Interprofessional communication in a socio-hierarchical culture: development of the TRI-O guide

Figures & data

Figure 1 Procedures of this study.

Abbreviations: AI, appreciative inquiry; FGDs, focus group discussions; IPE, interprofessional education; NGT, nominal group technique; TRI-O, open for collaboration, open for information, open for discussion.

Table 1 Attributes of IPE communication skills in the context of wider socio-cultural gaps in four initial categories and grouped into three “O” framework (TRI-O)

The attributes →	Teamwork	Roles and responsibilities of health professionals	Patient safety	Communication
The TRI-O framework ↓
Open attitude for collaboration	1. Awareness 2. Care 3. Equity 4. Commitment 5. Health professional concern 6. Health professional “egoless” 7. Need each other 8. Understanding	9. Confidence 10. Confidentiality	11. Comfortable 12. Helpfulness	13. Active listening 14. Attentiveness 15. Exploration first 16. Communication 17. Communicative 18. Openness 19. Respect 20. Trust 21. Willingness to collaborate
Open for information	22. Responsiveness	23. Less competitiveness 24. Supports	25. Alternative medicine 26. Ethics 27. Patient centeredness 28. Patient concern 29. Safety 30. Satisfaction	31. Informative
Open for discussion	32. Collaboration 33. Cooperation 34. Coordination 35. Teamwork 36. Working together	37. Abilities 38. Authority 39. Clarity 40. Complementary roles 41. Less individuality 42. Roles and responsibilities of individual professionals 43. Roles and responsibilities of other health professionals 44. Substitute roles	45. Monitoring and evaluation	46. Complementary information 47. Discussions 48. Sharing information

Abbreviation: TRI-O, open for collaboration, open for information, open for discussion.

Table 5 Perceptions of students, years 4 and 1, before and after training using the TRI-O guide

Role-players	Superficial reflection of students before discussions with the TRI-O guide	Deeper reflection of students after discussions with the TRI-O guide	Interpretations of the qualitative data
A medical student, year 4, who acted as the physician (student 1)	“I have tried my best to provide comprehensive care to the patient.”	“In my perception, I was trained to work alone, I do not know how to ask help from other health professionals because I feel as a doctor I must do all procedures correctly. But next time I would love to get help and be helpful for others.”	Typical thinking by the perceived higher social hierarchy, in this case, is “the physician”, which changed after the training into a willingness to collaborate.
A nursing student, year 4, who acted as the nurse (student 2)	“I have tried my best to provide care to the patients. Actually I would do more, I can clean the wound and help educate the patient but apparently, we do not have much time.”	“I know that I should take care of the wound, I knew all theories and skills to do a wound debridement for a diabetic patient, including the principles of dry and wet wound care, but I do not know how to explain it to the doctor that I know lots of things, so I just wait for him to ask me.”	Hesitation to initiate communication to the perceived higher hierarchy is typical.
A nutritionist student, year 4, who acted as the nutritionist (student 3)	“Hmmm… I did not do much, yes I agree we don’t have the time. I would like to assess the patients’ habits of daily nutrition and educate him with proper diet for diabetic patients so he could not get to the diabetic ulcer stage….”	“I would like to participate in the consultation, I had tried to give a ‘code’ for the doctor for my turn, but I do not know how to communicate collaborative care to other health professionals…”	Using nonverbal signs, which is typical in this socio-hierarchical context.
A trained SP	“Yes the doctor was friendly and kind and also other health professionals, the nurse is really kind…actually I would ask something, but the doctor had explained.”	“Well…yeah….as far as I remember, the doctor seemed to talk by himself, the nurse and the dietician talking to me but not to each other, ooh...and I would like to ask many questions …”	Clearer articulated concern of the “patient”.
A medical student, year 1, who acted as the physician (student 1a)	“Hmmm I didn’t know what to do, but I think I came to the important things like vital-sign.”	“I did not anticipate that it will be this complicated, but next time I will ask help from others instead of giving instructions, and I will learn to apologize and to say thank you.”	Awareness of the initiation of the discussion and information sharing and decision-making with the perceived higher hierarchy on the basis of patient safety after the training.
A nursing student, year 1, who acted as the nurse (student 2a)	“I tried to bring the patient into a safer place.”	“I will do my job my best, I will try to provide comfort for the patients, and I will obey doctor’s suggestions. If the suggestion is less complete I will communicate and discuss with the doctor for the best care for the patients.”
A nutritionist student, year 1, who acted as the nutritionist (student 3a)	“I tried to take care of her by buying her a hot soup…(laughing).”	“I will try to communicate in more assertively with the doctor and discuss with him and the patients on proper nutrition for the patients.”

Abbreviations: SP, simulated patient; TRI-O, open for collaboration, open for information, open for discussion.

Table 2 A guide of IPE communication developed in this study

Structure	Content of IPE communication guide as knowledge based for the purpose of collaborative teamwork practice toward better patient-centered care and patient safety	Construct from IPEC, 2016 (only appears in this paper and not for the training)	Communication attitude strengthened: “interpersonal skills”	5-point Likert scale from the most disagree (1) to strongly agree (5)
Open attitude for collaboration To have an attitude of minimizing the social hierarchy and to be open for a collaborative teamwork with other health professionals	1. Ability to respect role, task, and function of other health professionals, with awareness that every health professional needs to cooperate together for the sake of patient safety as well as provider safety.	CC3. Express one’s knowledge and opinions to team members involved in patient care and population health improvement with confidence, clarity, and respect, working to ensure common understanding of information, treatment, care decisions, and population health programs and policies. CC4. Listen actively and encourage ideas and opinions of other team members. CC6. Use respectful language appropriate for a given difficult situation, crucial conversation, or conflict.	Example: I respect other health professionals as partners who I can rely on when I need.	1	2	3	4	5
	2. Ability to build trust and equal relationship with other health professionals.		Example: I am willing to learn (receive and share information) from other health professionals.
	3. Ability to start a mutual relationship between health professionals.		Example: I welcome other health professionals’ contribution to help my task.
Structure	Content of IPE communication guide as knowledge based for the purpose of collaborative teamwork practice toward better patient-centered care and patient safety	Construct from IPEC, 2016 (only appears in this paper and not for the training)	Communication attitude strengthened: “assertiveness skills”	5-point Likert scale from the most disagree (1) to strongly agree (5)
Open for information (verbal and nonverbal) To initiate communication with other health professionals in a proper assertive manner	4. Ability to initiate interpersonal communication with other health professionals.	CC3, CC4, CC6, etc. CC5. Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others.	Example: I will initiate communication with other health professionals, eg, for a “lifesaving” case that needs immediate action as well as for chronic illnesses that need continuous and intensive treatment because we need each other to complement our tasks.	1	2	3	4	5
	5. Ability to communicate concern with other health professionals (between individual or during a group meeting).		Example: I will initiate communication regarding patients’ concern.
	6. Ability to explore the use of alternative medicine (which is a habit in the non-western contexts) with other health professionals.		Example: The use of traditional medicine is a habit. Therefore, I communicate this issue carefully also to other health professionals.
	7. Ability to maintain ethics during communication with other health professionals.		Example: I respect health professionals’ norms, values, and beliefs during communication with other health professionals.
Structure	Content of IPE communication guide as knowledge based for the purpose of collaborative teamwork practice toward better patient-centered care and patient safety	Construct from IPEC, 2016 (only appears in this paper and not for the training)	Communication attitude strengthened: “advocating and negotiating skills”	5-point Likert scale from the most disagree (1) to strongly agree (5)
Open for discussion To be able to share information and share decision with other health professionals based on patients’ concern and the latest evidences in health sciences	8. Ability to share information and to provide proper complementary information to other health professionals (via verbal, nonverbal, or written communication).	CC2. Communicate information with patients, families, community members, and health team members in a form that is understandable, avoiding discipline-specific terminology when possible. CC7. Recognize how one’s uniqueness (experience level, expertise, culture, power, and hierarchy within the health team) contributes to effective communication, conflict resolution, and positive interprofessional working relationships CC1. Choose effective communication tools and techniques, including information systems and communication technologies to facilitate discussions and interactions that enhance team function. CC8. Communicate the importance of teamwork in patient-centered care and population health programs and policies.	Example: I will strengthen, adjust, and synchronize any information that has already been given by other health professionals in a constructive manner.	1	2	3	4	5
	9. Ability to apply paradigm, ie, willing to help, willing to strengthen information, and willing to adjust information from other health professionals – based on role, task, and function of health professionals.		Example: I will discuss any appropriate information with other health professionals to strengthen and adjust previous information for the patients.
	10. Ability to approach mutual agreement with other health professionals for any patients’ problem.		Example: I will discuss and negotiate any unsynchronized information from other health professionals for mutual agreement.
	11. Ability to collaborate and cooperate with other health professionals for any patients’ problem.		Example: I will maintain good relationship of collaborative practice with other health professionals.

Abbreviation: IPE, interprofessional education.

Table 3 Results of the NGT

Structures	1	2	3	4	5	6	7	8	9	10	11	12	Total
1. Open attitude for collaboration
1.1	2	5	5	5	5	1	4	5	5	5	4	5	56
1.2	2	5	5	5	5	5	5	5	4	5	4	5	60
1.3	4	5	5	5	5	5	4	5	5	4	3	5	60
2. Open for information
2.1	2	5	5	5	4	5	5	5	2	5	5	5	58
2.2	2	5	5	5	4	4	4	5	4	4	4	5	56
2.3	4	5	5	5	5	4	5	5	4	4	5	5	61
2.4	2	5	5	5	3	4	4	5	2	4	4	5	53
3. Open for discussion
3.1	2	5	5	5	4	4	4	5	5	4	4	5	57
3.2	2	5	5	5	4	4	4	5	5	4	5	5	58
3.3	1	5	5	5	5	3	4	5	4	5	5	5	57
3.4	2	5	5	5	4	5	5	5	5	4	5	5	60

Abbreviation: NGT, nominal group technique.

Figure 2 Illustration of the use of the IPE TRI-O communication guide in the study.

Abbreviations: IPE, interprofessional education; TRI-O, open for collaboration, open for information, open for discussion.

Table 4 Pre–posttest results on year 4 and 1 students’ perceptions before and after training using the TRI-O IPE communication guide

Students	N	Mean (± SD)		P-value	CI (95%)
		Pre	Post
Year 4
All	107	52.52 (±4.15)	54.00 (±4.21)	0.001	–
Medical education	34	53.50 (±3.74)	54.88 (±4.35)	0.014	–
Nursing	33	52.00 (±4.34)	53.27 (±4.84)	0.033	–2.44 to –0.11
Health nutrition	40	52.13 (±4.29)	53.85 (±3.47)	0.014	–3.08 to –0.37
Year 1
All	53	52.98 (±3.92)	56.00 (±2.97)	0.001	–
Medical education	30	52.30 (±4.23)	56.17 (±2.91)	0.001	–
Nursing	12	52.50 (±3.23)	54.58 (±3.53)	0.116	–4.77 to 0.60
Health nutrition	11	55.36 (±2.94)	57.09 (±1.92)	0.127	–4.04 to 0.58

Note: Paired sample t-test, significant if P<0.05.

Abbreviation: TRI-O, open for collaboration, open for information, open for discussion.