An interprofessional experience preparing a collaborative workforce to care for older adults

ABSTRACT

The development and evaluation of an interprofessional education (IPE) pre-professional geriatrics experience involving learners from 10 different health discipline programs is described. The experience provided learners with opportunities to use small-group collaborative approaches in two 3-hour interprofessional sessions. Learners gained exposure to geriatric principles and awareness of the needs of older adults and their families using case studies developed by experienced interprofessional faculty. Learners completed pre- and post-experience surveys and worksheets on their confidence to function in interprofessional teams, knowledge of other disciplines, perceptions of importance of each discipline in providing older adult care, and the qualities considered for a successful team. Data were collected over three offerings of the experience (2016, 2017, 2018) and analyzed using paired sample t-tests and ANOVA. A total of 562 learners participated with outcome measures indicating increased knowledge of older adult services different health professionals provide and increased confidence in knowing when to complete care referrals. Mean increase in learners’ confidence to function in interprofessional teams was significant, suggesting the experience was effective in facilitating confidence in functioning and improving views of other disciplines’ roles. This experience demonstrated that learners gained exposure to apply geriatric principle skills and critical thinking as interprofessional team members.

KEYWORDS:

• Interprofessional education
• geriatrics
• gerontology
• interdisciplinary team-based care

Introduction

Significant efforts are being made to increase interprofessional education (IPE) in curricula that prepare health professionals. As health care increases in complexity, it is apparent that no one discipline trains learners to adequately meet all the needs of vulnerable populations. Older adult patients, in particular, stand to gain from professionals who are educated to collaborate with each other. The population of older adults is projected to increase in the United States to 88.5 million over the next 50 years, and much of the care they receive will be provided in the home or ambulatory settings, rather than in skilled nursing facilities and hospitals (Conti et al., 2016). Given that there is a shortage of primary care providers who specialize in geriatrics and that many health professions have limited specialty education in this area, care of the older adult patient will benefit greatly from an IPE health systems approach. Additionally, older adults have multiple social and health-related needs that require support from multiple disciplines. Without a team-based approach, patients may experience gaps in care that are correlated with poor outcomes, such as issues with mobility, physical activity, nutrition, polypharmacy, finances, transportation, unmet dental needs, mental illness, and end-of-life care. Professionals trained as part of a comprehensive team will not only understand what other disciplines offer but will realize and use these disciplines’ resources more effectively (Bookey-Bassett, Markle-Reid, McKey, & Akhtar-Danesh, 2016).

Collaboration and IPE are now required across the health sciences curricula and reflected in evolving accreditation standards. In the United States, the Interprofessional Education Collaborative (IPEC), established in 2009 for developing IPE competencies, now includes representatives from 14 health care professions: dentistry, medicine, nursing, osteopathic medicine, occupational therapy, optometry, pharmacy, physician assistants, physical therapy, podiatry, psychology, public health, social work, and veterinary medicine. In 2016, the group updated the competencies in the domain of collaboration and increased the emphasis on population health, recognizing the roles of all health care professions in providing optimal care and emphasizing communication and teamwork (IPEC, 2016).

The updated accreditation standards and IPEC competencies undergird the IPE Pre-professional Geriatric (PPG) Experience at the University of North Carolina (UNC) at Chapel Hill. The IPE PPG Experience was established in 2012 by faculty in four disciplines (occupational therapy, pharmacy, physical therapy, and public health – nutrition) and has since 2016 grown to 10 disciplines (adding dental hygiene, dentistry, medicine, nursing, social work, and speech and hearing sciences), due to funding from the Health Resources and Services Administration’s (HRSA) Carolina Geriatric Workforce Enhancement Program (CGWEP) grant.

Background

The IPE PPG Experience was developed based on a review of the literature, faculty interest, and feedback from learners themselves that their professional training did not have sufficient exposure to other disciplines, both in the classroom and on clinical rotations. Learners were interested but unaware of when and how to collaborate with or refer to other disciplines to improve the care of older adults. With the growing demands on providers to address the whole patient in health care today, the older model that a physician should always lead in providing care is no longer realistic.

The IPE PPG Experience simulates interdisciplinary health professional encounters using a collaborative approach in caring for older adults. The needs of older patients and their families are highlighted throughout the interprofessional experience, with teams comprising learners from dentistry, dental hygiene, medicine, nursing, occupational therapy, pharmacy, physical therapy, public health – nutrition, social work, and speech-language pathology. Learners gain exposure to a variety of geriatric principles, such as minimizing polypharmacy, using case studies and working with interprofessional faculty specializing in geriatrics and gerontology. The cases are designed to engage each learner in critical thinking while collaboratively constructing comprehensive care plans with person-centered goals.

Materials and Methods

Methodology design

Learner experience development process by faculty

In developing the interprofessional experience, the faculty team – both clinicians and educators – entered this project with knowledge learned through training, teaching experience, and work experience with the geriatric population. The pedagogical design did not follow a pure theory to practice model but rather an iterative process of reflecting within and building from experience, a Plan-Do-Study-Act evaluative process. To design and coordinate the IPE PPG Experience, at least one faculty member from each of the 10 health disciplines committed IPE planning time of up to 3 hours per month each fall semester. This was not always easy, given institutional boundaries and scheduling challenges. The faculty were divided into working groups to write the cases, coordinate the logistics of space and scheduling, and craft the formative and summative evaluations. An administrative coordinator was also designated to help with logistics of collating materials and organizing meetings between the faculty. Additionally, two PhD faculty members with public health backgrounds led the evaluation work group. Faculty developed marketing materials to explain the IPE PPG Experience to learners in their geriatric courses, and to recruit learners in disciplines that did not have the IPE PPG Experience as part of their coursework. Due to time and space limitations, each health discipline was limited to 25 learners for a total of 250 learners. Alignment and leveling of learners were also determined by each health discipline depending on their scope of practice and the content of the cases. During IPE planning meetings, faculty also determined the extent of facilitation and reached consensus on their roles in modeling interprofessional collaboration. The faculty designed a companion site on a learning management system platform for the course, which included elective readings and links to data collected for this experience.

Learner experience design

The IPE PPG Experience was designed to be held over 2 days in three-hour blocks each day. The schedule outline is described in Table 1. Goals for the experience were for learners to (1) be able to list the education and roles of other professions; (2) engage in an interdisciplinary collaborative process to analyze cases of older adults and create comprehensive plans for evaluation and intervention that are built around the client’s preferences and goals; (3) to work with an older-adult case example, discuss when to refer to other disciplines based upon the area of professional knowledge of those disciplines and the needs of the client; and (4) list the benefits of an interdisciplinary team approach to care for older adults.

Table 1. Interprofessional education geriatrics experience agenda

Day One		Day Two
1:45–2:00	Check in (Learners sign in by discipline).	1:45–2:00	Check in
2:00–2:30	Welcome, Introductions, History, IPE context for older adults, Goals	2:00–2:10	Transition to rooms
2:30–3:00	Modeling Teamwork by Faculty Facilitators Faculty model communication to create list of possible interventions, needs, and care plan prioritization. Learners de-brief observations and reflections.	2:10–3:10	Ice-breaker on Disaster Preparedness* Discuss Case #2 – “Puzzle” format Team Outcome: Interprofessional Education in Geriatrics Worksheet.
3:00–3:10	Transition to rooms	3:10–3:20	BREAK
3:10–3:35	Introductions – Stereotypes and myths	3:20–3:50	Discuss Case #3 – Ethical dilemma
3:35–4:25	Discuss Case 1 – Cross-talk and care prioritization	3:50–4:20	Team Debrief Discussion of teamwork Team Outcome: Interprofessional Teamwork Evaluation Worksheet.
4:25–4:35	Transition to auditorium	4:20–4:30	Transition to auditorium
4:35–5:00	Articulate learning points, Complete Evaluations & Wrap up	4:30–5:00	Complete Evaluation and Wrap up

*Only offered in the 2018 experience.

Prior to the first day of the event, learners were assigned to IPE teams representing all or most of the disciplines. One learner from each discipline, a maximum of 10 learners per group, was intentionally designed with every group having either a nurse practitioner and/or a medical student learner. As the IPE PPG Experience was mandatory for some disciplines and voluntary for others, a few of the groups did not have a representative from all 10 disciplines. On Day One, all learners gathered initially in a large auditorium for introductions and to observe faculty facilitators modeling collaborative decision-making in an IPE case discussion of an older adult client. Immediately following this demonstration, learners had the opportunity to ask questions, reflect, and make observations. Following the group discussion, IPE teams were dismissed to their small groups to tackle complex cases involving care of older adult clients. A faculty facilitator checked in with each group at the start and end and was available to the learner groups throughout their sessions. Agendas were provided to the learner groups, beginning with an ice breaker introduction where the learners described one myth about their profession they were to dispel. This exercise created the opportunity for teams to bond, explore pre-conceived stereotypes, and begin interprofessional collaboration. The first case incorporated medical conditions of depression, memory loss, and chronic pain and psychosocial concerns. In the learner team discussion, they were prompted to generate initial cross-talk and determine top priorities to address in a patient care plan, including noting any overlap, gaps, conflicts, or synergies between discipline-specific recommendations. Case discussion lasted 50 minutes and then learners reconvened in the auditorium to debrief and discuss the barriers, benefits, and surprises they experienced in working together as a team for the first day (see Table 1).

During Day Two of the experience, which occurred 1 week later, the same groups assembled and worked through two additional cases of older adult clients. In 2018, a disaster-preparedness ice-breaker was added, as a relevant concern calling for teamwork for vulnerable populations. The disaster-preparedness ice-breaker provided an imaginary scenario of an assisted living facility facing a hurricane, and learners were asked what priorities their discipline would focus on in responding to the crisis. Case 2 was presented as a puzzle case with each discipline holding discrete, discipline-specific information about the case. At times, the information conflicted among the disciplines. This was designed to simulate real-world practice, given that each discipline obtains specific patient information via a unique lens. Only through interprofessional cooperation and engaged team process can the learners arrive at a comprehensive understanding of the case. The third case was designed as an ethically challenging case in which the client may or may not have the cognitive capacity to direct their care. All of the cases including the faculty model case incorporated patients with diverse backgrounds inclusive of religion (e.g. Jewish) and race and ethnicity (e.g. Black/African-American, Spanish-speaking). All learner groups submitted a written case prioritization that included problem identification and potential interventions by specific health disciplines for all three cases.

Data collection

The primary outcomes of this experience evaluation encompassed measuring change in knowledge, confidence, and perspectives. Learners completed pre- and post-experience surveys asking about their confidence in functioning as a team member on IPE teams, their knowledge of other disciplines, how they viewed the importance of each discipline in providing care to older adults, and what qualities they considered important for healthy team process. The pre-experience survey was completed prior to the Day One experience. The post-experience survey was completed by learners at the end of the Day Two session. A sample version of the survey is available via request to the authors. Most importantly, learners were asked to predict how likely they would be to refer patients to each of the other disciplines and how interprofessional practice would add to the quality of care for older adults. Open-ended text questions were included in the post-experience survey to collect feedback on the experience in terms of strengths and suggestions for improvement, asking learners to comment on the most meaningful aspects of their participation in the two interprofessional sessions. Data were collected over 3 years (2016, 2017, 2018) using the same standardized survey instruments.

The sociodemographic survey (Table 2) was developed by Health Resources and Services Administration (HRSA), the collaborative agreement funders, and used for reporting purposes. Learners completed an anonymous 12-question demographic survey prior to Day Two of the experience, which documented the learners’ disciplines, ethnicity, and urban or rural upbringing. This survey was optional, but useful in collecting pertinent sociodemographic data.

Table 2. Characteristics of learners responding to optional sociodemographic questions*

Sociodemographic	N	%
Gender ^(n^=503) Male Female	64 439	12.7 87.3
Age group ^(n^=502) 20–29 years old 30–39 years old 40–49 years old 50–59 years old 60 or older	377 88 16 14 7	75.1 17.5 3.2 2.8 1.4
Ethnicity ^(n^=499) Hispanic/Latino Not Hispanic/Latino	29 470	5.8 94.2
Race ^(n^=506) White Black or African American Asian American Indian or Alaska Native More than one race	398 40 50 6 12	78.7 7.9 9.9 1.2 2.4
Previous Work Setting Rural setting^(n^=504) Yes No Urban setting^(n^=501) Yes No	40 464 196 305	7.9 92.1 39.1 60.9
Discipline ^(n^=558) Dental Hygiene Dentistry Medicine Nursing Nutrition Occupational Therapy Physical Therapy Pharmacy Social Work Speech-Language Pathology	42 60 39 43 61 63 63 60 70 57	7.5 10.8 7.0 7.7 10.9 11.3 11.3 10.8 12.5 10.2
Required for Coursework ^(n^=558) Yes No	499 59	89.4 10.6

*Total possible were n = 562, but as the survey was optional, not all learners were required to answer every question.

Data analysis

The primary goal of this analysis was to evaluate the effectiveness of IPE PPG Experience in (1) building confidence in functioning and care referral in interprofessional teams, (2) improving learner knowledge of and views on the importance of other disciplines who provide care to older adults, and (3) assessing learner perception of their own discipline’s importance in their ability to provide care. The evaluation of this experience was deemed exempt from review by the UNC Institutional Review Board, University Committee on Activities Involving Human Subjects due to the nature of the experience and the surveys already being an existing education/evaluation component of participating in the experience as a learner.

Quantitative evaluation instrument validity and reliability

During survey development, content validity of the survey instrument’s measured outcomes assessing confidence in functioning in interprofessional teams, knowledge of other disciplines, confidence in referring to or recommending other disciplines, and perspectives on the importance of each discipline in providing care to older adults were addressed. An interprofessional committee of faculty who specialized in geriatrics, gerontology, and statistics evaluated the survey instrument for intended measures and outcomes. The construct validity of the instrument assessing its dimensionality and the intercorrelation of the measures was examined with exploratory factor analysis. Instrument reliability was computed using Cronbach’s alpha coefficient to measure internal consistency. For all pre- to post-intervention outcome measures in the instrument, Cronbach alpha was 0.90, indicating strong internal consistency. Reliability was also assessed for the constructs measuring the importance of each discipline in providing care to older adults (alpha = 0.78), confidence in functioning in interprofessional patient care discussions (alpha = 0.77), confidence in knowing when to refer to or recommend other providers (alpha = 0.78), and knowledge of other disciplines (alpha = 0.91). These results suggest acceptable to very good reliability for both the overall instrument and the specific areas of interest (Tavakol & Dennick, 2011).

HRSA sociodemographic data

Sociodemographic data and pre- and post-experience outcomes were collected for three cohort years – 2016 (N = 147), 2017 (N = 214), and 2018 (N = 201), yielding a total analytic sample size of 562 learners. The SAS Statistical Package (SAS Institute Inc. V9.4) was used for all descriptive and inferential statistical analyses. Effect size calculations were performed with Gpower 3.1.5.

Descriptive statistics (means and standard deviations for quantitative data and frequencies and percentages for categorical data) were used to describe the learners’ sociodemographic characteristics and to summarize pre- and post-experience survey responses on a 10-point Likert scale. Normality of outcomes was tested using skewness and kurtosis criteria (Garson, 2012) and supported the suitability of parametric methods. For analysis of the open-ended survey responses, qualitative thematic coding (Williams & Moser, 2019) was conducted by a graduate student and confirmed by one of the faculty evaluators to identify emerging themes from learners’ responses to the question, “What has been the most meaningful aspect of your participation in the two interprofessional sessions?”

Learner outcomes

The primary outcomes of pre- to post-experience mean change in response to the domains of confidence in functioning in interprofessional teams, knowledge of other disciplines, perspectives on the importance of each team discipline, and confidence in referring to or recommending other disciplines were assessed using the paired sample t-tests, with intervention effect size also calculated. Response changes for individual survey questions were also analyzed using the paired sample t-test, adjusted for multiple testing using the Benjamini-Hochberg False Discovery Rate (Benjamini & Hochberg, 1995). ANOVA was used to further examine the possible association of discipline and process factors (year administered, required vs. optional training) with response change.

Results/Findings

Descriptive statistics

Characteristics of learners choosing to answer sociodemographic questions are summarized in Table 2. Of the 562 learners, attrition was minimal across the 3 years, with 89% of learners (n = 500) completing the intervention and both the pre- and post-intervention surveys. The majority of learners responded to the optional background questions. Most learners were female (87%), and 75% were aged 20–29 years old, with a range from 20 to over 60 years of age. Seventy-nine percent identified themselves as White, 10% as Asian, 8% as Black, 1% as American Indian or Alaska Native, and an additional 2% indicated more than one race. Ninety‐four percent indicated a non‐Hispanic, non‐Latino heritage. Thirty-nine percent of learners responded that they had worked in an urban setting previously, while 8% had worked in a rural environment. Percentages of learners who grew up in rural areas were 20% for 2016, 17% for 2017, and 19% for 2018. All disciplines were well represented, with each comprising 7–13% of the sample. Eighty-nine percent of learners were required as part of a course to participate, but it was optional in all years for the medical and social work learners and in 2017–2018 for the nursing learners.

Inferential statistics – primary outcomes

Pre- to post-experience change for questions relating to confidence in playing specific roles in an interprofessional discussion about geriatric patient care is shown in Table 3. Learners’ levels of confidence, measuring 8 or greater in all areas measured on a 10-point Likert Scale post intervention, showed statistically significant increases (p < .0001), indicative of strong confidence. Confidence in leading discussions had the greatest change (a 2.7 mean increase).

Table 3. Learners level of confidence that they could play each of the following roles in an interprofessional discussion about patients

Evaluation Measure	N	Baseline Mean (SE)	Follow-up Mean (SE)	Change in Mean (95% C.I.)	p-value for Change^1
I could contribute knowledge from my field of study	560	7.37 (0.07)	8.84 (0.06)	1.47 (1.34–1.60)	<0.0001
I could prioritize plans for our patient’s care	559	6.45 (0.07)	8.33 (0.06)	1.88 (1.73–2.03)	<0.0001
I could lead discussion	557	5.34 (0.09)	8.00 (0.08)	2.66 (2.47–2.85)	<0.0001
I could synthesize the discussion in writing	554	6.21 (0.08)	7.98 (0.08)	1.77 (1.59–1.95)	<0.0001

¹Remain significant after FDR adjustment for multiple comparisons.

Ratings of level of knowledge about the types of services health professionals from varied disciplines could provide to older adults also saw statistically significant increases (p < .0001) after the training experience, with post-intervention scores of 7.9–8.5, as shown in Table 4. The greatest change occurred in learners’ knowledge of the services social workers and occupational therapists could provide (2.7 and 2.6 mean point changes, respectively), followed by that of speech-language pathologists (2.5 mean point change), each of which had low knowledge ratings by learners before the intervention (5.5–5.7 points).

Table 4. How learners rated their level of knowledge about the types of services these health professionals could provide to their patients

Evaluation Measure	N	Baseline Mean (SE)	Follow-up Mean (SE)	Change in Mean (95% C.I.)	p-value for Change^1
Dentist	559	6.28 (0.10)	8.31 (0.07)	2.02 (1.84–2.21)	<0.0001
Dental Hygienist	556	5.91 (0.11)	7.91 (0.08)	2.00 (1.79–2.21)	<0.0001
Dietitian	556	5.60 (0.10)	7.99 (0.08)	2.39 (2.19–2.59)	<0.0001
Nurse	549	6.96 (0.08)	8.10 (0.07)	1.14 (0.97–1.31)	<0.0001
Occupational Therapist	550	5.58 (0.12)	8.22 (0.07)	2.63 (2.42–2.84)	<0.0001
Pharmacist	558	6.22 (0.10)	8.48 (0.06)	2.26 (2.07–2.45)	<0.0001
Physical Therapist	553	6.49 (0.10)	8.41 (0.07)	1.91 (1.73–2.10)	<0.0001
Physician	556	7.61 (0.08)	8.48 (0.07)	0.88 (0.70–1.06)	<0.0001
Social Worker	557	5.71 (0.10)	8.41 (0.07)	2.70 (2.50–2.89)	<0.0001
Speech-Language Pathologist^2	404	5.50 (0.14)	8.04 (0.10)	2.54 (2.30–2.78)	<0.0001

¹Remain significant after FDR adjustment for multiple comparisons.

²Reduced sample size as question re: knowledge of the types of services provided by Speech-Language Pathologists was not asked in 2016.

The importance of each profession in providing health care to older adults also saw significant gains (p < .0001) as shown in Table 5, with post experience mean scores of 8.7–9.4, suggesting all disciplines were considered very important. The smallest mean change seen was for the medicine and nursing disciplines, as pre-intervention scores were already high, 9.2 and 8.9, respectively.

Table 5. Learners rated the importance of the following professionals (Dentist, Dental Hygiene, Medicine, Dietitian, Nurse Practitioner, OT, PT, Pharmacist, Social Worker, Speech/Language Pathologist) in providing health care to older adults

Evaluation Measure	N	Baseline Mean (SE)	Follow-up Mean (SE)	Change in Mean (95% C.I.)	p-value for Change^1
Dentist	557	8.20 (0.07)	9.05 (0.06)	0.84 (0.71–0.98)	<0.0001
Dental Hygienist	554	7.76 (0.09)	8.84 (0.06)	1.07 (0.92–1.23)	<0.0001
Dietitian	558	7.96 (0.08)	9.02 (0.05)	1.06 (0.93–1.19)	<0.0001
Nurse	557	8.93 (0.05)	9.28 (0.05)	0.35 (0.25–0.46)	<0.0001
Occupational Therapist	556	7.98 (0.08)	9.15 (0.05)	1.17 (1.02–1.32)	<0.0001
Pharmacist	559	8.82 (0.06)	9.37 (0.05)	0.55 (0.43–0.67)	<0.0001
Physical Therapist	554	8.28 (0.07)	9.17 (0.05)	0.89 (0.76–1.02)	<0.0001
Physician	557	9.24 (0.05)	9.41 (0.04)	0.17 (0.06–0.27)	0.0015
Social Worker	556	7.66 (0.09)	9.31 (0.04)	1.66 (1.49–1.82)	<0.0001
Speech-Language Pathologist^2	406	6.90 (0.12)	8.69 (0.08)	1.79(1.59–1.99)	<0.0001

¹Remain significant after FDR adjustment for multiple comparisons.

²Reduced sample size as question re: knowledge of the types of services provided by Speech-Language Pathologists was not asked in 2016.

Confidence in knowing when to refer to or recommend other disciplines resulted in large pre- to post-experience gains (1.7–2.6 mean point change) for all provider types, as shown in Table 6. The only exception was of referring to a physician, where again baseline mean confidence was already high (8.4) as compared to other disciplines (5.9–7.2).

Table 6. Learners level of confidence that, in their future practice, they would know when to refer their patients to the following health professionals

Evaluation Measure	N	Baseline Mean (SE)	Follow-up Mean (SE)	Change in Mean (95% C.I.)	p-value for Change^1
Dentist	555	7.20 (0.10)	8.93 (0.06)	1.73 (1.56–1.90)	<0.0001
Dental Hygienist	551	6.22 (0.12)	8.38 (0.08)	2.16 (1.94–2.37)	<0.0001
Dietitian	553	6.56 (0.10)	8.69 (0.06)	2.12 (1.95–2.29)	<0.0001
Nurse	551	6.60 (0.10)	8.29 (0.07)	1.69 (1.50–1.87)	<0.0001
Occupational Therapist	550	6.27 (0.11)	8.64 (0.06)	2.37 (2.17–2.57)	<0.0001
Pharmacist	555	6.54 (0.11)	8.72 (0.06)	2.18 (1.98–2.39)	<0.0001
Physical Therapist	551	6.99 (0.10)	8.90 (0.05)	1.91 (1.74–2.08)	<0.0001
Physician	557	8.39 (0.06)	9.16 (0.05)	0.76 (0.63–0.89)	<0.0001
Social Worker	551	6.20 (0.11)	8.80 (0.06)	2.61 (2.41–2.80)	<0.0001
Speech Language Pathologist^2	394	5.87 (0.15)	8.39 (0.09)	2.52 (2.27–2.77)	<0.0001

¹Remain significant after FDR adjustment for multiple comparisons.

²Reduced sample size as question re: knowledge of the types of services provided by Speech-Language Pathologists was not asked in 2016.

Finally, for primary outcomes, the four main evaluation domains with averages across the 3 years are summarized in Table 7. Mean increase in confidence in functioning in interprofessional teams was significant (p < .0001), with an effect size (ES) of 1.4, considered to be very large using Cohen’s criteria (Cohen, 1969). Large and highly significant effects were also seen in the other domains of knowledge of services provided by other disciplines (p < .0001, ES = 1.6, very large effect), importance of other disciplines in providing health care to older adults (p < .0001, ES = 0.8, large effect), and confidence in knowing when to refer to or recommend other disciplines (p < .0001, ES = 1.7, very large effect). Average gain across all domains showed a 1.7-point change pre- to post-experience (p < .0001, ES = 1.8, very large effect), suggesting the IPE PPG Experience was effective in facilitating confidence in functioning and referring within interprofessional teams and in improving knowledge of and views on the importance of other disciplines who provide care to older adults.

Table 7. Mean pre- to post-experience overall change and individual domains change

Evaluation Measure	N	Baseline Mean (SE)	Follow-up Mean (SE)	Change in Mean (95% C.I.)	p-value for Change
Confidence in functioning in inter-professional teams (Confidence)	562	6.34 (0.06)	8.29 (0.05)	1.95 (1.83–2.07)	<0.0001
Knowledge of services provided by other disciplines (Knowledge)	562	6.20 (0.06)	8.24 (0.04)	2.04 (1.93–2.16)	<0.0001
Importance of other disciplines in providing health care to older adults (Perspective)	560	8.21 (0.06)	9.15 (0.04)	0.94 (0.85–1.02)	<0.0001
Confidence in knowing when to refer to other disciplines (Confidence)	558	6.72 (0.06)	8.70 (0.04)	1.98 (1.87–2.08)	<0.0001
Average^1 across domains	562	6.96 (0.04)	8.65 (0.04)	1.69 (1.61–1.76)	<0.0001

¹Average of all answered questions; note some learners did not respond to one or more questions.

Inferential statistics – secondary outcomes

No yearly differences in change score were found in ratings of importance of other disciplines in providing care to older adults. Pre to post change in views on the importance of other disciplines in providing geriatric care did vary by discipline (p = .01), with a significant difference seen between Occupational Therapy (mean change of 0.6) and Pharmacy (mean change of 1.3). No significant discipline-based variation in change scores was found for confidence in functioning in or referring within interprofessional teams or in knowledge of services provided by other disciplines. Change scores did not vary in any domain based on whether the training was required or optional, with both groups showing considerable gains in all areas after the IPE PPG Experience. Additionally, all learners were asked both before and after the IPE PPG Experience to rank qualities of leadership. These qualities included good listener, being knowledgeable, curious, respectful, dependable, and flexible. Both pre- and post-intervention, being respectful received the highest rank, followed by listening, with being knowledgeable ranked third.

Qualitative Evaluation

When asked what the most meaningful aspect of participation has been in the two interprofessional sessions, learners highlighted the following themes: learning about other disciplines, showcasing own discipline and scope of practice, gaining new ideas of what they desire in future practice and learning what patient-centered care looks like. Table 8 displays quotations from learner feedback.

Table 8. Learner quotations aligned with emerging themes in response to the question: what has been the most meaningful aspect of your participation in the two interprofessional sessions? Learner responses could be grouped into the following themes

THEME	REPRESENTATIVE QUOTES
I learned about other disciplines	I learned about each profession, clearing the air about any myths. I had the opportunity to learn about what knowledge other professions have and how their knowledge allows me to improve what I do in my profession.
I got to showcase my discipline and the scope of my discipline’s practice	It was great to educate others on my discipline. I was so impressed by all of the other students and their passion for both their field and their patients! This experience gave me more confidence in my own knowledge and what I can contribute to patient care.
I have new ideas about what I want my future practice to be like	I feel that wherever I go into practice, I will be able to recommend patients to other disciplines and be able to collaborate more with these other professions as well. On these teams I could trust the expertise in the room to better able to focus on my area of expertise.
I learned what patient-centered care looks like	I enjoyed collaborating with colleagues and realizing how critical a biopsychosocial approach is to patient care. Working in a collaborative setting has been extremely helpful. Seeing the same situation from multiple perspectives has been eye-opening and intriguing. It allows all the pieces of the puzzle to come together with a hopeful outcome at the center of it all.

Discussion

Significant findings in almost all domains measured across 3 years indicated that the IPE PPG Experience improved learners’ appreciation of the value of interprofessional teams. Overarchingly, learners believe that interprofessional practice will improve the quality of care for older adults, as well as their own professional satisfaction. Learners gained significant knowledge and recognition of the importance of other disciplines. Learners also made gains in their understanding of good team process and key leadership abilities. Additionally, interprofessional learners predicted that they were more likely to refer patients to or recommend other disciplines’ involvement in the future. In the quantitative results, the significant positive correlations between knowledge of other disciplines, confidence in playing a role in interprofessional patient care discussions, and knowing when to refer to or recommend other interprofessional team providers suggest that knowledge of interprofessional services may influence confidence in working with and referring to other disciplines within interprofessional teams.

Reflecting on the Plan-Do-Study-Act (PDSA) evaluative process that was essential to the iterative process of developing the interprofessional experience, the faculty team as a community of practice, synthesized different teaching approaches, discipline pedagogy, and cultural awareness to its design. Each subsequent year, the faculty revised activities based upon evaluations from learners and ideas as new faculty joined the team. In this PDSA quality improvement process, four pedagogical principles appeared to be salient: modeling, learning as a social process, relevance to practice, and reflection.

Modeling: At the beginning of the first session, the faculty team role-played a case conference showing the learners what was expected of them as a team: effective communication, disciplinary contributions, client-centeredness, strength-based inquiry, and collaborative processes that learners would use in their small groups. Equally important, the faculty team displayed respect and connection to each other as everyone gathered in the auditorium, made introductions, and debriefed about the experiences. The faculty team realized that a poorly designed experience could reinforce negative stereotypes of disciplines (Baker, Egan-Lee, Martimianakis, & Reeves, 2011).

Learning as a social process: The interprofessional teams were orchestrated to function as learning communities comprised learners who each bring valuable expertise, share a goal (outcomes for patients), and discover how their work is made better by a diversity of knowledge, skills, and beliefs (Lave & Wenger, 1998). The IPE PPG Experience was designed to reinforce democratic processes and build habits of collaboration for future health care teams. Those habits include shared responsibility, respect, and inclusivity, as well as flexibility to assume roles in leadership or followership. In recognizing the diverse backgrounds of the learners, it was particularly interesting to note the number of learners who came from a rural background, which remained consistent at approximately 19% of the learners, and how that perspective contributed when constructing a shared plan.

Relevance to practice: The cases were composites of faculty experiences, designed to engage real-world reasoning that learners would encounter in practice with older adult patients. Cases contained information on the patients and their health conditions, abilities, context, and functioning in their daily lives. The cases had complexity, uncertainty, and missing information, accurately portraying real-world practice. Complexity was a prompt for collaboration (Davis & Affenito, 2016), uncertainty called for imagination, and missing information promoted inquiry. These forms of engagement were designed to draw learners into the story, to care enough about the “case” and their part in the team and to see this learning as contributing to how each learner could become a better health care provider.

Reflection: Reflection is an essential part of learning and best practice (Dewey, 1938; Kinsella, 2010; Schön, 1987). The structure of the sessions allowed time for reflection on learning by the individual learners; as well as by the faculty through use of the Plan-Do-Study-Act evaluation cycles.

Limitations

There were relevant limitations related to the nature of this experience. First, there were logistic challenges regarding space to accommodate the many disciplines, thus requiring us to limit learners to 25 per discipline. Also, while faculty did their best to ensure leveling and alignment of learners, some disciplines had to adapt to the time and coordination with the learners who were available. For example, only first-year medical student learners were primarily available to attend, while other disciplines had higher-level learners in attendance. Some learners who voluntarily participated in the experiences may have been biased toward valuing the experience. This experience was time-limited to two afternoons. The evaluation was immediately post-experience, and the long-term effects on attitude and future practice are not known. Such follow-up information would offer rich information for further development of the experiences. Additionally, of our learner population that participated, a large majority are identified as white and non-rural, which can be a limitation to incorporating shared diverse perspectives and generalizability of the results. Representation of different racial/ethnic groups and health disparity populations is important for diverse dialogue among learners as it can enrich learning principles of treating all patient populations in an equitable way (National CLAS Standards, 2013).

Future planning

Due to the success of the IPE PPG experience, the Assistant Provost for Interprofessional Education and Practice at the University of North Carolina at Chapel Hill has added this curriculum to the University’s IPE experiences that the Provost’s Office is now sponsoring. Thus, the Provost’s Office has made the commitment to continue to assist with the dissemination of the IPE PPG experience, which includes supporting an administrative coordinator to help assist with the execution and implementation of the experience. Future planning occurring now in the Provost’s Office is recruitment of additional disciplines for participation in the IPE PPG experience, including invitations to other UNC health profession graduate programs geographically located outside of Chapel Hill. With the frequency of online learning occurring due to the COVID-19 pandemic, the Provost’s Office plans to sponsor this IPE PPG experience online; affording the opportunity for other North Carolina institution learners from different parts of the state to participate.

Additionally, the design of the cases and of the experience continues to evolve to address contemporary issues and complexities to optimize learning, such as management during a global pandemic, increased diversity in social determinants of health and cultural backgrounds presented, and greater attention to the impact of health disparities. There is an aspirational hope that continuing to have these IPE experiences tailored to care of the older adult population will increase provider satisfaction and reduce burnout that will help to preserve the health care workforce for a growing demographic of older adults.

In summary, this collaborative approach toward caring for older adults is the key to successful patient-centered care. The IPE PPG Experience has significantly increased future practitioners’ confidence in teamwork and understanding of when to refer/recommend older adult patients to other specialties. Ultimately, bringing interprofessional teams together in practice will improve the health and well-being of older adults while reducing health inequities.

Data availability statement

The data that support the findings of this study are available from the corresponding author, KS, upon reasonable request.

Disclosure statement

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

Additional information

Funding

This project was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) Geriatrics Workforce Enhancement Program award under grant number #U1Q28734. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.