Interprofessional teamwork training for nursing and medical students in Norway

Abstract

Background: This thesis focuses on interprofessional teamwork (TPT) training for medical and nursing students in Norway, seeking to expand and deepen the knowledge base underpinning such training. The topic raises a number of issues linked to the current status of TPT and TPT training, the conceptual understanding of the perspectives needed for planning and design of TPT training, and the strategies and measures conducive to future improvements. The results discussed in this thesis are published in four separate papers, referred to as papers T-TV.

The expectation that TPT can help reduce patient harm may be regarded the main driver of TPT training in health education and healthcare practice. Policywise, the World Health Organization has highlighted TPT as a core component of the recommended skill-set of healthcare workers. Reiterating this position, Norwegian government authorities have enacted policies calling for collaboration across professions and educational programs, including interprofessional clinical training. To date few studies have explored students', faculty members', and clinical practitioners' conceptualization of TPT training, especially not across diverse stakeholder groups. Students' views are arguably of special interest; in spite of this little attention has been devoted to their perspectives on TPT and TPT training.

Aims: The overarching aim of the thesis is to present in-depth accounts of the stakeholders' perceptions, experiences and recommendations for TPT training in healthcare education in Norway, with the intention of strengthening the knowledge base for the planning, designing and implementation of such training. Against this backdrop the following objectives have guided the research:

• To explore the status of TPT training in the context of the Norwegian education of medical and nursing students. • To develop a conceptual understanding of TPT training in healthcare, based on the perspectives of the stakeholders. • To develop and conduct a pilot TPT training session for nursing and medical students.

More specifically, seven research questions were crafted to operationalize the objectives.

Methodology: This thesis is qualitative in nature, employing an explorative and descriptive case study design. The case is set in the Norwegian educational system for nursing and medical students, and encompasses two universities and a university hospital. The case content focuses on the perspectives of stakeholders (students, teachers, and clinicians). The case is explorative due to several novel aspects, including bringing together the views of students, teachers, and clinicians for a qualitative inquiry of perspectives, ideas, and practices pertaining to TPT and TPT training in a pre-graduate educational setting.

Paper T queried all 32 of Norway's nursing and medical educational institutions for information on TPT training offered through study programs. Data in papers TT and TTT were acquired mainly through focus group interviews; paper TV is based on data obtained from debrief sessions that followed simulation-based TPT training sessions. Tn addition, the study included data from individual interviews and observations carried out at a hospital ward (paper TTT). The data analysis was mainly inductive, based on content analysis, a technique that generates categories and themes that are grounded in the data. The data analysis resulted in the development of a conceptual framework for TPT training.

Results: The four papers together constitute a cohesive effort to expand and deepen the knowledge underpinning TPT training for medical and nursing students in Norway. Grounded in the perspectives of the key stakeholders, the results are concerned with fundamental principles. Below, the main results are structured according to the seven research questions:

What are the commonalities and differences in the IPT contents adopted in the curricula of the various educational institutions? (paper T). Encouraged by government policies, all of the medical and nursing schools in Norway had adopted objectives of providing TPT training. The curricula of these schools were similarly structured with two components: theoretical lecturing and clinical practice.

How are the components of IPT embedded in nursing and medical curricula in Norway? (paper T). Most of the schools - medical and nursing - had introduced TPT as a topic in theoretical lecturing; only three nursing schools had yet to do so. Tn clinical practice, the uptake of TPT training was slower; one of four medical schools, and 25 of 28 nursing schools did not offer TPT training.

What are students’ perceptions of their professional roles in the context of IPT? (paper TT). A knowledge gap was found to exist between the medical students and the nursing students; meaning the medical students had incomplete knowledge of the capabilities of the nursing students, and vice versa. The knowledge gap was perceived as an obstacle to TPT. The analysis further exposed a traditional pattern of professional roles prevailing in TPT, influencing the professional understanding of responsibility. The medical students were inclined to individual behavior, assuming responsibility, while the nursing students perceived themselves as coordinators inclined to sharing responsibility.

How do students perceive IPT arenas? (paper TT). There was substantial variation in the students' perceptions of TPT arenas (e.g. ward rounds, psychiatric wards), reaching from arenas with good collaboration, to arenas characterized by rigid hierarchical structures. Psychiatric wards were highlighted as arenas favorable to collaboration and TPT. The students suggested the huddle meetings and the daily rounds as useful arenas to serve as a basis for TPT training.

How do the relevant stakeholder groups perceive the contents of IPT in the education of nursing and medical students? (paper TTT). Students and other stakeholders perceived TPT and TPT training favorably but still profoundly influenced by professional role patterns, with the medical students and physicians occupying the dominant role. The perceptions of TPT and TPT training among the stakeholders exposed three perspectives through which issues pertaining to TPT training were addressed: clinical professionalism, team performance, and patient-centered perspective.

Together the perspectives constitute a conceptual framework that provides a structure for addressing a broad range of phenomena associated with TPT and TPT training. The results furthermore concluded that the patient-centered perspective was conspicuously under-represented among the stakeholders.

What characterizes interprofessional communication among nursing and medical students in a simulation-based training session and how do students describe it? (paper TV). Based on the perspectives of the students, the analysis identified two characteristic communication types: clinical exchange and collaborative exchange. Less manifest in the students' communication was patient- centered exchange. Medical students were perceived as likely to favor clinical exchange, and consequently de-emphasizing the need for collaborative and patient centered exchange.

How do nursing and medical students perceive the use of SBAR in a simulation- based training session? (paper TV) Functioning best for clinical exchange, the introduction of SBAR proved only partly successful and required customization to the simulation scenarios at hand.

Conclusion: TPT training as part of clinical practice for nursing and medical students is still being introduced into the Norwegian educational system. Based on stakeholders' perspectives, this thesis has contributed to expanding and deepening the knowledge base underpinning TPT and TPT training. The students' perceptions were of particular interest, and revealed the existence of a mutual knowledge gap among nursing and medical students. A conceptual framework consisting of three dimensions: clinical professionalism, team performance, and patient-centered perspective has been developed, and may serve as a tool for planning and designing TPT training. A pilot TPT session provided insight into communication processes and reiterated the need for the patient-centered perspective.