“Getting Out of That Siloed Mentality Early”: Interprofessional Learning in a Longitudinal Placement for Early Medical Students

Abstract

Purpose 

Although descriptions of interprofessional education often focus on interactions among students from multiple professions, embedding students from 1 profession in clinical settings may also provide rich opportunities for interprofessional learning (IPL). This study examines affordances and barriers to medical students’ interactions with and opportunities to learn from health care professionals while learning health systems science in clinical workplaces.

Method 

In May 2017, 14 first-year medical students at the University of California, San Francisco participated in a semistructured interview about IPL experiences during a 17-month, weekly half-day clinical microsystem placement focused on systems improvement (SI) projects and clinical skills. Communities of practice and workplace learning frameworks informed the interview guide. The authors analyzed interview transcripts using conventional qualitative content analysis.

Results 

The authors found much variation among the 14 students’ interprofessional interactions and experiences in 12 placement sites (7 outpatient, 4 inpatient, 1 emergency department). Factors influencing the depth of interprofessional interactions included the nature of the SI project, clinical workflow, student and staff schedules, workplace culture, and faculty coach facilitation of interprofessional interactions. Although all students endorsed the value of learning about and from diverse health care professionals, they were reluctant to engage with, or “burden,” them.

Conclusions 

There are significant IPL opportunities for early medical students in longitudinal placements focused on SI and clinical skills. Formal curricular activities, SI projects conducive to interprofessional interactions, and faculty development can enhance the quality of workplace-based IPL.

National and international accreditation requirements for many health professions schools mandate interprofessional education (IPE), which brings students from different professions together to learn with, from, and about each other.^1,2 Much of the literature describes IPE in classroom or simulated settings.³ Although necessary, providing IPE exclusively in these settings may preclude opportunities for rich formal and informal interprofessional learning (IPL) provided by clinical settings. Furthermore, limiting IPE to classroom and simulation activities may diminish students’ perceptions of its authenticity and relevance.

Situated learning theory posits that learning occurs through coparticipation and interaction with practitioners.⁴ From this theoretical perspective, immersing students in health systems, particularly early on, may positively affect the development of competencies and identity related to interprofessional collaboration.⁵ However, scalable IPE in clinical settings remains elusive, largely because of organizational and logistical barriers. These barriers include reconciling different academic calendars, accessing learners with comparable levels of experience and numbers, and accommodating large numbers of learners. Barriers faced by faculty and staff include lack of requisite time to create IPE activities, recognition for such efforts, mechanisms for sustainability, and IPE-related educator skills.⁶ To justify the substantial effort and resources needed to overcome these barriers, workplace IPE should contribute to outcomes valued by patients and health systems.³

Recent attention to health systems science, defined as principles and processes for improving the quality, outcomes, and costs of health care delivery for patients and populations,⁷ has opened new possibilities for workplace-based IPE. Gonzalo and colleagues recommend including health systems science alongside basic and clinical sciences in undergraduate medical education by engaging students in “value-added clinical systems learning roles.” In these roles, students learn health systems science as they contribute to efforts aimed at improving systems and patient care outcomes.^8,9 These roles may also create authentic opportunities for workplace IPE as viewed through a communities of practice (CoP) framework. The CoP framework recognizes a diverse array of health care professionals as teachers and a broad range of clinical settings as sources of learning opportunities for students. From this perspective, students can engage in legitimate participation even early in training via value-added roles and tasks that allow them to experience and appreciate the health care environment from multiple viewpoints.¹⁰ Such roles provide interprofessional experiences in clinical settings but avoid the logistical challenges of convening students from multiple professions. The integration of health systems science and interprofessional experiences afforded by the workplace may legitimize teamwork by providing positive and negative experiences of interprofessional collaboration in clinical contexts rather than in the hypotheticals of the classroom, thus reinforcing students’ need to learn collaboration-related skills.

As more institutions adopt the health systems science framework and create value-added learning roles for students,⁹ educators can benefit from knowledge of how these roles create and affect opportunities for workplace IPL. Variation in these roles and diversity among clinical sites—with their accompanying unpredictability and inevitable factors beyond control—challenge the quality of all workplace learning experiences.¹¹ Billett’s framework of workplace learning, combined with the CoP concept described above, offers a way to examine the affordances and constraints of workplaces as learning environments and how learners’ personal values, history, and agency guide their engagement in learning.^12–14 Drawing upon this framework, we sought to answer the following questions: What affordances and barriers to IPL do students in value-added clinical systems learning roles encounter? How do these experiences affect their view of interprofessional collaboration?

Method

Design

We used a descriptive qualitative approach to examine students’ experiences of IPL in a clinical microsystem clerkship (CMC).¹⁵ We chose this approach given the exploratory nature of our work and our desire to present common content and concepts discussed by students without substantial interpretation.¹⁵

Participants and setting

All 150 first-year medical students at the University of California, San Francisco participate in a 17-month CMC. The value-added clinical systems learning roles in the CMC were operationalized as student-led systems improvement (SI) projects.¹⁶ During the CMC, groups of 6 students spend a half day per week at a single microsystem site working on their projects and clinical skill development. Students have a designated faculty coach in their CMC who provides guidance and mentoring for their learning experiences and SI projects. List 1 shows CMC learning objectives pertaining to IPL. These learning objectives are met through a formal IPE curriculum that entails activities in both the classroom and clinical microsystem as well as through SI projects and patient care activities. To assess their interprofessional collaboration skills, students are required to obtain nonanonymous, formative feedback from 1 nonphysician colleague in their CMC twice during the course via a 2-item, open-ended survey.¹⁷

List 1

Learning Objectives Pertaining to Interprofessional Learning in the Clinical Microsystem Clerkship at the University of California, San Francisco

• Summarize the evidence for increasing interprofessional collaboration within current contexts in health care.
• Describe one’s own roles and responsibilities and those of professionals on the health care team.
• Describe and analyze characteristics (attributes, behaviors, values) of effective interprofessional collaboration.
• Select, justify, and demonstrate specific communication strategies and tools that facilitate effective communication and collaboration in groups that are diverse with respect to profession, demographic background, and areas of interest.

The University of California, San Francisco Committee on Human Research reviewed the study and deemed it exempt.

Data collection

We invited 30 first-year medical students to participate in a 30-minute semistructured interview. We purposively sampled students from diverse settings (inpatient, outpatient, and emergency department across 3 types of health systems).

We used CoP and workplace learning as guiding frameworks to develop our interview questions. To understand the CoP and related affordances from students’ perspectives, we asked students to tell us who they interacted with during their CMC and what these interactions entailed (e.g., types of activities). We also asked about sources of guidance and support for working with various health care professionals, as well as barriers to such interactions. (The interview questions are provided in Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A706.) A trained research assistant conducted and audio recorded all interviews, which were then transcribed and deidentified by a third party. All interviews were conducted in May 2017.

Data analysis

We (J.R., M.W., B.O.) analyzed our data using techniques associated with conventional content analysis, which involves “interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns.”^18(p1278) Consistent with the qualitative descriptive approach, using this analytic technique allowed us to develop categories from our data rather than impose preexisting categories on our data and to engage in more extensive interpretation.^15,18 We reviewed transcripts after each interview to provide feedback to the research assistant, to identify topics for additional probing, and to determine when the information provided in the interviews was sufficiently powerful to support themes.¹⁹

After interviews were completed and transcribed, the authors designed a coding process to maximize trustworthiness.¹⁸ For breadth of perspective, all 3 authors reviewed a sample of 4 interviews to develop preliminary categories for coding. The codes were based primarily on salient content in the interviews, then organized into larger categories that aligned with general concepts from CoP and workplace learning (e.g., community members, activities and practices, support for participation and affordances, barriers to participation). To check for comprehensiveness of categories and consistency in code application among authors, we each coded 2 additional interviews, discussed our coding to make adjustments, and reconciled differences to consensus. When the codebook was finalized, each author was a primary coder for one-third of the interviews, and a second author reviewed the coding. Differences were reviewed and reconciled (investigator triangulation).¹⁸ We also checked for discrepant points of view and discussed ways to represent these in our findings (negative case analysis).¹⁸ We used Dedoose version 8.0.42 software (SocioCultural Research Consultants, LLC, Manhattan Beach, California) for final coding.

After coding was complete, we reviewed excerpts associated with each code and organized our findings according to Gonzalo and colleagues’ CoP-informed framework for student roles and systems learning: (1) the members of the community, represented by students’ descriptions of the health care professionals and staff with whom they interacted; (2) the clinical setting of the learning experience, represented by students’ descriptions of the type and characteristics of their clinical microsystem; (3) the domains of knowledge operationalized in the community, referring to health systems science, clinical skills, and interprofessional collaboration; and (4) opportunities for legitimate peripheral participation by students or ways through which students can both learn and add value to the community of practice and the health system.¹⁰ In addition, we identified learning outcomes described by students.

Researcher perspectives

All 3 authors are involved in IPE at their institution. Two authors (J.R., M.W.) were involved in designing formal IPE curricular activities and assessment in the CMC, which gave them some insight into experiences described by students. The other author (B.O.) was not involved in CMC and interpreted data from an external perspective.

Results

We interviewed 14 students in 12 placement sites, achieving our goal of capturing perspectives from students placed in diverse clinical settings and obtaining sufficient information to support our key findings.¹⁹ Students reported interacting with a wide variety of health care professionals in these settings (Table 1). The majority of students’ interactions with health care professionals occurred in the context of the students’ SI projects, through practicing clinical skills, and through curricular assignments. Several factors affected students’ interactions with health care professionals in their clinical microsystem and were present across settings. We described these factors, organized according to Gonzalo and colleagues’ CoP-informed framework, for student roles and systems learning.

Table 1: Clinical Microsystem Clerkship (CMC) Student Characteristics and Context, University of California, San Francisco, 2017

Members of the community

Health care professionals who had previous experience integrating novice learners into their clinical setting welcomed students into their community, which facilitated learning.

They had already gotten used to a few years of med students coming through and trying out these projects and asking them to be flexible about their workflow. And so by the time we showed I think they were really great about it. (St 8)

Settings in which the composition of the care team was constantly changing (e.g., emergency department, postanesthesia care unit) made it more challenging for students to have meaningful interprofessional interactions. Moreover, interactions were hampered when the schedules of students and staff members did not consistently align.

We weren’t going in regularly. And if we were, it was every Thursday and there’s always turnover in terms of people’s work schedules, and so it was hard to develop rapport, in terms of the nursing staff who we would see in the PACU [postanesthesia care unit]. (St 12)

I think the only challenge could be scheduling meetings because we only came once a week. And so having to schedule around their schedules can sometimes be difficult and you also didn’t want them to rearrange their schedule to accommodate us. (St 11)

In contrast, where there was stability of the care team’s staff, students more easily developed longitudinal interprofessional relationships that facilitated IPL.

We’re lucky to be in an outpatient setting that I think is more conducive to building long-term relationships because with this unique clinic setup where the staff actually stays the same. . . . I think that helped because they got used to seeing us, we got used to seeing them. (St 8)

Faculty coaches played an important role in inviting the students into the community by introducing them to other health care professionals and using their social capital to help smooth the way. Coaches also used strategies such as scheduling recurring meetings for students to update health care professionals at the site on their projects and soliciting students’ input during clinical team meetings.

I think at every step my coach was always there to either make an introduction or send an email also just to introduce who I was. . . . She always made it very easy. I think the clinic is small enough so that everyone knows each other and everyone knows that we’re there, and so it was pretty easy to approach the nurse manager. (St 6)

We did do a few presentations throughout the year; maybe every month we would actually present to both CMC [student] groups, and also all the staff were invited to come and watch our presentations. . . . It was just another opportunity for people to learn about what we were doing in our projects and ask questions or give us their feedback. (St 4)

Clinical setting of the learning experience

Students’ interprofessional interactions and learning were influenced by the characteristics of the clinical setting. The pace and workflow of some settings affected students’ willingness to engage with other health care professionals.

I think part of it’s just the nature of the ED [emergency department]. That it’s busy and everybody is out doing their job and when you’re trying to talk to someone it means you’re taking away from playing an actual role in patient care. And so we weren’t super eager to start placing large demands on everybody’s time there. (St 1)

Probably the time, just being there once a week in the morning when there’s a lot going . . . you either have MDR [multidisciplinary rounds] or they’re doing their med pass. So time constraints and workflows is probably the biggest barrier. (St 5)

Physical space and layout also factored into students’ experiences. Close proximity of the students’ workspace to other health care professionals facilitated interprofessional interactions. In other sites where dedicated space for students was not available, students described less interprofessional interaction.

Our clinic had a meeting space in the back that wasn’t far removed from the actual clinic. So the majority of our work was done somewhere in the clinic area . . . and I think that helped because even if you only see them in passing it’s easier to talk to and work with people if you’re actually in the same physical space. (St 8)

Domains of knowledge operationalized in the community

The CMC experience was expected to build students’ knowledge of health systems science, clinical skills, and professional roles and responsibilities via formal curricular activities and informal learning opportunities in the microsystem.

Many students specifically mentioned the formal curricular activity of interviewing and shadowing 2 nonphysician team members as useful to their IPL. Students used an interview guide to inquire about their training, roles, and views on interprofessional collaboration.

In the beginning, we shadowed nurses. I shadowed a charge nurse and then a bedside nurse. And we also went to their morning huddle. And so that was really helpful in terms of understanding their workflow, their culture, and creating a rapport with them. (St 5)

Opportunities for legitimate peripheral participation

Students’ SI projects were the main source of opportunities for legitimate peripheral participation in the clinical microsystem, though students revealed disparate amounts of interprofessional interactions through these projects. Students who reported the greatest IPL worked on projects focused explicitly on improving interprofessional collaboration (e.g., improving communication), required the workflow knowledge and expertise of other professionals, or affected the workflow and responsibilities of other professionals in the microsystem (Table 2). In addition, engagement and buy-in from leadership for an SI project made it more likely that health care professionals on the team were engaged. Two students whose SI projects were less interprofessional in nature described efforts to engage in interprofessional workplace learning by seeking out other opportunities to learn from health care professionals.

Table 2: Systems Improvement Project Characteristics and Students’ Interprofessional Experiences in the Clinical Microsystem Clerkship (CMC), University of California, San Francisco, 2017

I requested that I have an opportunity to interact in the clinical setting with different people. So they saw to it that I was able to go to the hospital and work with pharmacists, follow people on rounds. I worked with some dental students on different aspects of the 24-hour callback program. But all the instances in which I worked interprofessionally—with pharmacists or dentists—it was very much outside the capacity of the QI [quality improvement] project. (St 13)

Although the CMC conceptualized students as becoming members of their microsystem’s CoP, students generally did not initiate interprofessional interactions outside of their SI projects or specific assignments. Although they acknowledged that their projects would ultimately improve the care delivered in a given clinical setting, students perceived that in the short term their efforts would burden the staff. In addition, while practicing clinical skills and completing curricular assignments, students described feeling intrusive because they weren’t contributing directly to patient care, and interacting with other health care professionals often meant interrupting them in the course of their work. One student explained, “They had their own schedules, they had their typical workflow, and for us to go out of our way and interrupt them can feel like an inconvenience to them and also make us uncomfortable to ask them to do all these extra things that aren’t normally part of their job” (St 4). Another described feeling “strange” and “very entitled” as a first-year medical student walking into patients’ rooms, taking up so much of patients’ time, and potentially disrupting nurses’ workflow “without asking the nurses first” (St 9).

One student emphasized the difference between interactions that “felt very, very genuine” because they aligned with a goal valued by both the student and health care professional that required their collaboration versus activities where the student lacked a clear sense of purpose and “reason to go up and talk to somebody” (St 8).

Student-reported outcomes of interprofessional interactions in the CMC

All students valued the opportunities for IPL and articulated benefits of seeing firsthand why and how interprofessional collaboration is important (Table 3). The most commonly mentioned outcome of interprofessional interactions in the CMC was learning about the roles and responsibilities of nonphysician staff and their significance to patient care. Students often associated this learning with the curricular assignment to interview and shadow another health care professional. Students also expressed an appreciation for the expertise and perspectives of other health care professionals and described how they might apply this new awareness in their future careers. Some students reflected that seeing positive examples of interprofessional collaboration and learning good habits early in their careers were important to counter not only the development of bad habits but also the notion that physicians occupy the top of the health professions hierarchy. Students also described learning from specific challenges to interprofessional collaboration and observing their impact on patients. Some discussed barriers to interactions between professionals, including professional hierarchies and cultural differences, and the importance of breaking down these barriers early in training. One student reflected: “I feel like it’s important to get out of that siloed mentality early. So now going forward, I feel more inclined to interact with other types of clinical specialties” (St 13).

Table 3: Student-Reported Outcomes of Interprofessional Interactions in the Clinical Microsystem Clerkship (CMC), University of California, San Francisco, 2017

Discussion

We identified affordances and barriers to workplace IPL from the perspectives of early learners in value-added clinical systems learning roles. Clinical sites that provided more IPL opportunities had experience with novice learners, experience undertaking SI projects, or both; faculty coaches who actively worked to integrate learners into the community of practice; staff welcoming and supportive of learners; and student workspaces located close to other professionals. Barriers to IPL occurred in sites in which team members frequently changed or in which scheduling conflicts prevented students from working with other professionals with any frequency or depth. Students’ agency in engaging their interprofessional colleagues was hindered by a number of factors and heavily depended on whether their projects required interprofessional input. Despite these challenges, students expressed appreciation of the roles and responsibilities of diverse health care professionals and the impact of interprofessional collaboration on patient care.

Value-added clinical systems learning roles, operationalized in this study as participation in SI projects, showed potential to fulfill key features of effective workplace IPE: authentic activities and interactions, centrality of and contribution to patient outcomes, and diverse health care professionals serving as teachers.³ Yet, as with all workplace learning, our results revealed affordances and detractors of this learning. We highlight 2 key IPE affordances potentially within educators’ control, namely, operationalization of the SI project and faculty roles. To fully realize their purpose of facilitating interprofessional interactions, it is imperative that projects are intentionally designed to engage other health care professionals. This imperative also applies to other types of value-added clinical systems learning roles, and educators should consider both obtaining input from different health professions in creating these roles locally and providing well-considered guidelines for the community of practice on how these roles will facilitate students’ interprofessional interactions. In terms of faculty roles, our findings suggest that faculty who oversee students at clinical sites can facilitate learners’ engagement in a variety of ways, such as including students in team meetings and facilitating formal learning activities. Additional strategies may include role modeling interprofessional collaboration and reflecting on both the positive and negative examples of interprofessional collaboration the students observe. Making an effort to capitalize on teachable moments and reflect with learners about the roles of all health care professionals working in the clinical microsystem may also help promote IPL and development of teamwork skills.²

In addition to workplace affordances, Billett’s framework recognizes that how learners “engage with activities and opportunities depends on the value and meaning they assign to it.”¹² In our study, students clearly valued interprofessional collaboration and articulated specific aspects they viewed as important, such as increased knowledge of roles and expertise of others and observing the interdependence between professions in a way that flattened their preconceived hierarchy of the physician at the top. This result suggests that learners begin training with socialized stereotypes in mind and that early IPE experiences may positively affect attitudes toward interprofessional collaboration. Yet, despite valuing interprofessional collaboration, most students reported feeling like an inconvenience to others, which strongly influenced their willingness to engage. The primary reason cited was that they did not wish to interrupt another busy team member’s work of caring for the patient. That most students in our study—despite some being in settings that made them feel welcomed and included—felt like a “burden” suggests that they believed patient care outweighed the legitimacy of their own roles and learning needs. They experienced a tension between engaging other health care professionals for their learning while respecting their busyness and responsibilities. This feeling may be particularly pronounced for early learners in value-added learning roles such as SI projects because they are not directly involved with patient care.

Helping students find meaning in their interactions with other health care professionals may alleviate their feelings of being burdensome. Trained faculty who offer both scheduled and spontaneous opportunities to debrief and explore students’ feelings of being a burden, and parallel issues such as professional hierarchies, culture, and power, may facilitate students’ engagement and give them skills to negotiate their place in the complex web of health care professionals now and in the future. It is also important that the community of practice recognize how it affects students’ socialization in the workplace.²⁰

Although the common definition of IPE suggests students learning from each other, others have called for IPL with just 1 type of health professions student, given the significant commitment of time, resources, leadership, and administrative support required to bring students from different professions together.²¹ All health professions require training in clinical placements in which different health care professionals are likely present. Studies of physiotherapy students indicate that although variable, students’ IPL in their clinical placements was valuable.^22–24 This finding concurs with the present findings. Enhancing IPL opportunities in existing uniprofessional placements could overcome substantial logistical barriers that often defeat workplace IPE efforts and offer substantial value.

Our findings represent the views of students in value-added clinical systems learning roles at a single institution. Other institutions have operationalized these roles in different ways, such as in roles more directly related to patient care, which may afford different IPL experiences.¹⁰ Also, our findings are based on the views of the 14 students who volunteered to participate. Although these students worked in a variety of settings and reported diverse experiences and roles, their responses may not capture the full range of perspectives among students in their class and may not fully identify contextual factors affecting their learning experiences.¹⁸

Fostering the development of students’ professional identities and competence as collaborators requires more than placing them in clinical sites with diverse health care professionals. The findings from this study inform ways to counter unevenness in the amount and quality of IPE across clinical sites through formal curricular activities and the design of SI projects that are conducive to IPL. However, having a workplace IPE curriculum and SI projects is not sufficient. Program leaders must also prioritize faculty and staff development to enhance IPE facilitation skills in the workplace. Our study also underscores the importance of including the learners’ perspective and acknowledging powerful influences that undermine their engagement with other health care professionals, even when they value interprofessional collaboration.