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The Development of Professional Identity and the Formation of Teams in the Veterans Affairs Connecticut Healthcare System’s Center of Excellence in Primary Care Education Program (CoEPCE)

Meyer, Emily M. PhD; Zapatka, Susan APRN; Brienza, Rebecca S. MD, MPH

Author Information
doi: 10.1097/ACM.0000000000000594
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Abstract

Postgraduate health professional education redesign is important for both the medical and nursing communities as evidenced by recent publications. To illustrate, the Alliance for Academic Internal Medicine Education Redesign Task Force released six recommendations for improving health professional training, including competency-based evaluation, trainee-centered education, improved ambulatory training, and the creation of a core faculty.1 The United States Department of Veterans Affairs (VA) has also recognized the importance of educational redesign in its creation and advocacy of the patient-centered primary care medical home.2 Further, in 2010, the VA Office of Academic Affiliations (OAA) launched the Centers of Excellence in Primary Care Education (CoEPCEs)—one of which is the subject of this report—in an effort to develop and implement innovative approaches for training future health care providers in postgraduate professional programs to function effectively in teams to provide exceptional patient-centered care. Current training models that maintain separate, parallel “silos” of health professional education and physician-directed care are no longer adequate because high-quality, patient-centered primary care is best achieved through interprofessional collaboration and teamwork.3,4

Educational redesign in primary care is not new; in as early as 2001, Wagner and colleagues5 advanced the chronic care model. The Institute of Medicine (IOM) and others have continued the call for redesign, advocating interprofessional education and collaboration in training and practice.6,7 Per these reports, nurses must become active team members; they and physicians must collaborate better to improve health care in the United States.6,7 The Carnegie Foundation has also emphasized the importance of team learning and professional identity development in educational curricula by working with faculty members and clinicians in an immersive environment.8 Still, national postgraduate interprofessional training in the fields of adult-focused internal medicine (IM) and primary care has been minimal, despite this growing literature touting the success of interprofessional education.9–11

Team learning in an immersive environment may help address the well-documented challenges between the nursing and medical professions. Historically, interactions between physicians and RNs have been fraught with tension.12,13 Research indicates that physicians are perceived to be at the top of the health professions hierarchy.12 At times, physicians have maintained a patriarchal or dominant position, whereas those in the nursing profession have been viewed as occupying a less prestigious, or even subservient, role.14,15 Even research focused exclusively on nurse practitioner (NP)–physician relationships shows that some physicians believe they provide higher-quality clinical examinations and consultations during primary care visits than do NPs.16 Existing hierarchical structures (e.g., physicians hold final patient decision-making responsibilities and must approve NPs’ care plans) also give social and cognitive authority to the medical model.17,18 This hierarchy may lead to lower levels of satisfaction for NPs, frustration with functional interprofessional collaboration, differing perspectives on workplace roles, and a lack of understanding of others’ professional identities.16,19

Professional identity is vital for physicians and NPs alike. Physicians and NPs must understand their own roles before they can work successfully together in primary care or other settings. Davies20 describes professional identity as “integral to primary care health philosophy” and necessary for successful collaboration and teamwork. Pullon21 notes, “Professional identity, that has to develop over time, and through successfully negotiated interactions with others, forms the basis of individual interprofessional understanding.” Additionally, professional identity development is integral to successful health professional education for not only trainees but also faculty members working in team-based settings.8,22 Physicians and NPs develop their professional identities as they progress through their training, but often with little knowledge or understanding of what the other profession entails.

To address the current discordance in professional identity development and collaborative practice, different health professionals must first understand and respect others’ roles.19,20,23 Understanding and respect start with exposing trainees to different training models so that the former may develop flexible and responsive professional identities.20 Training should not only include faculty representatives from different health professions but also emphasize interprofessional collaboration and identity development.8 In addition to respect, trust, and open communication, redesigned training models should address the following: organizational structures and philosophy; leadership and administrative support; and systemic factors, including professional power, socialization, and culture. The IOM recommends eliminating divergent models of education as one possible solution.6 Long-term, sustainable changes in how NPs and physicians communicate and work together require the development and reinforcement of interprofessional teams.6

As mentioned, the OAA-funded CoEPCE initiative represents one model of redesigned primary care education. The VA Connecticut Healthcare System (VACHS) CoEPCE model (described in further detail below) employs interprofessional teams to deliver primary care to patients. These teams consist of IM residents, registered nurses, medical assistants, pharmacy residents, health psychology fellows, and NP fellows. The NP fellows are participants in the newly created one-year postmaster’s Adult Interprofessional Nurse Practitioner Fellowship program. All team members work collaboratively at the West Haven Firm A Primary Care Clinic providing continuous care for a shared panel of veteran patients. The CoEPCE physician residency/NP fellow partnership affords providers from both disciplines the opportunity to learn together and from each other, building professional relationships that will help eliminate barriers to future collaborative practice and lead to improved access, safety, and quality of primary care for patients.

One of the initial goals of the VACHS CoEPCE was to understand the historical philosophies of nursing and medical models and their impact on future professional identity and interprofessional team development. To better understand these well-established cultures, we analyzed how different health professional trainee groups interacted and evolved over time. Implementing theoretically grounded qualitative methods, we assessed how CoEPCE NP fellows’ and medical residents’ professional identities changed, as well as how the CoEPCE team identity evolved. This study presented a unique opportunity to assess group formation and meaning-making at the most basic level and to illuminate the relative strengths and weaknesses of a nontraditional, team-based approach to postgraduate primary care training.

The following research questions drove our qualitative study:

  1. How did professional identities or roles of NP fellows and physician residents change during the first training year?
  2. How did the VACHS CoEPCE group identity evolve?
  3. Does the VACHS CoEPCE represent a distinct culture of postgraduate health professional education?

Method

This qualitative, longitudinal study occurred between September 2011 and August 2012 at the West Haven Firm A Primary Care Clinic.

Participants and the VACHS CoEPCE program

The study participants, all volunteers, were postgraduate health professional trainees—either NP fellows or medical residents—who participated in the VACHS CoEPCE. The participating NP fellows, like all NPs, were independently licensed, board-certified health care providers in adult primary care. The Adult Interprofessional Nurse Practitioner Fellowship, which is open to recently graduated adult-, family-, or geriatric-focused NPs, was created and implemented by the VACHS CoEPCE. The fellowship, which includes a one-year curriculum, was the first of its kind to specialize in adult primary care using an interprofessional learning approach. Although NP fellows were full-time employees of VACHS, they functioned as trainees for their fellowship program.

The participating medical residents were postgraduate year (PGY) 1 interns and PGY2 residents. Resident trainees participated in the VACHS CoEPCE for the duration of their residency experience (36 months). Residents in the CoEPCE participated in full-time immersion blocks: two 8-week blocks in first year and four 4-week blocks in the second year (an immersion block is a concentrated period of time in which the resident is without call or other responsibilities and can dedicate full-time work to a single panel of patients). Residents were scheduled for four clinic sessions per week—three half-day sessions and one full day—for these immersion blocks.

During the immersion blocks, NP fellows and residents participate in an interprofessional educational curriculum rooted in the VA medical home model and the four patient-centered care CoEPCE domains: (1) patient-centered shared decision making, (2) interprofessional collaboration, (3) sustained relationships (i.e., continuous and longitudinal interaction with patients), and (4) performance improvement. Although the total durations of NP and IM resident training programs differ, both groups participate in all aspects of the curriculum. Because IM residents are at the CoEPCE for a longer time period, they often move on to more advanced educational activities, such as leading or developing new educational sessions, working more closely with a mentor, and launching their own research projects.

Throughout the first and second academic years, trainees shared patient panels in the clinic (practice partnerships) as well as jointly participated in all educational sessions. The curriculum included interactive clinical case discussions, a journal club, health policy/advocacy sessions, and collaborative presentations of issues related to treating the complex population of U.S. veterans. Trainees also engaged in huddles with their “teamlet” (e.g., assigned nurses, medical assistants, and attending faculty members) three days a week to discuss matters related to specific patients, and they participated in larger team meetings throughout the week to learn about new firm initiatives and talk about broader patient care issues.

In addition to the clinical work they completed for their immersion blocks, the residents visited their continuity clinic one half day per week. They did not participate in curricular activities during this time, but were expected to huddle with their teamlet. The remainder of their time was assigned to other learning environments consistent with Accreditation Council for Graduate Medical Education (ACGME) requirements. NP fellows participated in all immersion block activities and curricula but also provided a “bridge” of coverage when residents were not available (i.e., at the continuity clinic or fulfilling other ACGME requirements), resulting in team continuity of care for patients.

Procedure and analysis

For the present analysis, one interviewer (E.M.M.) conducted four sets of semistructured interviews. Trainees from the 2011–2012 academic year who were amenable completed interviews at three different data collection points, as scheduling allowed. All trainees from the 2012–2013 academic year participated in preprogram interviews (August 2012). We invited all trainees from both years to participate as part of an ongoing VACHS CoEPCE evaluation, informing them that the goal was to better understand their educational and clinical experiences in this pilot program. In collaboration with NP colleagues, the VACHS CoEPCE research coordinator (E.M.M.) and physician codirector (R.S.B.) developed interview guides to capture trainees’ experiences, expectations, and impressions of the program. Please see List 1 for sample interview questions used at each time point. They wrote the interview guides to be flexible and adaptable to discussions as necessary. The institutional review boards at VACHS and Yale University deemed this project exempt research. No written informed consent was required, and we offered trainees no incentives to participate.

List 1 Sample Semistructured Interview Questions Asked of Internal Medicine and APRN Trainees Participating in the Veterans Affairs Connecticut Healthcare System CoE Program, 2011–2012 Cited Here

Preprogram questions

  • What are the major reasons you became an APRN/physician?
  • What contributed to your decision to apply to this program?
  • In your opinion, what are the primary differences between APRNs and MDs?
  • What does each group potentially bring to a team?
  • Currently, how do you perceive the collaborations between these two professions?

Midyear questions

  • How is your team doing? Have you noticed any changes in the group from the first to second academic year [for those returning to CoE]?
  • Do you feel you have changed in any way—professionally or personally?
  • I am especially interested in hearing about your experiences working on an interprofessional team. Now that you’ve had the opportunity to work with your team for a while, can you talk a bit about how you see each of your respective roles evolving?
  • What do you think you are getting out of working on this team? In other words, how is your experience different from a CoE with only MD or APRN trainees?
  • Do you feel different now from when you started the program in [insert appropriate date here]?

End-of-year questions

  • To get things started, could you share an experience you had in the CoE over the past academic year that really stands out in your memory?
  • How would you describe the interactions between CoE residents and APRN fellows?
  • Please share one important lesson you learned this year about teamwork in the health care environment.
  • Are there ways in which your participation in the CoE has affected who you are professionally? Briefly explain.
  • How does the team experience here in the CoE compare with other team experiences you’ve had with clinical colleagues outside the CoE?

Abbreviations: APRN indicates advanced practice registered nurse (or nurse practitioner); CoE, Center of Excellence (or Center of Excellence in Primary Care Education).

The trainee interviews were recorded and transcribed verbatim. Transcripts were then uploaded into the qualitative data analysis software program Atlas.ti (Version 6.2; Berlin, Germany). Initially, we used an exploratory approach to analysis; specifically, we employed open, iterative coding and the constant comparative method of grounded theory.24 We recorded data in the form of quotes that ranged from brief phrases to entire paragraphs. We achieved validity by engaging in three distinct phases of data reduction. Stage 1 consisted of first reading the transcripts and documenting preliminary thoughts, emergent themes, and commonalities. The lead qualitative investigator (E.M.M.) completed this stage of analysis. After the first review of all interviews, this investigator extracted representative quotations to use as a template during further refinement and coding meetings. The investigator also generated flowcharts and figures to organize and show relationships among the emerging themes. In Stage 2, the authors met to create and/or revise major code categories. In Stage 3, the authors subjected the transcripts to a final thematic analysis, refining codes, identifying illustrative quotations, and generating conceptual maps. To achieve trustworthiness of findings, the lead analyst (E.M.M.) met regularly during all three stages with project staff members who were content experts (i.e., NPs and MDs) to review coded quotations and themes. They also presented early iterations of the analysis for critique at regional and national meetings (see Previous presentations).

Results

At the end of the 2011–2012 academic year, we had conducted a total of 28 interviews. We interviewed a total of 6 NP fellows and 12 IM residents from two different classes (please contact the authors for full details about which trainees they interviewed at each stage). The interviews lasted between 20 and 60 minutes each. Through analysis, the following themes emerged: (1) the reasons trainees applied to the CoEPCE, (2) the professional identity of NPs, (3) the professional identity of medical residents, and (4) the development of a group identity for each of the VACHS CoEPCE teams.

Why the trainees applied to the CoEPCE

One of the major themes that emerged was that trainees had specific motivations for applying to the CoEPCE. The IM residents were interested in the CoEPCE’s innovative approach to primary care education, and the NP fellows liked the idea of additional training. Some trainees were attracted to the opportunity to gain experience working in interprofessional teams, and others felt that the CoEPCE would prepare them well for work in a changing health care landscape.

Innovative approach to primary care education.

CoEPCE trainees had numerous reasons for joining the program; however, commonalities were immediately evident. First, nearly all the IM residents and NP fellows remarked on, in their words, “the cutting-edge” nature of the CoEPCE and how it allowed them to gain advanced training in outpatient clinical care. To illustrate, one PGY1 intern remarked,

I made up my mind during my interviews for residency that I wanted to make sure I had a very solid, positive, inspiring experience with primary care, and I think this just perfectly fits the bill for that.

A PGY2 medical resident similarly reflected:

I thought there was a lot of thinking outside the box.… I’m interested in medical education and I liked the very unique, group-taught, self-taught, self-learning that was happening here in terms of how they think about teaching each other.

Lastly, a PGY1 valued “even just the structure [of the CoEPCE]; the message of its protected time” for outpatient primary care.

The opportunity for additional training.

NP fellows also reported another reason for joining the CoEPCE. During preprogram interviews, they all discussed the need for additional education and support. Although the medical residents appreciated the opportunity to improve their knowledge base and learn more about primary care, NP fellows saw the CoEPCE experience as vital to their professional development. One fellow stated:

I knew that I wanted to do some kind of residency program because I knew that I didn’t want to just go out and practice. Typically … as far as nurse practitioner residencies go … they don’t really exist.

Another NP fellow commented: “It’s so much more than you would get even from other rotations, so I was like, of course, I need to do this. How can I not?” Still another NP fellow reflected:

Well, I think it’s better than what I could have done. Like going in to private practice and then you’re expected to do this and I’m sure you’d have some type of orientation but it’s almost like […] you’re thrown in the pool.

Desire for interprofessional experience.

Trainees—NP fellows and medical residents alike—also joined the CoEPCE because of a desire to immerse themselves in interprofessional teams. They wanted to be part of a group unlike any they had been in before. When she joined the program in 2011, one PGY1 resident commented, “The fact that I will get to interact on a more professional level with people from other disciplines was more exciting because that’s something you don’t really get otherwise.” Another PGY1 said that “having to talk, deal with other people with different specialties/disciplines [is] just actually rare, unique.” A third reflected:

My perspective as a [medical] student was that residents often just interacted with residents but I feel like once you go into a private practice or once you become an attending, you spend less time interacting with your peers. Doesn’t mean you don’t interact with people in the same profession but you really do spend more time actually getting to know the nursing staff, getting to know the support staff, and trying to work together.

NP fellows reported similar motivations. One remarked, “[T]he future of our health care system is interprofessional teams working together.” Another explained that her attraction to the VACHS CoEPCE was the “specific goals of this program, the interprofessional collaboration and the real focus on shared decision making.”

The health care system is changing.

The final reason trainees gave for joining the CoEPCE was the evolving landscape of health care and their desire to become involved in a program that specifically addresses the changing health care needs of the U.S. population. To illustrate, one of the PGY2s who participated in the CoEPCE’s inaugural year said,

I think this is the direction of where health care’s going in this country and if this country is going to continue to administer health care, I believe that I’ll be one of the few practitioners [who] comes straight out of residency saying this is the idea of tomorrow as opposed to the ideas of yesterday.

An NP fellow commented: “It’s a silo the way it is right now, and that’s not the way it should be because that’s not reality. That’s not the way it is in practice.” Finally, a third CoEPCE participant, a PGY2 resident, remarked,

[T]his is an opportunity to improve myself in terms of my practice and learning but also to partake in something that will eventually have to improve the health care and health outcomes of this nation.

Every participant applied to this program because he or she wanted to be a part of something novel and cutting edge; all of them wanted to break the status quo and reconstruct what it means to be a primary care provider.

Developing individual and group identity

Data from the early interviews showed that medical resident and NP trainees were invested in negotiating their individual professional identities in order to create a meaningful group dedicated to the common goal of improving patient care.

Developing individual identity: NP fellows.

NP fellows resoundingly identified with the nursing profession, notably its aspects of preventive care, education, and advocacy. One fellow remarked, “Primary care is just at the foundation of everything I believe in and have learned through school … the best way to treat something is just to prevent it from ever happening,” and another said, “I believe a huge part of my job is also caring for the family and the caregiver.”

Another NP commented at length,

I think [nursing is] very strongly rooted in advocacy, especially more modern nursing theory and philosophy. I love that it’s been a profession of women. I think that frees it from some of, frankly, the paternalism of medicine; although I think that gap is closing.

Despite the NP fellows’ ability to describe what being an NP means on a philosophical level, they entered the CoEPCE uncertain of their ability to practice independently. All fellows had strong educational backgrounds; still, a sense of hesitancy affected how they saw themselves as clinicians and team members. This feeling likely resulted from being new providers in a new work environment. To illustrate, one fellow commented,

I don’t think anybody told me during school that we would be ready to go out and just start seeing patients. Nobody expects that.… We go from being totally not competent to hopefully at graduation you’re competent but extremely novice. Nobody expects you to be able to manage things 100% on your own.

Other NP fellows’ comments also indicated an early tentativeness:

[T]o feel like I can stand next to them [physicians] and be considered one of their colleagues, that intimidates me and so I think that is where a lot of the difficulty is going to come because I wonder now … what do they think about us?

One NP fellow even remarked that physicians are “so smart” and that, comparatively, “I’m the idiot.”

As the academic year progressed, the NP fellows’ confidence increased dramatically:

[The fellowship has] given me footing, a good, sure footing and a good foundation from which to learn and from which to move. I think probably being head-to-head with the medical residents has given me a better sense of who I am as a nurse practitioner.

At the end of the training, one fellow reflected, “I feel like I really gained, I’ve become respected by all the residents,” and another commented, “[T]he fact that they absolutely trust me to do a good job with their patients … that’s the ultimate compliment.” Yet another fellow remarked,

I now feel totally comfortable going in presenting to whatever MD I will work with in the future because … I know where they came from and how to sort of mold my presentation.

Developing individual identity: IM resident trainees.

Like the NP fellows, IM residents were able to clearly articulate their professional identities, even if that role was evolving. Nearly all of them attributed their career choice to a lifelong interest in science and a desire to understand disease processes. One PGY1 intern stated:

Well, I love medicine. It’s a combination of man’s greatest aspirations, like the ability to really understand the pathophysiology of disease and transfer it into outcome, so … for me, [it’s] very rewarding and so that’s a reason why I’m pursing medicine.

A PGY2 resident reflected, “But then in medical school, what I really loved was internal medicine and the physiology, the pharmacology, all of that, the real kind of nuts and bolts; I like to say the grammar of medicine.” Finally, a PGY1 resident’s comment also reflects a strong identity as a physician:

I like being the main provider for a patient who can coordinate that person’s care and make decisions about [whether] this person really need[s] specialty care.… I like also just making the bigger decisions or helping patients make the bigger decisions about their care and their choice[s] in life.

Interestingly, unlike the NP fellows, residents did not demonstrate initial clinical uncertainties. Nor did they vocalize any concerns about how they might be perceived by their NP fellow peers. In fact, they were quite disconnected from other health professions. Although some could speculate on a basic level (e.g., “I think nurse practitioners have a much greater emphasis and ability to do preventive medicine”), many PGY1 residents had an extremely limited understanding of what an NP actually does. Illustrative comments from interns include “I think that a lot of physicians don’t know what an NP is”; “I didn’t quite know what nurse practitioners brought to the table in terms of knowledge base”; and “I think that, I mean, we just don’t know that they are there and we don’t really know what they do. I mean it’s, that’s the truth.”

As time passed, CoEPCE residents commented on how their clinical competency improved. Perhaps most fascinating was the dramatic shift in how they saw their skills complementing those of the NP. At the end of the year, one PGY1 intern reflected,

I think I feel much more comfortable in primary care as a provider from a knowledge perspective, but also from a team-based [perspective]; how to work with people and how to get done what needs to get done from a patient’s perspective.

Two other interns provided similar insights at the end of the year: “I feel very comfortable managing patients and working on a team,” and “I’m more team-based in my care for patients and that’s one huge thing that I’ve noticed now.”

Trust and appreciation of NP fellow peers stimulated the team-based dimension of residents’ professional identity. At year’s end, a PGY1 said, “My entire perception of nurse practitioners has changed and how to work on a team has changed.” Another intern offered,

We bring different skill sets to the table because there’s also a difference in training in terms of how to listen to the patient and the biopsychosocial model so if we are on a resident team only, we wouldn’t do any of that.

Two other illustrative year-end comments from PGY1 medical residents are as follows:

I feel comfortable working with a diverse set of practitioners, whether they be nurse practitioners or [physician assistants] and sort of understanding where they’re coming from and being able to arrive at a mutually acceptable conclusion for patients.

We basically can go back and forth with patients, you know, get cc’d on notes. I trust that when my patient is seen by [my NP team member], it’ll be done on the same level, the same level of excellence, so yeah, the collaborative effort is almost seamless.

From artificial to real: Developing a VACHS CoEPCE group identity.

When the program launched in the fall of 2011, NP and resident trainees were randomly assigned to teams. The first months represented a trial period in which team members learned about one another’s respective strengths and weaknesses; they also grew to know one another on a personal level. The structure of the CoEPCE was such that trainees spent a concentrated amount of time together across immersion blocks. Trainees were initially apprehensive, yet optimistic of how the team dynamic would evolve, as illustrated by one NP fellow: “I don’t really know how it’s going to work, but I love collaboration and I love teamwork and I think it’s going to be very exciting to kind of—gel as a team.” Similarly, a PGY2 resident commented,

The purpose of the program is to increase interdisciplinary collaboration, working more with nurse practitioners … so I’m interested to see how it is; how this is any different than what happens in other clinics.

On completion of the first year, evidence of a “tight-knit team” or “crew” was apparent. NP fellows and residents alike commented on how close the teams had grown; the CoEPCE had become “more of an open environment to discuss cases.” The themes of trust, respect, and a sense of friendship permeated the interviews. A graduating NP fellow commented:

I think we’ve actually done well in our team all working together. I think that there has been a real … my sense is that the residents have a much greater comfort and ease working with the health tech and nurse than they might have otherwise. There’s a familiarity.

Residents’ comments were similar. One PGY2 resident said: “And we’ve all talked about things and just feel like over that time [the group bond has] really grown. It’s just tremendous. It’s great,” and a medical intern remarked: “But what I really value about this group is that everybody’s open to it. Everybody seems quite open. And in their own way.” To further illustrate, an outgoing NP fellow observed:

Everyone’s just wonderful and it’s really a pleasure to work with people [whom] you know they … they always have your back. Like, if I’m swamped I know one of them will take my patients for me because they know I’d do the same for them. It’s … it’s very satisfying.

Lastly, an IM resident also mentioned the simple delight of a good team: “I think the day-in-and-day-out of just working with this giant team and managing a big panel of patients has been fun.”

Also of importance is the association between an effective interprofessional team and quality patient care. One rising PGY2 resident reflected:

I think that’s [continuity among team members is] an important part of primary care in the long run, and I think those experiences are the most rewarding. Not only to the patient but the provider also.

Another resident connected team cohesion and patient care:

This is how we’re going to work together. Basically it’s to provide the best patient care that we can provide, but it’s also to create a proper environment for all parties or all kinds of professional schools to kind of exist in the same place.

Lastly, a PGY1 intern noted that interprofessional teams improve patient outcomes through

improved user ability, making a clinical experience more pleasurable and also, decreasing the amount of time the patients have to wait and increasing the quality time a provider’s able to spend with patients.

Discussion

The VACHS CoEPCE is an experiment in interprofessional education and collaboration. Nursing and medical training models have long been divergent, but with the changing needs of the U.S. health care system, team-based models of care are increasingly necessary. Coeducating residents and NPs in primary care clinics is uncommon; this innovative VACHS CoEPCE initiative and the results of the first year of training are fascinating and enlightening.

Our research questions

The data we gained through our research provided answers to all three of our original research questions: How did professional identities for NP fellows and physician residents change? How did the VACHS CoEPCE group identity evolve? and Does the VACHS CoEPCE represent a distinct culture of postgraduate health professional education?

Professional identity.

Data suggest that NP fellow and resident professional identities do change over time. Before participating in the VACHS CoEPCE, both groups had a clear understanding of why they chose their respective careers; however, their sense of self was abstract. We heard all too often the idea, repeated like a mantra, that nurses are better at education and preventive care, while physicians are better at biology and chemistry. Still, the data from the early interviews provide evidence that CoEPCE trainees brought a tangible commitment to change and an openness to adapting their professional identities to meet the needs and demands of a larger mission. NP fellows were initially apprehensive, but over time that sense of unease dissipated. At the beginning of the program, residents understood neither NP education nor the role of NPs in patient care; their understanding grew with time. By year’s end, trainees functioned as a cohesive primary care “unit” through which longitudinal and shared patient care was successfully delivered.

Group identity.

The strong sense of self that trainees acquired over the academic year was directly related to the VACHS CoEPCE group identity. As NP fellows and resident physicians gained confidence in their own professional identities and roles, a parallel progression occurred with the group identity: Groups developed from an artificial mix of distinct professionals into a cohesive team with common goals and mutual respect. Working side by side in intensive immersion blocks over a full academic year allowed trainees to truly get to know one another. Trainees developed a collective understanding of roles and responsibilities as well as a strong sense of respect and trust. This understanding is likely what led to the unique CoEPCE group identity (e.g., “I think that we all let down some barriers … and we became real colleagues”).

A distinct culture.

Participants’ reflections and observations from this first academic year of the VACHS CoEPEC—including evidence of the development of strong friendships; a common language; and a shared, implicit understanding—are indicative of the early stages of culture change. One IM resident explicitly mentioned this transformation:

So my next step is to find a job where I can use these skills. There’s no way, no way in hell after this experience, I can go to an average job and see patients day in, day out. I need more. I have to have more than that. I want to be that culture shift wherever I end up. And I have the skills to do it.

Connecting with theory

Many of our observations support the tenets of symbolic interaction theory (SIT).25 SIT provides a basis for understanding how VACHS CoEPCE trainees construct meaning in their unique subgroup of postgraduate health professionals (i.e., they engage in “meaning-making”). Through this process of meaning-making, the trainees have illuminated not only how they perceived themselves as individuals but also how they saw themselves as part of a larger group. Further, SIT posits that social groups are constantly constructing and reconstructing meaning in a social environment. In line with SIT,25 our data show that trainees actively create a space in which two divergent categories of health professionals—NPs and medical residents—can come together to work toward one common goal and, in turn, begin to effect positive changes in the culture.

This capacity to shape or reshape culture is, alone, enough reason to continue investigating the VACHS CoEPCE model and to do further work to understand what is necessary for widespread adoption and sustainability. The implications for health care practice are immediate. If the health professions educational system adopts an interprofessional approach, learners will be better prepared to navigate and successfully work in today’s ever-changing health care system. Primary care is likely to become a heterogeneous field, so an interprofessional training structure will orient future clinicians to this reality of practice. However, the medical education community must still be mindful of the macro-level obstacles that remain. As explained by one NP fellow:

If in the society in which we live, if medicine is dominant in health care, then [what we do in] our little group and even in our little rooms [will not matter]; the medical model is going to be dominant. […] it’s sort of, I think, naïve to think it won’t be but that’s part of the challenge.

Limitations

The main limitation of this study is the self-selection of respondents. VACHS CoEPCE trainees represent a unique group of health professionals who actively sought out postgraduate interprofessional collaboration opportunities. Thus, they may be more receptive to nontraditional approaches and may not represent the general population of medical residents and NPs. Also, because the interviews we conducted are part of an ongoing process of program evaluation, trainees might have withheld negative impressions of the program out of pressure to provide socially desirable responses. Lastly, we examined only one CoEPCE site, so we are unable to compare across groups and draw broad conclusions. Regardless, we believe that insights gleaned from this study are useful for further program development and research.

Future research

This longitudinal qualitative study is just the beginning of what will likely—and hopefully—be great interest and research into interprofessional education and practice. Our results suggest that the initiative was well received; still, further exploration is needed. We will continue to collect longitudinal qualitative data from VACHS CoEPCE trainees over the next several years, and we will continue to conduct ongoing analyses of professional and group identity formation. In addition, we plan to work collaboratively with the four other CoEPCE sites in, respectively, Cleveland, Boise, Seattle, and San Francisco to compare the experiences of trainees across programs. Lastly, pre- and posttest quantitative measures of team formation, trust, patient satisfaction, and clinical outcomes and performance improvement are under way.

Conclusions

VACHS CoEPCE medical residents and NP fellows began the academic year with different reasons for entering primary care, but through an interprofessional postgraduate training program, trainees developed an appreciation and respect for not only their own role and professional identity but also those of others. Through a process of “meaning-making”25 and group negotiation, members of the two typically distinct groups ultimately became a team that realized the importance of relationships, growth, and collaboration both in the clinic and classroom. Trainees found a way to marry divergent philosophical models, and they actively worked together to establish a transformed culture in which they delivered excellent patient-centered, team-based primary care.

Acknowledgments: The authors wish to thank Dr. Malcolm Cox for his visionary leadership in conceptualizing the Centers of Excellence in Primary Care Education (CoEPCE) initiative. The authors also thank Veterans Affairs Connecticut Health System (VACHS) CoEPCE faculty members, who have contributed substantially to this program: Dr. Shawn Cole, Dr. Anne Hyson, Dr. Cara Kurlander, Dr. Rachel Laff, and Ms. Susan Langerman. Next, the authors acknowledge Ms. Jill Edwards, APRN, for her dedication and innovative contribution to the VACHS CoEPCE. Lastly, the authors extend their thanks to colleagues at the Veterans Affairs Office of Academic Affiliations and at the CoEPCE’s Coordinating Center, who have provided ongoing support and oversight: Dr. Stuart Gilman, Dr. Judith Bowen, and Dr. Kathryn Rugen.

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