Health service user participation in interprofessional collaborative learning — a systematic review on the use of digital solutions / Die Teilnahme von Gesundheitsdienst-Nutzenden an interprofessionell kollaborativem Lernen — ein systematischer Review über den Gebrauch digitaler Lösungen

This systematic review aimed to identify which digital solutions can facilitate service users to participate in an interprofessional learning process of service providers, who reflect on the users’ health in a consensual approach. A systematic review was conducted to answer the following questions: (1) Which digital solutions can facilitate the participation of health service users in collaborative learning of interprofessional service providers? (2) How do service users participate in collaborative learning of interprofessional health teams or networks with the use of digital solutions?

Included studies met all of the following criteria: 1) English language, 2) original empirical work, 3) involving a service user and service providers from a minimum of two professions, 4) any health caring profession, including teachers and technicians involved in digital health services, 5) interprofessional collaborative learning in the range of team or network interaction, 6) identified or applied digital solutions used in a learning process.

We excluded studies that were: 1) proceedings, posters, books, protocols, frameworks, dissertations, reviews, editorials or comments, 2) focused on patient education or safety, inpatient, critical, veterinary or dental care, 3) without evaluation.

Reasons for these eligibility criteria were: 1) English being an international, scientific language, 2) to identify primary research with outcome measures and to exclude grey literature. 3) According to the aim and rationale of this review, the involvement of service users was mandatory, and for interprofessional interaction at least two professions are needed. 4) Any caring profession was included based on the definition of Ellis & Hogard (2021) to consider a broad range of stakeholders that contribute to delivering primary health care. 5) The concept of interprofessional collaborative learning and interaction by means of teams or networks applied as defined in the introduction (CAIPE, 1997; Edwards et al., 2004; Reeves et al., 2010). 6) To avoid a selection bias of research methods, not only the application, but also an identification of digital solutions were included. Finally, some exclusion criteria were used to support the focus on primary care of people’s overall health, while the exclusion of patient education was added as an amendment to the study protocol to clarify the focus on learning of service providers.

Search terms (displayed in Table 1) were synonymised within their PICO criteria (Centre for Evidence-Based Medicine, 2020) and evaluated in Medical Subject Headings (MeSH). Terms and synonyms were combined within their categories with OR and categories with each other using AND, as Table 1 describes. Some terms were excluded by being combined with NOT. Where possible, language (English), and species (humans) were applied, justified by the eligibility criteria. For the terms (communicat* OR collaborat* OR teamwork OR network OR coordinat*) the limitation [Title/Abstract/Keywords:] was used. The terms ‘function, functioning or ICF’ were used to emphasise publications with the International Classification of Functioning, Disability and Health (ICF) as a common framework and language (Leonardi et al., 2022), yet this was not included in the eligibility criteria.

The databases CINAHL (via EBSCOhost), MEDLINE and PubMed Central (via PubMed), ScienceDirect (www.sciencedirect.com), Scopus (www.scopus.com) and the register Cochrane Trials (via Cochrane Library) were searched on October 13 2022. Each search number was protocolled with its search query and results.

The query was adapted to the respective structure of the search function in the relevant data resources. The ScienceDirect interface did not support wildcards and allowed a maximum of eight Boolean characters per field. Thus, search terms were limited to the MeSH term interprofessional relations and the terms health, medical or care, combined with educate, learn, train, or teach, function, functioning or ICF and digital or technology. In the field “title, abstract or author-specific keywords” the terms communication, collaboration, teamwork, network or coordination were used. At Cochrane library, a maximum of five fields were allowed. Thus, the terms interprofessional, health and function were combined with communicat*, collaborat*, teamwork, network or coordinat* as terms in title, abstract and keywords.

The PRISMA flow diagram (Figure 1, adapted from Page et al., 2009) shows the steps of selecting relevant publications. The results of database and register searches were imported into the literature management tool ‘Zotero version 6.0.19’. The first author removed duplicates as proposed by ‘Zotero’ and screened each record and full text report based on the eligibility criteria. First the exand then the inclusion criteria were applied, all criteria in their described hierarchical order. The last author dealt with arising conflicts (n = 24). We used ‘Microsoft Excel’ as a data management tool and for exchange about conflicts. Figure 1 shows when publications were excluded and for what reason.

Figure 1:

The first author collected data from each report into the data management tool based on the following predefined domains (under consideration of Li et al., 2022): 1) year 2) country, 3) setting, 4) aim, 5) study design, 6) participants, 7) the use of digital solutions in interprofessional collaborative learning, 8) the participation of service users in the collaborative learning process. In line with the research questions, the last two domains were the most relevant, while other details from reported interventions or outcome measures were not considered in further detail.

Tabulation methods were used to present the results of individual studies and synthesis following the order of their publication. No statistical synthesis methods were used and therefore no effect measures were calculated. To be eligible for synthesis, data had to be reported in the respective domain. The first author synthesised data by clustering the described domains thematically. Countries were clustered per continent, study design was clustered in qualitative, quantitative and mixed methods. Settings were distinguished by whether participants accessed digital solutions from classrooms, from service provider facilities (outpatient or ambulatory care), or from the service users’ permanent living environment (home-based care). Furthermore, the number of service users and service providers involved and the participants’ professions were summarised.

To synthesise interventions and outcomes, the first author used the data management tool to identify the use of digital solutions and the participation of service users in interprofessional collaborative learning. The prepared synthesis was then reviewed by the co-authors. Due to the diversity of aims and methodology, tools to assess risk of bias could not have been evaluated in overall across findings. Thus, risk of bias in the included studies was not assessed by using any instrument or tool.

Eligible studies were published between 2000 and 2022, although we did not restrict our search to these years. Seven studies were conducted in North America (Bluml et al., 2000; Byerly et al., 2021; Javadi et al., 2018; Lempicki & Holland, 2018; McGilton et al., 2011; Sabus et al., 2011; Shorten et al., 2015), six in Europe (Andersson et al., 2021; Korstjens et al., 2021; Metzelthin et al., 2013; Poss-Doering et al., 2020; Saia et al., 2020; Swallow et al., 2016), three in Asia (Liaw et al., 2020; Uslu-Sahan & Terzioglu, 2020; Yang et al., 2017) and two in Oceania (Darlow et al., 2015; Lucas et al., 2020). In Table 3, the origin countries of each study and the order of publication year are described.

In seven studies, participants accessed digital solutions from classrooms located either in higher education facilities (n = 5) or training centres in hospitals (n = 2). All other studies were either situated in outpatient and ambulatory (n = 7) or in home-based settings, which include continuing care facilities such as nursing homes (n = 4).

The aims and study designs of the reports are displayed in Table 3. By using digital solutions, two reports aimed at understanding the collaboration between service users and providers (Andersson et al., 2021; Korstjens et al., 2021) and three studies explored how to improve patient’s care (Bluml et al., 2000; Poss-Doering et al., 2020; Saia et al., 2020). Five studies described the development and testing of the collaborative use of a digital solution (Sabus et al., 2011; Shorten et al., 2015; Swallow et al., 2016; Javadi et al., 2018; Lempicki & Holland, 2018). Eight studies evaluated a collaborative learning intervention that uses digital solutions (Byerly et al., 2021; McGilton et al., 2011; Metzelthin et al., 2013; Darlow et al., 2015; Liaw et al., 2020; Lucas et al., 2020; Uslu-Sahan & Terzioglu, 2020; Yang et al., 2017).

Seven studies applied qualitative methods, including observations (Bluml et al. 2000; Byerly et al., 2021), individual (Saia et al., 2020) and focus group interviews (Andersson et al., 2021), reflective ethnography (Korstjens et al., 2021), an iterative, participative design and development process (Shorten et al., 2015) and a process evaluation (Metzelthin et al., 2013). Four studies used mixed methods, specifically a development and feasibility study (Javadi et al., 2018), two pre-posttest designs, one supplemented with a focus group interview (McGilton et al., 2011), the other with a thematic analysis of reflective statements (Lucas et al., 2020). Poss-Doering et al. (2020) applied thematic analysis to interview data and a descriptive analysis to survey results. From the seven studies which applied quantitative methods, Sabus et al., (2011) also applied a descriptive analysis to survey results, Yang et al. (2017) a pre-post comparative cross-sectional study, Darlow et al. (2015) applied a controlled trial, and four studies used randomised controlled trials (Lempicki & Holland, 2018; Liaw et al., 2020; Swallow et al., 2016; Uslu-Sahan & Terzioglu, 2020).

The investigated studies reported on a total of 1,236 service providers (n = 18; MS = 53.5; 2–354), 537 service users (n = 11; MS = 13; 1–397) and additional ten simulated service users (n = 7; MS = 1; 1–2), which were either video recordings to be followed by encounters with real service users (Darlow et al., 2015), patient avatars (Liaw et al., 2020; Sabus et al., 2011), mannequins (Uslu-Sahan & Terzioglu, 2020; Yang et al., 2017), standardised patient actors (Lempicki & Holland, 2018), or both of the latter (Lucas et al., 2020). In some studies, simulated service users were accompanied by standardised actors playing family members, a caring husband (Lucas et al., 2020), daughter (Uslu-Sahan & Terzioglu, 2020), or not further specified (Yang et al., 2017). Family members were counted as service users, organised volunteers (Javadi et al., 2018) as service providers. Service users or providers were not counted if their exact number was not reported (Darlow et al., 2015; Javadi et al., 2018; Yang et al., 2017) or if they were not reported as participants in the study (Metzelthin et al., 2013). From the 11 studies that involved real service users, some involved them as stakeholders, e. g. from a self-help organisation (Poss-Doering et al., 2020).

In total 21 professions participated in the results (n = 18; MS = 3; 2–10). Table 4 displays the involved professions in the order of their frequency.

Javadi et al. (2018) included other non-specified consulting specialists and non-paid volunteer pairs of undergraduate students and retired professionals or other experienced community members. Metzelthin et al. (2013) reported invitations to team meetings (providing a social worker, homecare provider or pharmacist as examples) and referrals to further disciplines (e. g. nutritionist, speech therapist) that were not interviewed and thus not counted as participants.

We provide a descriptive overview of the digital solutions used in the 18 included articles (Table 3). Digital solutions were used, on the one hand, to facilitate the interprofessional collaborative learning process, and on the other hand, to facilitate interactive communication between service users and interprofessional providers, which fostered learning about and from service users in a consensual approach. Several studies used more than one digital solution.

The following digital solutions facilitated interprofessional collaborative learning: Two studies applied avatars in a virtual reality environment, one was role-played by an instructor to teach interprofessional home assessment (Sabus et al., 2011), and the other was based on a prepared script and accompanied by a facilitator avatar located in a ward (Liaw et al., 2020). In one study, video recordings and pictures were used to engage reflection of communication in previous collaborative interaction (Korstjens et al., 2021), while four other studies used video demonstrations that were followed by live interaction, specifically a role-play on communication (McGilton et al., 2011), contact with a simulated service user (Lucas et al., 2020; Yang et al., 2017), or the visit of a person living in the community (Darlow et al., 2015). Two of these video demonstrations were part of a more extensive e-learning intervention (Darlow et al., 2015; Yang et al., 2017), while another e-learning intervention on communication did not report any video usage (Poss-Doering et al., 2020). One study reported the usage of a power-point-presentation to be followed by a simulation intervention (Uslu-Sahan & Terzioglu, 2020). In total, three studies applied high-fidelity simulation, yet only one, a SimMan® 3G simulator (Yang et al., 2017), could be identified as a mannequin that was equipped with digital technologies. The study of Uslu-Sahan & Terzioglu (2020) used a scenario template that described digital technologies, but did neither describe digital technologies in their simulation applications nor specify the terms high-fidelity and hybrid simulations any further. Lucas et al. (2020) used medium and high-fidelity simulators to apply nasogastric tube insertion, which was rated as mechanical simulation.

Interactive communication between service users and interprofessional providers formed the basis of learnings in studies that used the following digital solutions: Lempicki & Holland (2018) applied the web-based video conferencing service Zoom in comparison to a face-to-face encounter. Saia et al. (2020) identified the need to develop information and communications technology for information sharing, and to use the latest technology to communicate, e.g. by social media solutions, according to the service users’ preferences. In addition, clinical service user data was exchanged in a consensual approach in eight studies: Digital records were exchanged between service users and providers via web site (Shorten et al., 2015), web portal (Andersson et al., 2021) and web applications that were designed to be used on a mobile device in general (Swallow et al., 2016) or on a tablet (Javadi et al., 2018). Poss-Doering et al. (2020) used tablets for displaying digital material to service users and identified the use of shared digital records as supportive to continuity of primary care in networks. Two further studies recommended (Metzelthin et al., 2013) and applied (Bluml et al., 2000) documentation and exchange systems, without specifying them in any detail. Data of digital records was collected manually from digital devices that measured cholesterol (Bluml et al., 2000) and blood-pressure (Andersson et al., 2021). In the study of Byerly et al. (2021), live exchange between learning service providers on digital records in front of a local computer system was followed by a face-to-face encounter.

Digital solutions facilitated participation of service users in interprofessional learning via collaboration on their data (n = 5; Andersson et al., 2021; Bluml et al., 2000; Javadi et al., 2018; Shorten et al., 2015; Swallow et al., 2016) or via general communication (n = 3; Korstjens et al., 2021; McGilton et al., 2011; Saia et al., 2000). In three studies, digital solutions were identified as facilitators of interprofessional interaction, but service users participated at a different moment of the reported study (Byerly et al., 2021; Metzelthin et al., 2013; Poss-Doering et al., 2020).

In five studies, interprofessional learners interacted with played or digitally simulated service users (Lempicki & Holland, 2018; Liaw et al., 2020; Sabus et al., 2011; Uslu-Sahan & Terzioglu, 2020; Yang et al., 2017). In addition, four studies used videos as a solution to train learners on how to interact with service users (Darlow et al., 2015; Lucas et al., 2020; McGilton et al., 2011; Yang et al., 2017).