Fostering collaborative practice through interprofessional simulation for occupational therapy, physiotherapy, dietetics, and nursing students

ABSTRACT

Literature regarding simulation for learning interprofessional collaborative practice (IPCP) indicates a need to include a range of health professions and to focus on students’ development of team communication and conflict resolution skills in day-to-day healthcare delivery. This study evaluated the impact of interprofessional simulation for occupational therapy, physiotherapy, dietetics, and nursing students on interprofessional collaboration competencies, specifically collaborative communication and conflict resolution during day-to-day interactions, and their intention for IPCP during placement. A series of simulations featuring the potential for interprofessional conflict and involving explicit coaching on communication and conflict resolution were conducted. A single cohort pre-test post-test design included the Students’ Perceptions of Interprofessional Clinical Education Revised (SPICE-R), the Interprofessional Collaborative Competencies Attainment Survey (ICCAS), and an open response survey question on future intended practice. A total of 237 students participated in the simulation experience. Overall scores and scores on all IPCP competencies in the ICASS (n = 193) and SPICE-R (n = 226) improved for all professions post-simulation. The mean score of the ICCAS increased for 98% of the respondents and similarly the mean score of the SPICE-R increased for 71% of the respondents. Open-ended responses indicated students’ intentions to pursue self-leadership in IPCP. Students who participated in an interprofessional simulation reported perceived improvements in IPCP competencies and were encouraged to initiate IPCP when on placement in the practice setting.

KEYWORDS:

• Conflict resolution
• Health professional education
• Interprofessional collaborative communication
• Interprofessional collaborative practice
• Interprofessional education
• Simulation

Introduction

Interprofessional collaborative practice (IPCP) is defined as “multiple health workers from different professional backgrounds providing comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings” (World Health Organization, 2010, p. 13). Research over the past decade suggests that IPCP is fundamental to promoting positive health outcomes by integrating the expertise of all healthcare team members into patient-centred care (Reeves et al., 2017). Conversely, inadequate or ineffective communication and collaboration among team members has been shown to adversely affect patient safety, their satisfaction with services provided, and work satisfaction for the health professionals in the team (Reeves et al., 2017; Walsh et al., 2014).

Pre-professional training in interprofessional (IP) practice, otherwise known as interprofessional education (IPE), is seen as fundamental to successful IPCP in the clinical setting and has become a major focus of university health profession programs (Boet et al., 2014). IPE includes students from at least two professions in experiences aimed at learning with, from, and about each other’s professional roles (Hammick et al., 2007). It most often uses learning experiences that can be scaled up to meet the demands of student cohort numbers, such as observation-based learning, seminars, or classroom-based case studies (Reeves & Barr, 2016).

Simulation-based learning, or simulation, replicates possible situations that might occur in practice, providing students with the opportunity to practice their decisions and responses in the moment (Rossler et al., 2021). Given the lower-stakes nature of simulation compared to the real clinical setting, it provides a safe environment for students to learn practice-related skills before, or alongside, training in the clinical setting (Giles et al., 2014). Simulation typically focuses on the students’ interaction with simulated or standardized patients to support student skill acquisition in direct patient care (Ker & Bradley, 2014). Clinical simulation has long been recognized as a learning activity that can support IPE through learners from different professions sharing knowledge and completing clinical activities together (Baker et al., 2008).

Background

A recent systematic review and meta-analysis of the effects of IPE simulation for healthcare students found only 11 studies that evaluated outcomes using a validated tool (Marion-Martins & Pinho, 2020). Although most studies within the review reported improved scores on team functioning or teamwork competency after the simulation, the experience led students in some of the studies to recognize the need to improve their communication skills (King et al., 2016; MacKenzie et al., 2017). This indicates that the development of IP communication skills may need to be explicitly targeted in IPE simulation. Conflict management, considered a key skill in IPCP (Interprofessional Education Collaborative, 2016), and one that graduates have reported little exposure to during their pre-entry training (Jones et al., 2020; Moriarty et al., 2011), was targeted in only four studies, with little explanation regarding how the experience was designed to develop this competency (Marion-Martins & Pinho, 2020).

Nursing is the most commonly included profession in student IPE simulation (Marion-Martins & Pinho, 2020), with nursing students most often participating in simulations with medical students (Granheim et al., 2018). However, as most IPE simulation studies are situated within hospital scenarios (Marion-Martins & Pinho, 2020), recognition of the importance of all allied health team members in this context may be driving more IPE simulation in recent years that brings together nursing and allied health students (Gellis et al., 2018; King et al., 2016; Nichols et al., 2019; Pinto et al., 2018). Although allied health student-only simulation is still rare, simulations are emerging that more selectively target professions likely to work closely together in managing specific health conditions, such as dietetics and exercise physiology students working with people with diabetes (O’Shea et al., 2019) or occupational therapy and physiotherapy students working with people post-stroke (Collins et al., 2021).

A commonality with most IPE simulations is that they involve student professionals working collaboratively with a standardized patient (Collins et al., 2021; Ekmekci, et al., 2013; Marion-Martins & Pinho, 2020; Mills et al., 2020) often in an emergency situation (Fusco & Foltz-Ramos, 2018; King et al., 2016; Nichols et al., 2019). In clinical practice, much of the team relationship-building and patient-related discussions among team members that lead to IPCP occur outside of health professionals’ direct interaction with patients (San Martín-Rodríguez et al., 2005). In emergency situations, communication is necessarily rapid and purposeful, with little opportunity to communicate in ways that build team relationships, such as discussing the details of one’s clinical role, opinion or reasoning in a less pressured situation, or making collaborative plans for longer-term patient care. More recent interprofessional simulations have provided students with the opportunity to interact with each other without the “patient” present. However, this has been part of the simulation briefing, rather than a component of the simulation itself (O’Shea et al., 2019), and it is unclear how the simulation was specifically designed to focus on, and develop, students’ team communication skills during these interactions (MacKenzie et al., 2017; Mills et al., 2020).

Discipline-specific simulation-based learning has increasingly been employed partway through allied health professional degrees as a way of preparing students for their later clinical placements in health facilities (Penman et al., 2020a, 2020b). While some IPE simulation has been implemented before clinical placements (Mills et al., 2020), research investigating student outcomes has typically focused on attainment of competencies at a standstill point, without consideration of how students intend to apply what they have learnt into the future. Exploring students’ intentions for IPCP may assist understanding of the potential transference of new IP awareness and skills from university IPE initiatives into the clinical setting. This study aimed to evaluate health students’ perspectives on changes to their IP competency and intentions for future practice following an IPE simulation experience. The IPE simulation targeted the development of day-to-day team communication, collaboration and conflict management.

Methods

This study was a single cohort pretest posttest design conducted at The University of Queensland, involving undergraduate occupational therapy (OT), physiotherapy (PT), dietetics (DT), and graduate entry Masters nursing students who participated in a series of simulations as part of their usual coursework. Ethical clearance was obtained from The University of Queensland – Institutional Human Research Ethics, approval number: 2020003071. Data was collected across one University Semester: February-July, 2021.

Participants

All participants were entry-level healthcare students, with the OT students completing an undergraduate honors degree, and PT, DT and nursing students completing Graduate Entry Master’s degrees. To be eligible for the study, participants were required to be enrolled in the course within which the simulations were situated and to have participated in the simulation. The simulation was an assessed component of the course for OT, accounting for 20% of the course grade. For DT, the simulation was a pass/fail assessment piece, while for PT and nursing the simulation was compulsory but not assessed. Both OT and DT students needed to complete a written reflection after the simulation. Whilst attendance in the simulations was compulsory as part of course requirements, participants were reassured that participation in the research was voluntary and that their decisions to partake in or abstain from the research would not impact their current or future relationships with the University. The simulations were situated at different points in the program for each student cohort, as shown in Table 1.

Table 1. Timing of simulation in the degree program and proximity to full time placement.

Discipline	University semester in which simulation was situated	Position of simulation in relation to full time placements
Occupational therapy	Semester 1, Year 3 of 4 year degree	Immediately before placements
Physiotherapy	Semester 1, Year 2 of 2 year degree	Immediately before placements
Dietetics	Semester 1, Year 1 of 1.5 year degree	Immediately before placements
Nursing	Semester 1, Year 2 of 2 year degree	During placements

Description of simulation

The simulations were held over a 12-week period within the University’s on-campus simulation hospital ward. The ward is a purpose-built clinical space designed to reflect the reality of an Australian hospital setting to ensure the high-fidelity nature of the simulation (Lasater, 2007). Three patient case studies were developed, each involving an OT student and a student from another discipline, resulting in an OT-PT case, an OT-nursing case and an OT-DT case. The simulation case studies were designed using the Canadian IPCP framework (Canadian Interprofessional Health Collaborative, 2010) to intentionally embed its six key competencies: role clarification, team functioning, communication, client-centred practice, collaborative leadership, and conflict resolution into each scenario. Each case scenario targeted day-to-day communications and problem-solving within the allied health team, but in order to address all key competencies, case content was developed with the intention of creating competing priorities and potential conflict between professions and highlighting knowledge or expertise gaps of each. Students from each discipline needed to manage the scenario by explaining their role and clinical reasoning, intentionally seeking to understand the perspective of the other discipline and navigating a collaborative discussion to make an agreed upon plan for the patient. For example, in the OT-nursing case, the nurse has concerns about the patient’s motivation to assist with self care tasks and is doing most tasks for them. For reasons that are discovered during the simulation, the nurse is not encouraging the patient to use assistive equipment prescribed by the OT to increase their independence. In the OT-PT case, the OT student is provided with information that the PT may think the patient with a brain injury is ready for discharge, and in conflict with this, OT student has significant concerns about the patient’s cognition. In reality, the PT is also concerned about the patient’s cognitive status and wants to seek more information about this from the OT and gain advice on how to reinforce any cognitive strategies recommended by the OT. The case information provided to the nursing and OT students is provided in Supplementary File A.

Students were timetabled into the simulations at different weeks in the semester, with OT students completing all three simulations across three weeks (i.e., OT-PT, OT-DT and OT-nursing), and PT, DT and nursing students each completing 1–2 simulations with OT students. If participating in two simulations, the second one occurred with different OT students and the PT, DT and nursing students were encouraged to improve on their performance from the previous simulation. The OT-DT simulation was the only one involving a standardized patient (played by a DT student) and the only one in which the OT students’ simulation performance was assessed. This resulted in the OT students completing two simulations involving the other student professionals only (with no “patient” present) before the OT-DT simulation, when they were communicating with the other professional in front of the patient. The DT students always had the standardised patient present in their simulation, whereas the PT and nursing students had no patient present.

The simulation was 95 min in total, structured as follows: a 45-min preparation session (Gliva McConvey et al., 2020) guided by either a discipline-specific clinical educator or the simulation ward coordinator (with a clinical background in speech pathology), a 20-min simulation, and a 30 min facilitated debrief with each set of simulation participants (Eppich & Cheng, 2015). During the preparation, the clinical educators for each student group provided explicit coaching to develop: team communication and functioning (e.g., communicating without discipline-specific jargon, using approachable interaction to develop a collegial relationship); client-centred practice (e.g., raising how to involve the patient’s family or advocate for their cultural preferences); and conflict resolution skills (e.g., deciding how to raise a different opinion with the other discipline without seeming defensive or insensitive to others’ perspectives). The debriefing session was guided by prompt questions to encourage students to identify how the simulation made them feel, what they had learnt about the other profession, and how they could communicate or behave differently during the simulation to improve client outcomes and the professional relationship.

Outcome measures

A single cohort pretest posttest design was used to evaluate the impact of the simulations on student perspectives of changes to their IP competency and intentions for future practice. The research included three evaluation methods which are detailed below.

Students Perceptions Of Interprofessional Clinical Education – Revised (SPICE-R)

The Students’ Perceptions of Interprofessional Clinical Education Revised (SPICE-R) (Dominguez et al., 2015) was used as a pre-post measure. The SPICE-R is a self-report survey designed to measure health professional students’ perceptions of IPE and IPCP. Dominguez et al. (2015) undertook research involving 221 first-year nursing, optometry, pharmacy, physical therapy, and health administration students that validated the SPICE-R, demonstrating that the measure is valid and reliable (Dominguez et al., 2015). The measure contains 10 survey items that participants respond to using a five-point Likert scale (options being one through five), with higher scores indicating that respondents agree more strongly with the item.

Interprofessional Collaborative Competency Attainment Survey (ICCAS)

The Interprofessional Collaborative Competencies Attainment Survey (ICCAS) (MacDonald et al., 2010) was the secondary evaluation tool. The ICCAS is designed to assess change in interprofessional collaboration-related competencies in health professional students and practising clinicians before and after IPE training interventions. MacDonald et al. (2010) created the survey, which contains 20 competency statements that participants respond to via a five-point Likert Scale (MacDonald et al., 2010). In this study, a revised version by Schmitz et al. (2017) was used (Schmitz et al., 2017) which is reported to be both valid and reliable (Archibald et al., 2014). The measure contains 20 survey items that participants respond to using a five-point Likert scale (options being one through five), with higher scores indicating respondents’ improved perceived performance in the item.

Open response written question

Participants responded to an open response written question, “How do you intend to use what you have learnt in the learning activities, whilst you are on placement?.” This question enabled an open response to allow for appropriate depth (Patton, 2002) and to prompt students to think forward to their intended future actions to support IPCP based on their learning in the simulation.

Data collection

Data were collected via hard copy survey immediately prior to participants’ first simulation and after completion of their final simulation. Paper-based surveys were used in acknowledgment of the advantage of familiarity with hard copy survey completion (Booker et al., 2021). To ensure the anonymity of the participants’ responses, the pre- and post-surveys were matched using an anonymous, participant generated code. Following data collection, pre- and post-surveys were matched, and data inputted for analysis.

Data analysis

Quantitative data were analyzed using descriptive and inferential statistics. Data were assessed for normality using graphical distribution (boxplot) and Shapiro-Wilk test (p < .05). All data were not normally distributed, and non-parametric tests were used. Data are presented as medians and interquartile ranges. Results were assessed for each tool via total score, domain score and individual question score. Comparisons were conducted between and within professional groups prior to and post-simulation. Wilcoxon signed rank test was used for within subject comparisons. Krustal-Wallis H test with pairwise comparisons using Dunn’s (1964) procedure with a Bonferroni correction for multiple comparison were used for group comparisons.

Qualitative data resulting from the open response question were thematically analyzed (Braun & Clarke, 2019, 2022). Researchers undertaking the thematic analysis (JC/RM) immersed themselves in the data by reading through the data multiple times, whilst annotating the transcripts with initial codes, which were then grouped into themes. The researchers undertook this process independently then met to compare codes and themes. Discrepancies in themes were then discussed until consensus was achieved. To ensure the reflexivity of the qualitative research procedure, both researchers (JC/RM) undertook the process of epoche (Englander, 2016) to identify their own biases and experience that may have impacted the results of the study. This process allowed the researchers to intentionally study the data and construct themes (Englander, 2016; Varpio et al., 2017)

Results

Demographics

A total of 237 students participated in the simulation experience, eliciting 226 matched pre- and post-SPICE-R measures and 193 matched pre- and post-ICCAS measures (Table 2). A total of 227 students responded to the open response question in the ICASS. Incomplete SPICE-R and ICCAS forms or those without matched pre- and post-simulation measures were not included in the analysis.

Table 2. Demographic characteristics.

	SPICE-R					ICCAS
	Total n (%)	Dietetics n (%)	PT n (%)	Nursing n (%)	OT n (%)	Total n (%)	Dietetics n (%)	PT n (%)	Nursing n (%)	OT n (%)
n	226	39	42	46	99	193	37	31	33	92
Age
18–24	147 (65)	27 (69)^a	15 (36)b	16 (35)^b	89 (90)^c	136 (71)	26 (70)^a	13 (42)a	13 (39)^a	84 (91)^b
25–34	65 (29)	9 (24)^a	24 (57)b	24 (52)^b	8 (8)^a	47 (24)	8 (22)^a,b,c	16 (52)c	16 (49)^a,c	7 (8)^b
35–44	10 (4)	2 (5)	2(5)	4 (9)	2 (2)	8 (4)	5 (5)^a,b	1 (3)a,b	4 (12)^a	1 (1)^b
45–54	4 (2)	1 (2)	1 (2)	2 (4)	0 (2)	2 (1)	1 (3)	1 (3)	0	0
Gender
Male	57 (25)	9 (23)^a	22 (52)b	12 (26)^a,b	14 (14)^a	143 (74)	10 (27)^a,b	17 (55)b	10 (30)^a,b	13 (14)^a
Female	169 (75)	30 (77)^a	20 (48)b	34 (74)^a,b	85 (86)^a	50 (26)	27 (73)^a,b	14 (45)b	23 (70)^a,b	79 (85)^a
International Student	46 (20)	6 (16)^a	19 (45)b	10 (22)^a,b	11 (11)^a	41 (21)	7 (19)^a,b	15 (48)b	9 (27)^a,b	11 (12)^a
Previous tertiary study	146 (65)	38 (97)^a	40 (95)a	43 (94)^a	25 (25)^b	116 (60)	36 (97)^a	29 (94)a	30 (91)^a	21 (23)^b
Worked in health setting	79 (35)	6 (15)^a	19 (45)b,c	27 (59)^c	27 (28)^a,b	63 (33)	5 (14)^a	15 (48)b,c	19 (58)^b	25 (27)^a,c

Differences between subscript letters indicates significant differences between professions for each measure p < .05.

SPICE-R

Pre- and post-simulation there were no significant differences in overall SPICE-R score between males and females, age groups (18-24 yrs, 25-34 yrs, 35+yrs), domestic and international students, or between students who had prior experience in a healthcare setting and those who had none.

There was a significant increase in the SPICE-R score for the whole student group post-simulation (p < .0001) : 71% (n = 161) of students had an increase in overall score, 16% (n = 35) had a decrease in overall score, and 13% (n = 30) had no change in overall score. There was a significant increase in all three domains of the SPICE-R post-simulation for all students (p < .01), with 67% (n = 151) students reporting an increase in interprofessional teamwork and team-based practice (Domain 1), 49% (n = 111) for roles and responsibilities for collaborative practice (Domain 2), and 38% (n = 86) for patient outcomes from collaborative practice (Domain 3). Table 3 shows the SPICE-R results by profession.

Table 3. Median (IQR) score pre and post simulation activity for each SPICE-R domain by profession.

Domain	Dietetics (n = 39)		PT (n = 42)		Nursing (n = 46)		OT (n = 99)
	Pre	Post	Pre	Post	Pre	Post	Pre	Post
SPICER median score	4.5 (4.1–4.8)^a	4.7 (4.5–4.9)^a	4.5 (4.1–4.7)^a	4.7 (4.4–4.85)^a	4.15 (3.9–4.6)^b	4.6 (4.15–4.9)^a	4.3 (4.1–4.6)^ab	4.6 (4.5–4.8)^a
Interprofessional teamwork and team-based practice	4.5 (4.3–4.8)^a	4.8 (4.5–5.0)^a	4.5 (4.0–4.5)^a	4.8 (4.5–5.0)^a	4.0 (3.8–4.5)^b	4.8 (4.0–5.0)^a	4.3 (4.0–4.5)^ab	4.5 (4.5–4.8)^a
Roles/responsibilities for collaborative practice	4.3 (4.0–4.7)^a	4.7 (4.3–5.0)^a	4.3 (4.0–4.7)^a	4.5 (4.0–5.0)^a	4.0 (3.7–4.4)^a	4.3 (4.0–4.8)^a	4.0 (3.7–4.3)^a	4.3 (4.0–4.7)^a
Patient outcomes from collaborative practice	5.0 (4.3–5.0)^ab	5.0 (4.7–5.0)^a	5.0 (4.6–5.0)^a	5.0 (4.7–5.0)^a	4.5 (4.0–5.0)^b	5.0 (4.3–5.0)^a	4.7 (4.3–5.0)^ab	5.0 (4.7–5.0)^a

Median(IQR); differences between subscript letters indicates significant differences between professions at each time point p < .05.

ICCAS

Males scored significantly higher in overall ICCAS score (Male: 3.1 (2.64–3.83); Female: 2.7(2.25–3.2)) and in all domains prior to the simulation compared to females (p < .05). In the post-simulation measure, males also scored significantly higher compared to females in overall ICCAS score (Male: 3.98 (3.46–4.48); Female: 3.7 (3.3–4.15)), communication (Domain 1) (Male: 4.0 (3.55–4.45); Female: 3.6 (3.2–4.0)), and conflict (Domain 5) (Male: 4.0 (3.7–4.7); Female: 4.0 (3.3–4.3)) (all p < .05).

Older students (25 years+) had significantly higher scores than younger students (18–24 years) in overall score and all domains pre-simulation (p < .05). Older students (25 years+) also had significantly higher scores than younger students (18–24 years) in overall score and all domains except patient centred care post-simulation (p < .05). For the patient-centred care domain, students over 35 years scored significantly higher than those 18–34 years post-simulation (p = .004).

There were no significant differences between domestic or international students in overall ICCAS scores or domain scores pre- or post-simulation. Students with prior experience in a healthcare setting had significantly higher scores for communication (Domain 1) (3.0 (2.6–3.6) vs 2.8 (2.2–3.4), p = .045) and collaboration (Domain 2) (3.0 (2.6–3.6) vs 2.7 (2.0–3.3), p = .031) prior to the simulation, and also had significantly higher scores for collaboration (Domain 2) post-simulation (4.0 (3.3–4.7) vs 3.7 (3.0–4.3) p = .035).

There was a significant increase in score for all ICCAS domains for the whole student group after the simulation (p < .0001), with 94% of all students (n = 181) showing improvements for communication (Domain 1), 91% (n = 175) for collaboration (Domain 2), 94% (n = 181) for roles and responsibilities (Domain 3), 89% (n = 173) for patient-centred approach (Domain 4), 86% (n = 166) for conflict management (Domain 5), and 85% (n = 165) for team functioning (Domain 6). Table 4 shows the ICCAS results by profession.

Table 4. Median (IQR) score pre- and post-simulation activity for each ICCAS domain by profession.

Domain	Dietetics (n = 37)		PT (n = 31)		OT (n = 92)		Nursing (n = 33)
	Pre	Post	Pre	Post	Pre	Post	Pre	Post
ICASS median score	3.0 (2.65–3.83)^a	4.0 (3.23–4.6)^a	3.65 (2.75–4.05)^a	4.15 (3.9–4.6)^a	2.5 (2.15–2.8)^b	3.5 (3.2–3.85)^b	3.15 (2.75–3.75)^a	4.0 (3.63–4.8)^a
Communication	3.0 (2.5–3.7)^a	4.0 (3.0–4.7)^a	3.6 (2.8–4.2)^a	4.2 (3.8–4.8)^a	2.6 (2.2–2.8)^b	3.4 (3.0–3.75)^b	3.2 (2.8–3.7)^a	4.0 (3.4–4.3)^a
Collaboration	3.0 (2.3–3.7)^a	4.0 (3.0–4.7)^ab	3.7 (3.0–4.0)^a	4.0 (3.7–5.0)^a	2.3 (2.0–3.0)^b	3.3 (3.0–4.0)^b	3.0 (2.7–3.7)^a	4.0 (3.7–4.7)^a
Roles and responsibilities	3.0 (2.5–3.8)^a	4.0 (3.4–4.8)^a	3.3 (2.5–4.3)^a	4.3 (4.0–4.8)^a	2.4 (2.0–3.0)^b	3.5 (3.3–4.0)^b	3.0 (2.5–3.8)^a	4.0 (3.5–4.5)^a
Patient centred approach	3.0 (2.5–3.7)^a	4.0 (3.7–4.85)^a	3.3 (2.7–4.3)^a	4.3 (4.0–4.7)^a	2.3 (2.0–2.7)^b	3.7 (3.3–4.0)^b	3.0 (2.3–4.7)^a	4.0 (3.5–4.5)^a
Conflict	3.3 (2.85–4.0)^a	4.3 (3.3–4.7)^a	3.7 (3.3–4.7)^a	4.3 (4.0–5.0)^a	2.7 (2.3–3.0)^b	3.7 (3.3–4.0)^b	3.3 (3.0–4.0)^a	4.0 (3.7–4.7)^a
Team functioning	3.0 (2.25–3.75)^a	4.0 (3.0–4.5)^a	3.5 (3.0–4.0)^a	4.0 (3.5–4.5)^a	2.0 (2.0–2.5)^b	3.5 (3.0–4.0)^b	3.5 (2.0–4.0)^a	4.0 (3.5–4.25)^a

Median(IQR); differences between subscript letters indicates significant differences between professions at each time point p < .05.

Qualitative results (open response question #22 in ICASS)

Following the analysis of the open text responses, three themes emerged: 1) effective communication, 2) approach to patient care, and 3) scope of practice.

Effective communication

Participants voiced that following the simulation, they would be able to communicate with other health professionals and clients in a more confident and effective manner. This was attributed to the knowledge and skills they gained in asking the other discipline for clarifications and moderating their use of discipline specific “jargon” (OT, P21). Additionally, they felt as though their communication strategies, specifically “being aware of non-verbals” (OT, P70) was stronger following the simulation.

The activity has given me confidence in my ability to interact with both patients and other professions on placement. On placement I will communicate clearly and involve the patient. (DT, P1)

I intend to use less jargon as I understand that a lot of it isn’t as simple as I thought, also, giving more in-depth explanations of assessments to provide clarification. (OT, P13)

Consider jargon used when talking to other members of IP team and not assuming what they know, always clarify anything you’re unsure of. (PT, P16)

Participants noted that they intended to apply these newfound skills during their student placements.

I will apply my experience gained from these activities to my placement. For example, avoid professional jargons and explain things well. Also, respect everyone with eye contact, gesture, and positioning. (DT, P6)

I will use what I have learnt and communicate more clearly within the interdisciplinary team to further understand the patients, their functional levels, abilities and their goals to provide better care. (PT, P39)

Approach to patient care

Most participants felt that the simulation had changed their perceptions of client and family-centred care and that they had an increased appreciation of the contribution of interprofessional practice to these concepts. This change in perception was described to be a better understanding of the collaboration required between clients and the healthcare team.

The IP team working together will make the patient have a better experience in the hospital … communicating well with the IP team is very important. (Nursing, P5)

I intend to use my improved expression … to make sure the other professionals are heard and want to collaborate with me. Also increased collaboration skills will help with patient care and goal setting. (OT, P32)

Additionally, participants felt that they had increased their intention to use the skills that enable client and family-centred care, including shared goal setting and shared treatment planning.

I plan to establish professional relationships with interdisciplinary team members to better communicate patient and scheduling needs. (Nursing, P34)

I will be happy to work collaboratively with other (allied health professionals) in the treatment of our joint patients. I will be more aware of the overlap of treatment/management other [health professionals] have with my patients & more ready to work in a way that optimises patient care. (PT, P25)

Scope of practice

When reflecting on the simulation, participants felt that they had gained a better understanding of both their role in the interprofessional team, and the roles of other professionals. This was largely attributed to their increased “familiarity” (Nursing, P15) with their roles in the interprofessional team.

I will be more confident when talking to other health professionals. I have more knowledge on their roles and the difference between my role and theirs. (OT, P103)

I feel that I was able to develop my communication with understanding of allied health professionals and caring for a patient within a multidisciplinary team. (Nursing, P30)

They reflected that this knowledge and the continued acquisition of this knowledge will allow for a more efficient and effective interprofessional team.

I have learned that I don’t know enough detail about other professionals’ roles so will endeavour to find more out in order to be able to come to the best outcome possible for the patient. (DT, P32)

This increased my awareness of how other professionals work with the patients. I may be more aware of how we can involve other professionals to help the patient achieve the best outcome. (PT, P1)

Discussion

Using both quantitative and qualitative data, this study explored the impact of a novel IPE simulation activity designed to focus explicitly on all key competencies of IPCP and with a particular focus on communication and conflict resolution. Results from the ICASS and SPICE-R showed significant improvements to all IPCP domains and the overall score for all professions post-simulation, with communication showing the greatest improvement and conflict and team functioning the smallest (but still substantial) improvement. An open-ended question provided insight into students’ intentions of applying newly developed IP awareness and skills into their clinical practice, including the use of interprofessional communication skills within patient-centred care. These results suggest that the use of an IPE simulation with explicit pre-simulation coaching for collaborative communication and conflict resolution has a positive impact on a range of IPCP competencies and encourages students to pursue self-leadership in IPCP when on placement in the practice setting. This activity has provided a novel and relatively cost-effective way to provide IPE that allows intensive practice of IPCP skills, rather than just exposure to IPCP concepts, across whole student cohorts of several professions with the use of simulation.

Overall, there was a statistically significant increase in total SPICE-R scores measuring students’ perceptions of IP practice, and significant increases in individual items pertaining to roles and responsibilities, IP teamwork, and patient outcomes from collaborative practice. These findings are similar to previous published studies in IP clinical education (Zorek et al., 2014) and simulation (Forbes et al., 2018; Iverson et al., 2018; Rotz et al., 2016).

When evaluating changes in student perceived competencies by profession, there were some differences between OT and other health professional students in the ICCAS results. Occupational therapy students scored lower prior to the simulation compared to all other professions in all domains. The OT students also had the lowest scores after simulation for all domains, and DT students also scored lower than other professions for communication and team functioning. This difference in scores between professions could be partly related to the formal assessment embedded in the simulation experience for OT students that was not required of other students, which may have been a source of anxiety for the OT students (Le Blanc, 2009). In addition, the OT students participated in three simulations, as opposed to the one or two simulations experienced by the other professions. This repeated experience may have highlighted in more depth to the OT students the areas of IP competency they needed to develop, compared to the other students. Previous research has also found lower self-assessment of IP competencies among OT students (Ogawara et al., 2009) and indicated that, from the perspective of professional identity, occupational therapists’ clarity regarding their own roles and responsibilities may be challenging to develop and may need to progress before their development of teamwork and collaboration (Kururi et al., 2016).

The OT and DT students were also the youngest cohorts and the groups least likely to have previously worked in a healthcare setting. There were age-related differences in ICCAS scores, with younger cohorts (<24 yrs) scoring significantly lower prior to the simulation experience for all domains, and post-simulation for all domains except patient-centred care. Students without previous healthcare setting experience also scored lower in communication prior to simulation, and communication and collaboration post-simulation. These results potentially highlight the effects of life experience and exposure to the healthcare setting on students’ perceived abilities to meet IPCP competencies. University educators are encouraged to consider these factors when designing teaching and learning for IPE, for example, grading the support or scaffolding provided to students of different ages or life experience. A further consideration for the OT and DT students was that they were the only student cohorts to complete a simulation with a standardized patient present (the third simulation for the OT students, and both simulations for the DT students). It is possible that the need to tailor communication to both other professionals and patients simultaneously made these students more aware of the complexity of achieving client centredness during team communication, leading to lower self evaluation scores.

Both ICCAS scores and student qualitative responses highlighted the impact of the simulation on communication skills and intentions for patient-centred approaches to care. Students indicated that they were willing to purposefully initiate interaction and discussion with their interprofessional colleagues to ensure holistic care and better outcomes for the patient. This is an important finding as communication is a central skill for effective IPCP (Suter et al., 2009), and patient-centred care has significant impacts on patient outcomes (Martin et al., 2010; Zwarenstein et al., 2009). This finding highlights the role of simulation experiences in providing an impetus for, and confidence in, applying communication skills in real life practice. Further research is needed, however, to see how students’ intentions for future IPCP impact performance on clinical placements and in future clinical work.

In the current simulation, the explicit focus on coaching students in how to communicate verbally and non-verbally in a way that fosters a collegial relationship, mutual appreciation for other professionals’ roles and a collaborative plan for the patient is novel and has not been reported in previous IP simulation studies. Coaching of students in the intricacies of these interactions (e.g. non-verbal communication and body language that encourages information sharing, verbal feedback and paraphrasing that clarifies understanding and affirms the other team member) may be the key interventional feature that promoted relational coordination (Gittell, 1999) in the simulated teams. Relational coordination has been proposed to underpin positive behavioral outcomes such as timely and accurate communication, problem solving and perceived mutual respect (Lee & Doran, 2017).

Conflict resolution is an essential factor in reducing risk of injury, with IP conflict being significantly associated with major medical errors and adverse patient outcomes (Baldwin & Daugherty, 2008). Interprofessional conflict in a hospital setting requires rational and collaborative solutions to minimize the risk of compromising patient care and safety (Lee et al., 2014). New graduate nursing and allied health professionals, and their respective employers, identify managing a clinical workload, time management, and conflict resolution as difficult areas for new graduates (Moriarty et al., 2011). The findings of this study found that 75% of the students indicated an improvement in the conflict management domain following the simulation. This finding may relate to the purposeful creation of cases with conflicting professional priorities and the need for negotiation and exploration of patient-centred care, together with explicit pre-simulation coaching to help students tackle potentially “awkward” interactions, again promoting relational coordination (Lee & Doran, 2017). The fact that 25% of the students did not perceive an improvement in conflict management may be due to the widespread tendency to consider all team conflict as negative. However, literature suggests that if managed skillfully, conflict in teams can drive better service quality by discouraging “groupthink” (DiPierro et al., 2022). Intentional practice of conflict management within simulations could be an area for further focus and research to build this key competency.

Successfully integrating IPE simulation into health professional programs must take into consideration the challenges and costs involved. The ability to start and sustain simulation for IPE requires significant buy-in and commitment from staff across health professional programs to provide supervision, facilitation of activities and coordination of timetables and spaces, a challenge reported widely in IPE simulation research (Baker et al., 2008; Forbes et al., 2020). Future use of simulation for IPE must consider how best to prepare students across multiple professional groups and experience levels to engage in an IPE simulation of this nature. Coordinating sessions using limited physical and timetable spaces is not easily achieved and is a major challenge when considering expansion to a wider number of professional groups. One advantage to an IPE simulation focusing on interaction between professionals without the patient present, as described in this study, is the reduced need for standardized patients, which represents a significant cost reduction. However, the impact of having a standardized patient present or absent in the simulation was not explicitly investigated and should be addressed in future research.

Limitations

Several study design limitations constrained our ability to generalise findings. Selection bias inherent within the nonrandom sampling approach and small sample size from only one organizational site were limitations to this study. Recognition of the limitations of the outcome measures employed should also be considered. The use of the SPICE-R tool within non-clinical settings has been questioned based on early ceiling effects (Peeters et al., 2016) and this tool has not been specifically validated within a clinical simulation setting. Furthermore, a social desirability bias may be present for self-reported changes in attitudes, perspectives, and knowledge relating to collaborative practice following interprofessional education interventions (Mattiazzi et al., 2023). Limitations of the qualitative analysis include the use of a single question for data collection, which may have influenced the results, and that between group differences were not explored within the qualitative data.

Conclusion

The differences in the number of simulations experienced and assessment weighting attached to the simulation across the various disciplines and the potential influence this could have on student responses requires further consideration. A standardized approach to simulation exposure and the assessment embedded in the simulation would enhance the validity and reliability of data collected. Our results have shown that a brief and structured IP learning activity using facilitated planning, simulation and debriefing can successfully improve multiple IPE competency domains, most significantly communication and patient-centred approaches to care. The approach of using purposefully designed case studies to produce conflicting priorities between professions could provide opportunities to practice effective communication and conflict management strategies to prepare health students for clinical settings.

Acknowledgments

The authors would like to acknowledge Shrishti Subodh Tandale who contributed to the research during their participation in the 2021 Winter Research Program, at The University of Queensland.

Disclosure statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Notes on contributors

Jodie Copley

Jodie Copley, PhD B Occ Thy (Hons) is Professor and Head of Occupational Therapy in the School of Health and Rehabilitation Sciences at The University of Queensland. She is a Fellow of the Occupational Therapy Australia Research Academy and a Senior Fellow of the Higher Education Academy.

Romany Martin

Romany Martin, PhD, is Lectuer in Physiotherapy in the College of Health and Medicine at the University of Tasmania.

Clare Dix

Clare Dix, PD PhD is a Research Fellow in the School of Human Movement and Nutrition Sciences at The University of Queensland. She is an Accredited Practising Dietitian and Project Manager for the Nutritious Tools project creating the Grow & Go Toolbox – a digital platform for the first 2000 days.

Roma Forbes

Roma Forbes, PhD, MHSc, BHSc (Physio) is a Senior Lecturer in Physiotherapy at The University of Queensland, a Senior Fellow of the Higher Education Academy and a HERDSA Fellow.

Anne Hill

Anne Hill, PhD BSpThy is an Honorary Associate Professor in Speech Pathology in the School of Health and Rehabilitation Sciences at The University of Queensland and an academic consultant. She is a Senior Fellow of the Higher Education Academy.

Allison Mandrusiak

Allison Mandrusiak, PhD, BPhty (Hons) is Associate Professor of Physiotherapy and Director of Teaching and Learning at The University of Queensland. She is a Senior Fellow of the Higher Education Academy.

Adriana Penman

Adriana Penman, PhD; BSpPath; BEd (Primary) is a Senior Lecturer in Speech Pathology and the Acting Director of Teaching and Learning in the School of Health and Rehabilitation Sciences at The University of Queensland. She is also a Fellow of the Higher Education Academy.

Freyr Patterson

Freyr Patterson, PhD, BOccThy, MPH is a lecturer in Occupational Therapy at the School of Health and Rehabilitation Sciences at The University of Queensland and a registered occupational therapist. She an Associate Fellow of the Higher Education Academy.

Sarah Davies

Sarah Davies, MOccThy BSc (BioMed) is an Associate Lecturer in Occupational Therapy in the School of Health at the University of the Sunshine Coast, a PhD candidate in the School of Health and Rehabilitation Sciences at The University of Queensland. She is an Associate Fellow of the Higher Education Academy.

Jacqueline Jauncey-Cooke

Jacqueline Jauncey-Cooke, BN, MN, PhD is a Senior Lecturer in the School of Nursing, Midwifery and Social Work at The University of Queensland.

Niruthikha Mahendran

Niru Mahendran, PhD, BPhty(Hons) is a Lecturer in Physiotherapy at The University of Queensland.

Kelly Hooper

Kelly Hooper, Masters of Health Pfofessional Education, BNursing, is a Clinial Academic in the School of Nursing, Midwifery and Social Work at The University of Queensland

Cheryl Collins

Cheryl Collins, MDietSt, is an Associate Lecturer in Dietetics in the Shool of Human Movement and Nutrition Sciences at The University of Queensland.