Students			Social Work Interns			P-value^†
Time Point	N	Mean	SD	N	Mean	SD	N	Mean	SD	N	Mean	SD	N	Mean	SD
Earliest	21	5.37	1.14	1	-	-	7	5.14	1.54	7	5.89	0.52	6	4.97	1.16	0.319
Latest	35	5.81	0.79	14	5.82	0.76	7	5.88	0.81	7	6.01	0.48	7	5.54	1.13	0.735
Change	21	0.47***	0.60	1	-	-	7	0.74**	0.79	7	0.12	0.42	6	0.53**	0.43	0.159

*One dietetic intern completed the ISVS at two post-semester time points, therefore mean score was not calculated for that time point and a change score was not calculated for the group.

**P < 0.05 by paired t-test.

***P < 0.01 by paired t-test.

†By ANOVA.

Each of the ISVS-21 survey items showed an increase in mean score from post-one semester to post-two semesters. The mean score for item 3 (“I have gained an enhanced awareness of my own role on a team”) increased by 0.90 points, a substantial amount on a 7-point scale. Item 3 and item 10 (“I am able to negotiate more openly with others within a team”) both had significant moderate Hedge’s g effect sizes of 0.7. At the other end, the mean score for items 16 and 21 (“I have gained greater appreciation of the importance of a team approach,” and, “I have gained an appreciation for the benefits in interprofessional team work”) increased minimally. These two items also had the highest mean scores at both time points.

RIPC

Although the RIPC survey requires further validation with larger datasets, assessment of the survey’s validity based on existing data revealed a Cronbach’s alpha of 0.9. There was a significant increase in score pre/post intervention in terms of overall survey score and within three of the four IPEC core domains (Interprofessional Education Collaborative, 2016). Total scores increased by a mean of 13.94 (p < .05) on a 120 point scale. See Table 5 for detailed results.

Table 5. RIPC scores – total & subscales.

Time Point	N	Total		IP Communication		Roles & Responsibilities		Teams & Teamwork		Values & Ethics
		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Baseline	16	89.69	21.99	2.81	0.72	2.91	0.90	2.93	0.85	3.23	0.70
Post	16	103.60	18.63	3.85	0.66	3.45	0.63	3.57	0.67	3.66	0.67
Change	16	13.94*	23.73	0.35	0.79	0.54*	0.96	0.65*	0.89	0.43*	0.77

*P < 0.05 by paired t-test.

Interview and focus group thematic analysis

Twenty-seven trainees (77%) participated in at least one focus group. Four interprofessional team-specific and four discipline-specific focus groups were completed in all. Six individual interviews were completed in program year two, with a 35% participation rate. In program year three, three trainees were invited to complete an individual interview with a 100% participation rate.

Individual interview and focus group data identified several themes ranging from trainees’ perceptions of the benefits of participating in the CHAMPs program, to their recommendations for improving future iterations of the ICC. Four themes in particular provide context for interpreting key findings of the survey data and are described below. See Table 6 for more quotations pertinent to each theme.

Table 6. Qualitative themes.

Themes	Trainee Quotations
Patient-Centered Care:	“A patient came in, mainly concerned about her housing and secondary concerns included her eating habits. So the first visit we focused largely on her housing situation, so social work stepped up, and took the major lead in that session. Then we were able to bring things full circle in the next session to really hone in on the nutrition part of things with her diabetes. It felt good to have the patient feel like they left with more help each time, focusing on the patient’s priorities and the patient’s order. I think that builds a lot of trust.” (Medical Student #4)
Interprofessional Roles & Responsibilities:	“It did kind of start out where the nutrition student or practicum student were asking all the nutrition questions. So, maybe there was a slight like monopolizing of time at first. But as we got more comfortable with the visits and we saw how we interacted, our medical student would take on a little bit of the nutrition questioning and things like that. So, we started to rotate those roles. We’d say like, “Okay, why don’t you start off and get their chief complaint. What brings the patient in today?” So, the social worker would start with that. So, we started to shift those roles.” (Physician Assistant Student #4)
Team Dynamics:	“So the dietetic intern was trying to educate the client to add some carbohydrates to have some energy throughout the day. Then the medical student said, “Well what about whole grains?” I understand that the medical student just wanted to recommend something healthy but from my dietetic, nutrition background we should not be giving her too much on the plate, cause it seems like she has a lot to deal with in her life right now. We also don’t have sufficient information for us to actually just prescribe her and let’s say with brown rice. We have no idea if she actually enjoys brown rice or if she actually cooks for her family. So if she cooks brown rice, if her family does not like it, then that means that she needs to cook two batches which means more workload. We actually ended up talking about that at the end of the clinic.” (Dietetic Intern #5)
Lessons Learned:	“I think a lesson learned for me is that you can’t do everything by yourself. Like I think my dream going to medical school is like oh I’ll become a doctor, I’ll know so much, I’ll find these patients, I’ll fix all their problems, I’ll make sick people healthy! But really you can’t do it by yourself. You need the help of people in other professions. You need to rely on other people.” (Medical Student #5)

Patient-centered care

Patient-centered care describes trainees’ interactions with patients and their family members within the ICC and beyond the clinical encounter. ICCAS, ISVS, and RIPC scores affirmed that trainees developed an interprofessional team approach to providing patient-centered care. In interviews, participants reported learning how to facilitate effective communication during ICC visits and prioritize patient-centered care. For example, one trainee reported,

We would always open up the appointment by asking what they wanted to focus on today, or how things were going with them. What’s new since the last time we saw them? So, we really tried to let them dictate what the most pressing concern was. It may not always be the same as what our concern was, but we would try to let the patient lead goal setting. Like what’s one thing that you think you want to work on before we see you again next time? (Dietetic Intern #4)

Interprofessional roles & responsibilities

Results from ICCAS survey data demonstrated that medical student trainees had the lowest mean retrospective-pre scores and the largest mean change over time. Medical students described feeling uncertain with their initial contributions to their interprofessional team. One first year trainee reported,

At the beginning of the year, I literally couldn’t stop saying to my group, “I know nothing. I know nothing!” … I feel like I’m in a much better spot now than at the beginning of the year. (Medical Student #1)

On the other hand, PA trainees had the highest mean pre scores on the ICCAS and ISVS and the smallest mean change over time. PA students consistently described their preparedness for the interprofessional learning environment,

I think the PA profession is rooted in being a team member … we have a good foundation of medical knowledge. I think that’s probably what separates us from like other professions is being a little bit team-oriented. It makes us stick out a little bit. (Physician Assistant Student #2)

Most trainees identified that preceptor-led learning activities and interactions with peers and preceptors within the ICC informed them about each profession’s role. Trainees across disciplines reported acquiring skills beyond their traditional scope of practice. One trainee noted,

I’ve been able to mirror what I’ve heard from my peers. When a social work student speaks or when a dietetic intern speaks. Um, I’ve been able to see the skills that they are using to talk about anxiety, depression, nutrition goals and incorporate them into how I talk to the patient as well. (Medical Student #2)

Team dynamics

Trainees reported that interactions and communication between trainee team members were generally positive and improved over time. This aligns with RIPC survey data where trainees demonstrated the largest pre/post mean increase in the teams & teamwork domain. Trainees described the ICC as a consistent and unique opportunity to collaboratively plan patient visits, develop care plans, and support and learn from team members during clinical encounters.

The most impactful part of CHAMPs for me has been the team aspect and primarily the ability for our team to have the time and the intention to really grow as a team, and really kind of fine-tune our communication with each other and with patients. (Medical student #3)

Another trainee summarized the ICC as,

A positive experience but also a very supportive environment to take on leadership roles that aren’t usually available to us in this field. And just like with the repetition, I gained confidence in what I know. And just having both preceptors and other trainees, just really supportive environment requiring us like, to get the most out of it, on our end and for the patient. (Dietetic Intern #2)

At the same time, scores on two ISVS questions about appreciating teams and teamwork were high at both measured time points and therefore change increased minimally. This may be secondary to several factors including that trainees who chose to participate in the CHAMPs program may have entered with an existing commitment to or value of IP partnerships.

I think that a lot of it has to do with like the participants coming in with very open minds and being really invested already and like the idea of collaboration ….and I think having like a shared value base. (Social Work Intern #1)

Despite commonly describing a collaborative culture, trainees acknowledged that moments of disagreement between team members did occur and perceived hierarchies existed between professions. A social work trainee described the ICC patient arrival process as following the traditional medical model norms.

For my patients, I go and get them and bring them into the room. So, that changed in the ICC. I guess, we deferred to how the medical students would do it because the patients did have to like get their blood pressure taken and things like that so, they were roomed by medical assistants. (Social Work Intern #2)

Lessons learned

Trainees described wisdom they gained during their ICC experience and their plans to incorporate these “lessons learned” into future practice. Lessons ranged from learning how to self-advocate for one’s profession to valuing interprofessional partners to appreciating the time and space to be vulnerable with learning. A dietetic intern shared,

A really big lesson was being able to articulate what I could bring to the team, sort of like my role in patient care. I think nutrition in particular is not always valued as highly as some other disciplines by some providers, and so being able to go to a doctor or a nurse, and sort of concisely explain why what I had to say was important. It wasn’t something that I really learned anywhere else in my internship. (Dietetic Intern #4)

Trainees valued the roles and shared perspectives of their team members. One trainee noted,

It’s easy in certain clinical situations to be very tunnel vision, and just look at the patient from your own perspective … I’ve learned the importance of everyone’s role in patient care and not being afraid to include other people and talk to other people if you have concerns and opening those lines of communication more and building those relationships. (Dietetic Intern #3)

Core tenets of IPE, including reflecting and recognizing one’s own limitations in skills and knowledge and developing a trusting relationship with team members were respected and upheld by trainees. Examples include trainees from other disciplines creating and supporting a space for fellow team members to grow. One trainee shared,

For me, the most important skill that CHAMPs helped me cultivate was being comfortable with being uncomfortable … I think part of why I was able to reach this point-and its taken months, but because I felt really safe on my team and I could be really honest about like, “I’m really confused about this. I don’t understand this. I didn’t say that right. I’m sorry.” I was in a safe space where I could admit to those vulnerabilities. Um, and so with time, I think my team helped me reach this being comfortable with being uncomfortable, which is a skill that I’m going to take throughout all of the rest of med school. (Medical Student #1)

Discussion

The results of our evaluation of a longitudinal experiential interprofessional learning program demonstrate the positive growth of trainees with impacts on interprofessional knowledge, attitudes, skills, values and collaborative behaviors. Combining survey results with thematic analysis from interviews and focus groups provided a deeper level of understanding of trainee experiences and demonstrated that participation in an interprofessional care clinic improved collaborative practice in the outpatient clinical environment.

Most commonly, IPE is classroom based with smaller research studies employing both didactic and practice-based learning in their IPE (Reeves et al., 2011). Linking interprofessional education with practice in the primary care setting is necessary to adequately prepare future health professionals to provide equitable and collaborative patient care. However, practice-based IPE is not yet routine in the outpatient environment and sits on the fringe of clinical education (Kent and Keating, 2015). Practice-based IPE is charged to simultaneously achieve educational objectives while delivering optimal patient care (O’Leary et al., 2021). Community and academic health centers provide this opportunity, allowing learners to witness and transform the delivery of healthcare.

Providing care for patients on a longitudinal interprofessional team afforded trainees the ability to develop collaborative patient-centered skills as well as skills and behaviors beyond their traditional scope of practice. This cross-discipline skill acquisition impacted trainees in that they reported an increased awareness of their own and other professional roles and an increased ability to negotiate with and incorporate skills from interprofessional team members.

Our mixed methodology analysis with multiple assessment tools provides further understanding of how interprofessional education in practice supports and transforms learners and teams in the clinical environment. Our IPE practice model led to significant improvement in all ICCAS survey measures, demonstrating improved interprofessional collaboration among all trainees and within each discipline. The retrospective-pre/post design of the ICCAS was used specifically to combat ceiling effects (Archibald et al., 2014; MacDonald et al., 2009, 2010) and reduce response-shift bias (Drennan & Hyde, 2008), issues that have plagued IPE research (Archibald et al., 2014) and which were an obstacle to our own data collection efforts in the early stages of program implementation. ICCAS results demonstrate that our intervention was successful in meeting our objective to train health professional students to provide collaborative, whole-person care in the clinical setting. The ICC intentionally teaches learners to huddle as a team prior to patient visits to support team members in each of their roles. Focus group data highlighted the value of role recognition, team collaboration as well as the importance of communication and flexibility to help guide future patient care.

The ISVS is a measure of IP socialization that “can capture the transformation of professional beliefs, attitudes, and behaviors that take place through IPE” (King et al., 2016). This survey was administered at the end of each semester of participation with no baseline measurement, yet still demonstrated an overall increase in scores for all disciplines from the end of the first semester to the end of the second semester. Previous use of the ISVS has revealed similar improvements for medical students who have participated in observed structured clinical exams (Cyr et al., 2020). Our findings add to the literature as use of the ISVS with the other disciplines represented in our study has been limited, as well as in the interprofessional outpatient practice environment.

The RIPC survey was created by our internal team and introduced during program year three and is therefore limited in sample size. For this reason, data were pooled and not analyzed by discipline. Trainees’ self-assessments on interprofessional competencies increased overall post-participation. When further evaluated by domain, results demonstrated a significant increase in three out of the four domains (Teams & Teamwork, Values & Ethics, and Roles & Responsibilities). Scores on the Interprofessional Communication domain increased, but did not reach the threshold for significance. One possibility is that while all disciplines improved in the three domains noted, only some disciplines may have improved on the fourth. For instance, our curriculum places a heavy emphasis on team building and team dynamics which may have translated into an impact on trainees of all disciplines. On the other hand, trainees join the interprofessional team at different points in their training and with varying levels of experience, which could contribute to a steeper learning curve when it comes to trainees’ communication abilities.

The amount of improvement in perceived knowledge, attitudes, and skills varied between trainee disciplines. Similar to prior studies (Nagge et al., 2017; Haber et al., 2017), medical students had the lowest mean retrospective-pre score on the ICCAS. Additionally, medical students had the second lowest ISVS score at the earliest timepoint following social work. More than other trainees, medical students expressed not feeling prepared in their clinical knowledge and skills to participate in the ICC. There was a “disconnect between student expectation and experiences” (Rotz et al., 2015). Medical students who participated in CHAMPs began in the first semester of medical school and therefore in an early stage of their professional identity formation. As such, they shared uncertainty in their role given their limited clinical experience. Through the longitudinal experience, students recognized the value of observing and learning from their peers. This study demonstrated the notable growth in their interprofessional skills and findings suggest their appreciation for having the space and time to learn from other disciplines/team members.

PA students scored the highest of all disciplines on the ICCAS and ISVS at both time points, suggesting they did not have as much room to improve with the intervention. Several reasons may explain these findings including that many PA trainees have prior clinical experience before entering PA school, and they have chosen to go into a profession whose vision includes being a member of a healthcare team (AAPA, 2021). Additionally, at BU School of Medicine, the PA students are concurrently in classes with second year medical students which may have improved both their clinical knowledge and confidence on the ICC team.

Future directions for research include additional evaluation of our interprofessional model to better understand enablers and barriers to collaborative practice in the clinical environment as well as the impact of interprofessional education and collaborative practice on patient and system outcomes.

Limitations

Participation in the ICC was voluntary with medical and PA students completing the program outside of their educational obligations and social work and dietetic interns participating as part of their internship coursework. This self-selection could lead to a biased sample that is more motivated to collaborate with other health professionals than the general population, as interprofessional experiences for students in the clinical environment are rare at our university.

Ideally all preceptors would have been providers at the sites that hosted the ICC, but availability and staffing were a barrier to this. At one location all three preceptors were embedded within the site, at another location a faculty registered dietitian nutritionist was recruited from outside the health center, and at a third location only the physician was embedded within the site.

The RIPC survey tool has not yet been validated. Using our current data, the Cronbach’s alpha of 0.9 suggests that the survey items have high internal consistency, but this was calculated from a small sample. In addition, although the domains of the survey are based on IPEC’s 2016 competencies,(Interprofessional Education Collaborative, 2016) we do not currently have sufficient psychometric data to conduct a factor analysis or otherwise verify the presence of the four identified sub-domains in our tool. This work will need to be accomplished before results from the RIPC can be more conclusively interpreted.

The small sample size of trainees, especially when looking at the data in discipline-specific groups, should be considered when attempting to generalize conclusions.

Conclusion

A longitudinal interprofessional clinic in the primary care setting provided experiential learning opportunities for future social work, medicine, physician assistant, and nutrition providers with evidence of improved interprofessional skills including collaborative practice. Our mixed-methods results contribute to the growing body of literature on the transformative impacts and benefits of longitudinal interprofessional practice and education in the clinical environment.

Acknowledgments

The authors would like to acknowledge and thank the members of the initial grant writing team and curriculum contributors Molly Cohen-Osher, MD, MMedEd, Paula Gardiner, MD, MPH, Karla Damus, PhD, MSPH, MN, RN, Katherine Gergen-Barnett, MD, Lauren Scott, MD, PhD, and Suzanne Mitchell, MD. Special thanks to the patients, staff, leadership, and providers at participating health centers. We also thank grants administrator Jess Howard, research assistants Amanda Gorton, Rachael Manasseh, and Manvi Lohia, and Spanish translators Chrystel Murrieta and Walker del Aguila Ortiz.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

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

Additional information

Funding

This work was supported by the Health Resources & Services Administration under grant Health Resources and Services Administration T0B30021;.

Notes on contributors

Heather H. Miselis

Heather Miselis, MD, MPH, FAAFP, is a board-certified family physician providing inpatient and outpatient clinical care in Boston, MA. She is an Assistant Professor of Family Medicine and leads the interprofessional education curriculum at Boston University School of Medicine. As Principal Investigator of Boston University Community Health Alliance of Medical Professionals (BU CHAMPs), she has worked with others to develop an IPE and collaborative practice model in the primary care environment that addresses the quadruple aim. Her mixed-methods research evaluates the impact of interprofessional practice and education on health professional trainees and providers as well as patient and healthcare outcomes.

Stacey Zawacki

Stacey Zawacki, DrPH, RDN, is a Clinical Assistant Professor of Nutrition in the Department of Health Sciences at Boston University, and Director of the BU Sargent Choice Nutrition Center. A licensed, registered dietitian with a Master’s degree in Exercise Science and a Doctoral degree in Public Health, Dr. Zawacki has 20 years of experience specializing in cardiovascular disease risk factor management for diverse populations. She is a faculty leader for Boston University Community Health Alliance of Medical Professionals (BU CHAMPs), a HRSA grant designed to train students from multiple healthcare professions to work collaboratively in interprofessional teams treating underserved populations.

Susan White

Susan White MD, FACCOG is a generalist obstetrician–gynecologist with 20 years’ experience. Now at Boston Medical Center and an Assistant Professor of Obstetrics & Gynecology, she’s been involved in Physician Assistant education since 2007. As director of the PA Program at Boston University School of Medicine and founding Director of Didactic Education, she implemented a model combining PA and medical students in a Medicine, Disease, and Therapy course, making BU one of two PA programs to combine students. She developed an interactive curriculum on social determinants of health and served on a BUSM/Northeastern University planning committee for interprofessional activities

Leanne Yinusa-Nyahkoon

Leanne Yinusa-Nyahkoon is an occupational therapist with 20 years experience serving children and families from urban communities of color. Dr. Yinusa-Nyahkoon is a Clinical Assistant Professor in the Department of Occupational Therapy, Research Scientist in the Department of Family Medicine, and Research Associate in the Department of Obstetrics and Gynecology, all within Boston University. Dr. Yinusa-Nyahkoon’s research focuses on examining maternal and child health disparities and interprofessional care within urban community health centers. As a qualitative expert she values examining clients’, health professional trainees’, and health care providers’ perceptions of the environmental and social factors that contribute to health inequities.

Carol Mostow

Carol Mostow LICSW, an Assistant Professor of Family Medicine at Boston University School of Medicine, has trained and supported residents and faculty for 30 years at Boston Medical Center. She is the lead author with physician colleagues of the 2010 JGIM RESPECT model for communicating across power, difference and race with patients and learners and a subsequent DocCom module and podcast using RESPECT to build equitable, supportive, inclusive healthcare teams. A graduate of Yale, Simmons, and the Academy on Communication in Healthcare where she joined the national faculty, she also facilitates interprofessional rounds for the Schwartz Center for Compassionate Healthcare.

Janice Furlong

Janice Furlong, MSW, LICSW, is a Clinical Associate Professor at Boston University School of Social Work. She is a four-time recipient of BUSSW’s Teaching Excellence Award. In 2015, she received Boston University’s highest teaching award, the Metcalf Cup and Prize for Excellence in Teaching. Her practice and scholarly interests include interprofessional collaboration, development and evaluation of learner-centered teaching methods, gender bias in clinical practice, and clinical supervision. Ms. Furlong has forty years of clinical practice experience with children, families, and adults in a variety of inpatient and community mental health settings.

Katherine K. Mott

Katherine Mott, BA, is a Research Coordinator for CHAMPs, an interprofessional healthcare training program located in the Department of Family Medicine at Boston University. She has supported the CHAMPs program since its inception in 2016. She worked as a clinical research coordinator at Mass General Hospital in the Department of Neuroradiology, and as a research assistant in Brigham & Women’s Department of Neurology. Her educational background is in cognitive neuroscience, with over 12 years of experience in research settings.

Anika Kumar

Anika Kumar, BS is a Research Coordinator at the Health Equity Research Lab located in the Department of Psychiatry at Cambridge Health Alliance. She supported BU CHAMPs’ research initiatives for two years as a Research Assistant in the Boston Medical Center Department of Family Medicine. Her lead on qualitative research methods for the BU CHAMPs program highlights the nuances of team building, patient experience, and interprofessional clinical practice. Her educational background in Community Health and Psychology lends her to pursue evidence-based, community-centered research.

Michael R. Winter

Michael Winter, MPH, is Associate Director, Statistical Programming, at the Biostatistics and Epidemiology Data Analytics Center (BEDAC) at Boston University School of Public Health. He has over 30 years’ experience in data management and statistical analysis of quantitative public health and medical data and has co-authored more than 150 publications. His research interests include the areas of addiction, persons living with HIV, and LGBT health. Flora Berklein, MPH, is a Statistical Programmer at the Biostatistics and Epidemiology Data Analytics Center (BEDAC) at Boston University School of Public Health. Her research interests include racial health equity, addiction, and maternal health.

Brian Jack

Brian Jack, MD, is Professor and former Chair of the Department of Family Medicine at Boston University School of Medicine. He is active in research and dissemination of preconception care. The health IT system based on this work is now being disseminated in Lesotho in southern Africa, where he directs the Lesotho-Boston Health Alliance. His team created the “ReEngineered Discharge” program described in the book “50 Studies Every Physician Should Know” for which he received the 2013 Peter F. Drucker Award for Non-Profit Innovation. He is a member of the National Academy of Medicine.