Effective Learning of Interprofessional Teamwork

Rossler, Kelly L. PhD, RN; Buelow, Janet R. PhD, RN; Thompson, Anne W. EdD, PT; Knofczynski, Greg PhD

doi: 10.1097/NNE.0000000000000313
Feature Articles

Educators are actively identifying optimal teaching-learning strategies that afford future health care professionals opportunities to acquire skills necessary to function as a member of an interprofessional team. This article describes the development of an interprofessional team learning experience consisting of students from 6 health professions programs within 1 college of health professions. Student achievement of interprofessional team competencies were evaluated in a pretest-posttest format. Essential components of a 7-week program, teaching methodologies, and course evaluations are presented.

Author Affiliations: Assistant Professor (Dr Rossler), Louise Herrington School of Nursing, Baylor University, Dallas, Texas; Professor (Dr Buelow), Health Services Administration; Department Head (Dr Thompson), Rehabilitation Sciences; Associate Professor, Statistics (Dr Knofczynski), Armstrong State University, Savannah, Georgia.

The authors declare no conflicts of interest.

Correspondence: Dr Rossler, Louise Herrington School of Nursing, Baylor University, 3700 Worth St, Dallas, TX 75246 (Kelly_Rossler@baylor.edu).

Accepted for publication: June 26, 2016

Published ahead of print: August 3, 2016

Article Outline

The Core Competencies for Interprofessional Collaborative Practice presents guidelines for interprofessional collaboration and education that communicate a vision focused on providing students with competencies to practice teamwork and team-based care.1(pi) Educators are striving to create learning experiences that will provide the critical knowledge base and skills necessary for effective interprofessional teamwork. However, today’s students are being educated in a rich variety of programs from multistate locations and online programs, as well as in traditional face-to-face classrooms. Requirements for entry into health professions vary greatly, thus increasing the diversity of the student population. Educators are challenged by the multitude of curricular pathways now available for students seeking an undergraduate degree.

Regardless of the entry pathway, faculty need to ensure that students enrolled in health professions programs gain interprofessional teamwork learning experiences to prepare for entry into practice.2 Across the globe, faculty acknowledge how complexities integral to individual health professions programs present challenges in building a common core of interprofessional teamwork skills and knowledge. Some factors that influence both interprofessional education (IPE) methods and learning outcomes can include student demographic characteristics, diverse delivery formats of each health profession program, educator capabilities, faculty and institutional knowledge of IPE, physical design, and resources available to conduct teaching-learning experiences.3-6 While a variety of educational approaches are described in the literature, no consensus has been reached about the ideal educational approach to enable effective interprofessional collaboration.7 Meleis5 brought attention to several critical factors: multiple interpretations of the definition of IPE; the unique language of each health care profession; the need for alignment of health professions education; and the lack of valid, reliable, and established metrics exploring IPE. The Institute of Medicine provided compelling evidence for the need to align health care systems and education and evaluate the impact of IPE in the health care setting.8 In their vision series, the National League for Nursing recognized the nurse as a vital team member in the health care practice setting and urged nurse educators to embrace this new interprofessional learning paradigm. Guidelines for the transformation of nursing education through the implementation and evaluation of IPE initiatives were offered within this vision series.9

The purpose of this article is to share the components and outcomes of an interprofessional team learning experience consisting of students from multiple health professions and programs, such as off-campus clinicals, online programs, and traditional campus programs. All programs were within 1 state supported university in southeast Georgia. For this IPE learning experience, faculty provided a 7-week program with weekly online components and 1 half-day simulation workshop. Student learning outcomes were evaluated in a pretest-posttest format, using a standardized instrument.

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Learning Experience and Teaching Components

Team facilitators were faculty from a variety of disciplines who had experience working in interprofessional clinical and educational teams. All faculty volunteered their own workload time for this pilot project. Faculty met regularly over the preceding semester to design and test the online framework, develop procedures for course instruction, and construct grading rubrics for the IPE learning experience. No additional academic resources were necessary for this project. From the start, the interprofessional faculty members were aware that each health professions program within the college had widely varying enrollments, clinical assignments, and program requirements. After a variety of attempts to integrate IPE opportunities within the curricula of 7 professional degree programs, the format of this learning experience seemed most satisfactory for fitting into the array of health professions programs. However, an evaluation of student learning of interprofessional team skills, knowledge, and attitudes was needed. Student learning objectives focused on the following outcomes: (1) gain knowledge and ability to work with multiple health care professions, (2) be aware of significant outcomes from interdisciplinary health care teams, (3) identify effective team practices, and (4) perform as an effective team member. Teaching-learning strategies encompassed an online blended learning format and an interprofessional workshop.

This IPE team learning experience was designed to be a requirement within individual health professions courses and represented from 10% to 20% of each participating student’s grade within that course. All components were completed within the first 7 weeks of the semester. During the first week of the semester, individual course faculty introduced the participating students to the IPE team learning experience and identified how it fit within course requirements. Each student was assigned to an interprofessional team consisting of 6 to 8 students from different health professions and 1 faculty facilitator from the IPE committee. Students were invited to take a preprogram survey and then were directed to the online learning site to virtually meet their team members and faculty facilitator. From the beginning, all modules involved team-based discussion and problem solving.

After this first week of introductions, the IPE learning experience consisted of 4 weekly online teaching components: (1) didactic modules with audiovisual presentations and an accompanying quiz, (2) an evolving case study with required team work problem solving, and (3) online discussions where students provided discipline-specific recommendations related to the case study. The evolving case study, developed by the IPE faculty committee, was based on a hurricane evacuee involving a pregnant female with medical and social needs. The online learning promoted team dynamics through modules focused on peer introductions, interprofessional teams in health care, team processes, and team usefulness. These online learning modules were designed to incorporate 2 of the 4 interprofessional core competencies: roles and responsibilities and teams and teamwork. Each team’s faculty facilitator graded the weekly quizzes and weekly discussion postings related to the evolving case study.

At the beginning of the sixth week, students were provided with an online patient chart and instructed to review the documents in preparation for their face-to-face teamwork with a simulated patient during a Saturday morning workshop. To facilitate students’ schedules, the workshop date and time were provided at the beginning of the semester. During the workshop, the students worked as an interprofessional health care team to interview a standardized geriatric patient actor with complex medical and social needs. The role of the standardized patient was previously developed by the IPE faculty committee. Each interprofessional team had 20 minutes to plan its interview approach, 30 minutes to interview the patient, and 30 minutes to determine priority issues and health care recommendations for the patient. Faculty facilitators observed their teams and provided post hoc feedback on team dynamics and teamwork effectiveness exhibited during the learning experience. To conclude the workshop, all students gathered in a large ballroom to share their teamwork experiences in a guided discussion format. During the final week of the program, the students posted online reflections of their experiences and completed the postprogram survey. In addition, each student provided feedback on perceived peer participation and effectiveness for each member of their team. These data were used to assess the effectiveness of the 4 student learning outcomes.

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A total of 118 students from undergraduate and graduate health professions participated in the interprofessional team experience, and a total of 96 students completed both the preprogram and postprogram team experience surveys. The undergraduate students were in RN to BSN (n = 20), health administration (n = 25), and respiratory therapy (n = 12) programs. Graduate student participants were enrolled in physical therapy (n = 10), speech-language pathology (n = 13), and public health (n = 16).

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Measures and Instruments

Students were assessed at the beginning and conclusion of the interprofessional team learning experience with an online survey. Study instruments consisted of several demographic questions, the Interprofessional Socialization and Valuing Scale (ISVS), and a question regarding students’ knowledge about the professional roles of different health professions participating in the experience.10 The ISVS is a scale administered in a self-report format and is composed of 24 statements with a 7-point Likert scale (7 = “to a very great extent” and 1 = “not at all”). For this project, the Likert scale was reversed (1 = “to a very great extent” and 7 = “not at all”). This scale consists of 3 subscales: self-perceived ability to work with others (inclusive of 9 factor items), value working with others (inclusive of 9 factor items), and comfort in working with others (inclusive of 6 factor items). The internal consistency Cronbach’s α for the 3 subscales ranged from .79 to .89, with an α of .90 reported for the entire scale. Permission to use the ISVS instrument was obtained from King and colleagues, and the university institutional review board approved the use of student data from the preprogram and postprogram surveys. All participating students were informed of this evaluation.

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Data Analysis

As a relatively new instrument, the preprogram data from the ISVS were used to repeat the original data analysis of King and colleagues.10 This consisted of a principal component analysis with a varimax rotation. Examination of the eigenvalues and the scree plot strongly suggested that the 3 subscales were still appropriate. However, after evaluating the individual items’ loadings, 4 of the 24 items from the ISVS were deleted. Thus, the ISVS scale used in this study included 20 of the original 24 item original scale develop by King and colleagues.10

Once the factors with each subscale were determined, the data were analyzed for significant differences in mean scores from pre and post program for all students, undergraduate and graduate students, and each of the 6 professions participating in the team experience. For each profession, the 3 subscales were first tested using a multivariate analysis of variance statistical significance set at P ≤ .05 using SPSS (IBM Corp, Armonk, New York). Post hoc analyses were conducted utilizing a Sidac corrected level of significance to limit type I errors. Data analysis was also conducted for the survey question regarding the students’ self-perceived knowledge about the professional roles of other health professions.

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As presented in the Table, the ability, value, and comfort of working in teams’ scores improved significantly from preprogram to postprogram among both undergraduate and graduate students (P ≤ .001). Both nursing and speech-language pathology students had significant improvements in the means of all 3 subscales, with P values under .007. Statistically significant improvement was seen in at least 1 of the 3 subscales for students in public health, health administration, and physical therapy. Respiratory therapy students showed improvement but did not reach the level of statistical significance. Note that the lower the score, the more students valued and believed they were skilled in working in interprofessional teams.

Students were asked before and after the program to rate their knowledge of specific health professions. The results of students’ perceptions of their knowledge about different health professions’ roles are presented in the Figure. Students entered the program believing that they knew the roles of physical therapists, health administrators, and registered nurses the best (the lower the score, the more knowledgeable). By the end of the program, students’ knowledge of the professional roles significantly improved for all students, except the respiratory therapy students.

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Interprofessional teams are recognized as needed for effective patient care, yet faculty are struggling with providing this education within the complicated confines of our higher education system where individual programmatic constraints and inherent role boundaries of practice exist.11,12 The measured outcomes of this interprofessional team experience reveal significant improvements in students’ value and comfort in working with others, as well as their knowledge of other health professions. The RN-BSN nursing students, despite their high scores going into the program, improved significantly in all scores for the ability to work with others, value in working with others, and comfort in working with others. Of particular interest, all subscale scores of nursing students increased, suggesting that the practicing nurse students who were returning to obtain a baccalaureate degree still gained IPE and collaboration experience within the practice setting. Furthermore, other health professions gained a greater knowledge of nurses and their role within the health care team. Lee and Fawcett13 reported how professional identity among RN-BSN students was of concern. With a “variety of diverse practice-based experiences,”13(p96) this distinct group of nursing students may not have a clear understanding of the role of the professional nurse or how to develop a professional identity. Literature supports that students enrolled in both nursing and health care professions programs recognize the need to understand professional relationships, identify role attributes specific to becoming a member of a health care team, and are ready to engage in IPE educational experiences.14,15

One of the purposes of this study was to evaluate this learning experience as a strategy for effective student learning of interprofessional teamwork. From the positive results seen in all team subscale scores with both undergraduate and graduates, and specifically for the nursing program, it appears that this blended learning program can provide benefit for today’s rich variety of educational programs. For RN-BSN nursing students, current literature supports how student interaction with peers, instructor performance, and social presence are keys to success for online learning courses.16 Social presence has been related to how a student is perceived as a “real person.” The format for this IPE learning experience appears to offer environments conducive to levels of engagement where student participants could make meaningful connections.17 Although the respiratory therapy students’ perceptions did not significantly change, specific IPE curricula for this program in the clinical setting may offer more collaborative interactions with a variety of health care professionals.18 Content delivered during the online evolving case study or the IPE workshop simulation scenario might not have been as meaningful or offered a way for the respiratory students to connect with the other participating health professions students.19

Program schedules, licensing requirements, and location of student clinical internships are often recognized as common barriers to providing interprofessional experiences. By keeping our interprofessional team experience relatively short and within required program courses, students and faculty overcame these barriers. Online technology not only allowed for the effective dissemination of didactic information via virtual asynchronous presentations and quizzes but also eliminated scheduling conflicts among the student participants. Asynchronous discussions offered a means for students to participate at personally convenient times. The inclusion of a face-to-face half-day workshop to provide hands-on experience with teamwork, decision making, and interprofessional communication presented a scheduling challenge. However, many students reported that the workshop was important, reinforcing their achievement of learning outcomes and contributing to the overall success of the experience.

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Student Reflections

At the conclusion of the learning experience, students were asked to provide a reflection on their experiences, with specific prompting questions. Student course reflections substantiated much of our quantitative findings in regard to how students learned and gained valuable insights and skills in interprofessional teamwork. In addition, qualitative findings demonstrated what students perceived as their capacity to work as an effective member of a team. In response to the question, “What did you learn about yourself from this experience?” many students wrote about learning the necessity to improve personal communication skills. One nursing student noted, “I learned that I have to take myself out of my comfort zone and problem solve out loud, instead of analyzing in my head. By verbalizing and effectively communicating, problems can be solved from a team approach.” Another nursing student recognized listening as important, with the statement of “I learned that I am probably a bit outspoken in a team setting, maybe even come across as pushy…. I learned to be more respectful of others’ opinions and perspectives and to take time to actively listen, even if my perspective differs.” A health administration student reflected: “I learned I can get over my fear of speaking out because sometimes what I have to say is important.”

Several students explained that working in a team as not always easy, especially with other students who have, in the words of a student, “big personalities;” but the care a patient received from an effective team was impressive to the students. A physical therapy student stated, “I learned how to bounce ideas off the other professionals and ways that we can work together to maximize a patient’s plan.” A health administration student wrote, “When the team works together towards the common goal (patient’s health), the members can use each other’s ideas to make sure that all areas are covered and nothing is being left out.”

Survey data and final reflection writings demonstrated that students from the various disciplines were more knowledgeable about each represented health profession by the end of the program. While other health professions believed they knew most about nurses, there was still a significant gain in knowledge. Likewise, the nursing students learned more about other health professions. Student reflections demonstrated how learning about the different roles of their student peers was important. A physical therapy student explained: “I learned a lot about responsibilities of other health professions. Each member of the team brings a unique set of skills, which make treatment more valuable and more efficient.”

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One limitation of this study is its small sample size. Although the overall student sample size (N = 96) appears adequate for statistical analysis, the small numbers in the subgroups of individual health disciplines (10-25 students/program) are not robust enough to produce generalizable results. Data from the respiratory therapy students were limited as many chose not to complete the post program survey. During the semester in which the IPE experience was offered, the nursing students enrolled in the traditional program were not able to participate in the study, impacting the capacity to gather data related to this particular student population. Use of the ISVS instrument is identified as another limitation of this study. Although the ISVS was designed to measure the degree to which learning takes place in the area of interprofessional teamwork, the limited previous use of the tool makes comparative data unavailable. Further testing is needed to confirm the subscale factors. Future research also should include the addition of a comparative control group of students, as well as longitudinal surveying of program graduates to determine the retention of gains in interprofessional knowledge and teamwork.

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This interprofessional team learning experience offers one avenue to promote interprofessional team education within the complex higher education programs currently provided to students. The combination of online modules, a half-day face-to-face workshop, and the program as a requirement within courses are critical components, which afforded students the opportunity to interact, problem solve, and increase their interpersonal knowledge and skills. Likewise, faculty training, support for facilitating teams, onsite observing, and providing focused debriefing are essential for an effective experience for students. This project produced foundational components that have subsequently been used to create an IPE communications course within the College of Health Professions; another positive outcome was the development of an Interprofessional Collaborative Practice Model. Findings from this interprofessional team learning experience provide essential programmatic evaluation from which to guide current endeavors in nursing education and other health professions programs.

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health professions education; interprofessional education; interprofessional team; nursing education; online program; teamwork

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