Socialisation into interprofessional teams: A mixed-methods study among early health professional learners who engaged in a teams and teamwork module / Sozialisierung in interprofessionellen Teams: Eine Mixed-Methods-Studie zum Effekt eines Team- und Teamwork-Moduls bei Auszubildenden im Gesundheitswesen

The IPE Teams and Teamwork module was a 3-week virtual IPE intervention that took the learner a total time of 3–4 hours to complete. The module was at the introductory level and offered to students early in their training to ‘attain a deeper understanding of their own profession and interprofessional identities by gaining experience communicating with other professions on the healthcare team to enhance teamwork and learn about its connection to and impact on patient care delivery and population health’. The module was incorporated into existing health science courses as a required assignment. This module was one of the first experiences in a continuum of IPE for health profession students across the course of their studies.

For this project, we measured outcomes from the Winter 2021 cohort. Students were advised in writing that work in the course will be deidentified and analysed, but that they could opt out of having their work included in the analysis. Students across three health science schools and two campuses of a large midwestern university were randomly assigned to teams of 3–4 students resulting in 55 interprofessional teams. Students represented undergraduate nursing, undergraduate kinesiology, and doctoral physical therapy (PT) programs. Teams were kept to a maximum of four students because the literature shows that smaller teams lead to greater participation and learning (Lairamore et al., 2018; Shiang-Shaw, 2013). The students worked with the same team throughout the duration of the experience. Students were required to complete a module that introduced them to IPE, specifically the IPEC competencies and IPE opportunities at their respective institutions, before enrolling in the Teams and Teamwork module.

The module was designed around an IS framework, to break down barriers and practice interprofessional roles by gaining knowledge of effective teamwork that can be applied to collaborations with peers in an interprofessional scenario. We utilised the Tuckman's stages of team formation (Tuckman, 1965) as the framework for interprofessional team development throughout this module. The trajectory of team development with this framework goes from the simplest stage of ‘forming’, when students are learning how to put a team together, to the most high-functioning stage of ‘performing’, when team members are able to adapt to meet the needs of one another, which indicates an understanding of each other's interprofessional roles. The Teams and Teamwork module scaffolded assignments and self-evaluations for students to learn about and have continuous deep reflections on their team's development. The learning outcomes of the module included: 1) describe the practices of effective teams; 2) apply strategies to navigate disagreements about values, roles, and behaviours that arise among health care teams; and 3) provide feedback and reflect on individual and team performance.

Prior to starting the module activities during week one, students completed a pre-survey that included the validated Interprofessional Socialisation and Valuing Scale (ISVS) (King et al., 2016). The ISVS allows for measurement of interprofessional socialisation and readiness to function in an interprofessional team (interprofessional identity) across three subscales: 1) Self-Perceived Ability to Work with Others, 2) Value in Working with Others, and 3) Comfort in Working with Others. Students rated the extent to which a belief, behaviour, or attitude was present using a 7-point Likert scale (1 = not at all; 7 = to a very great extent). After the pre-surveys were completed, the students then engaged in individual preparatory work that included readings about team formation (Tuckman, 1965) and attributes of a high-functioning team (Eggenberger et al., 2014). Following the readings, students completed and documented an inventory covering conflict management styles (Whetton & Cameron, 2019). Then, students watched a video of a simulated interprofessional healthcare team meeting and engaged in a discussion board conversation about the behaviours, both negative and positive, that they observed. Finally, students read a case scenario pertaining to a cell phone use policy in a healthcare unit. Each student prepared for a virtual interprofessional team discussion by answering reflections pertaining to how they would handle conflict that arose within the case scenario. Of note, the case was intentionally created to be nonclinical given the introductory level of students enrolled in the module.

During week two, the student teams discussed the case scenario in a synchronous meeting collectively scheduled by the team within a remote meeting platform such as Zoom or Google Meet. They worked together to answer specific case questions using their own individual reflections from week one as a guide. Following the discussion around the case scenario in week two, the students reflected on two prompts: 1) How well do you think your team functioned? and 2) What will you change next time you work within a team?

During week three, the student teams virtually and synchronously engaged in a ‘Team Effectiveness Exercise’ during which they were challenged to evaluate and articulate one another's performance as a team member within the context of their interprofessional team by reflecting on both significant contributions and areas for improvement for each student. Specifically, students engaged in what was called a ‘round robin’ method during which they selected a team member to go first. Then, every other member of the team provided feedback to that individual, commenting on the most important contribution they made to the team as well as one area the individual could improve upon to improve team functioning. At the end of the meeting, the teams were asked to: 1) collectively decide what stage of team development they were at according to Tuckman's (1965) Model of Team Development that they read about in week one (i.e., Forming, Storming, Norming, Performing) and 2) describe key moments that impacted their team's development over the course of the module. At the end of week three, students completed a post-module survey that included the ISVS instrument.

A mixed-methods approach including written reflection and a validated IS instrument was used to offer greater insight into the IS perspectives and the ideation of interprofessional identity in students.

The students' demographics, specifically gender, race/ethnicity, health profession, and education level were summarised for frequencies.

At each time (pre- and post-module), the ISVS scores were averaged to create three outcome variables corresponding to the three subdomain scores noted as: Self-perception of Working Together (Q1, Q2, Q4, Q8, Q10), Comfort (Q3, Q5, Q6, Q11) and Values (Q7, Q9, Q12, Q13). Students with data at one time point have been included in the analysis. For data completeness, missing data was handled by mirroring responses from the available time point. Students with no data at either time point (baseline or post) were excluded from this analysis.

Qualitative data gathered from the open-ended reflective prompts that students engaged in during Weeks 2 and 3, included the following: 1) how well do you think your team functioned, 2) what will you change next time you work in a team, and 3) describe key moments that impacted team development. The responses were analysed based on grounded theory (Charmaz, 2006). Students were also asked to give their perspective on which stage of Tuckman's model (forming, storming, norming, performing) they felt their team had reached. We implemented a data-led thematic analysis approach in which emerging themes were determined a posteriori rather than with preconceived themes (Boeije, 2002; Charmaz, 2006). Two researchers used inductive reasoning to code the reflections. Specifically, one researcher (OSA and DF analysed different prompts) individually segmented data into codes (i.e. a single word or phrase). After independent analyses were completed, the codes were discussed amongst members of the research team (OSA, DF, VB). The codes were summarised into themes to gain insight and provide an overall picture of student participants': 1) perceptions of team functioning, 2) sense of what the students would change next time they are in a team, and 3) experience of key moments that impacted their team functioning.

Paired t-tests were used to detect differences in pre- and post-module scores. A one-way ANOVA was performed to compare the effects of gender, education level and health profession on the difference between the mean scores between pre- and post-module. We used Python 3.9.0 and RStudio version 1.1.463 (RStudio Inc., Boston, MA) for quantitative analysis. The themes from the thematic analyses were tallied for frequencies. The significance level for all statistical analyses was set at p<0.05.

A total of 221 students were enrolled in the IPE Teams and Teamwork module. Seventy-four percent (n=164) of the participating students were undergraduate kinesiology and nursing students, and 26% (n=57) were doctoral PT students (Table 1). A total of 206 students responded to ISVS at baseline (pre-module; 93% response rate). The post-module response rate was 87% with 192 students of the 221 students completing the ISVS. Most students were white (79%) and predominantly female (70%).

Students reported an increase in their interprofessional socialisation and readiness to function in interprofessional teams across all ISVS items (Table 2). Accordingly, there was an average increase from pre- to post-module self-reported socialisation and readiness across all three subscales: Self-perception of working together (+0.91; p<0.001), Values (+0.69; p<0.001), and Comfort (+1.05; p<0.001).

The difference in mean ISVS scores was not statistically significant by gender. There was an increase in mean scores across all three subscales of ISVS by education level (data not shown; all p<0.05). Nursing and kinesiology undergraduate students reported an increase in socialisation within interprofessional teams across all three subscales from pre- to post-module (Table 3), whereas physical therapy students reported an increase for Self-perception of working together and Comfort.

After reflecting on the question ‘how well do you think your team functioned?’, the majority of individual students felt their teams functioned well (n=192, 87%), while just 4% (n=10) felt their team did not work well together. One student's comment seemed to synthesise the general theme of working well together by stating, ‘I think our team functioned well. We were able to work together without conflict and share ideas fluently, without judgment. We were able to communicate well with the members who were not able to attend the meeting and get them involved’. The comments of those who felt their team did not work well together, underscored the importance of communication and roles/responsibilities for a high-functioning team. These less positive comments tended to focus on one or more team members either not being present or not responding to various modes of communication. One group commented, ‘But one of our group members did not attend our meeting. We attempted to contact him multiple times and he didn't respond, so we did the assignment without him’, while another stated, ‘¾ of my team functioned very well. The last member did not respond to emails nor Canvas notifications of us trying to reach her’.

When asked about key moments that impacted their team's development, seven main themes emerged (Table 4). Many teams indicated that getting time and space to get to know each other was significant for team development (n=23, 42%). About one-third of the teams indicated that allowing the opportunity for all team members to contribute to discussion fostered team development (n=17, 31%). Other themes that emerged included specific events like the first team meeting, engagement in individual and group reflections, and the ‘round robin’ exercise as well as specific tasks like attending the meetings.

Many students indicated that they would focus more on communication and engage more in personal self-assessments when asked what they would change when they work in a team next, as reflected by the responses, ‘I will participate more in the team meetings and speak out more’, and ‘I will let others speak first. Sometimes I talk a lot and I think I should let others speak more’, indicating an understanding of their individual part in creating a solid team dynamic (Table 5). Many responses centred around the concept of familiarity with comments including, ‘It was a little awkward, just because none of us know each other.... But I think if we were more familiar before we start it would help conversation to follow more fluently’; ‘We didn't take time to really introduce ourselves and our backgrounds…’. See more themes and related excerpts in Table 5.

By the end of the module, the majority of the interprofessional student teams perceived their team as being at the ‘performing’ level of team stage development (n=33 teams, 60%), as represented by one team stating, ‘We all actively give input on each decision which we then discuss and agree/disagree on. We were able to come to ‘group’ decisions by all giving our input so not one person overpowered another’. Fifteen teams (27%) indicated that they were at the ‘norming’ stage of team development, as one team described, ‘We are still establishing clear roles and responsibilities, and discussing our team expectations, yet we have also started working together as a cohesive group as we complete tasks’. Two teams (4%) indicated that they were at the ‘forming’ stage as represented by one team noting, ‘Our team believes that we are in the forming stage since we have not worked together for very long yet. We are still getting to know each other and learning how each member works best’. None of the teams (0%) made an indication that they thought they were at the ‘storming’ stage of team development, and five teams did not answer this question.

Early and sustained IPE opportunities ensure that practicing health professionals are ready and able to work collaboratively in clinical practice. Early exposure to IPE concepts and competencies socialises students into interprofessional culture, preparing them for experiential IPE in clinical settings. Theoretically, these clinical IPE experiences socialise students to an interprofessional team, resulting in improved healthcare delivery and outcomes for the patients (Reeves et al., 2013). Thus, integrating IPE longitudinally throughout health profession education not only impacts health profession training, but also the patient experiences.

This work has a few limitations to point out. The quantitative data collected from the ISVS were self-reported. The investigators did not collect data on each student's previous IPE experience, which could potentially affect pre-module (baseline) data. Also, this IPE experience was short-term. To capture long-term impacts on the learners, it would be ideal to provide continuous engagement in IPE for them to fully develop an interprofessional identity and allow for continuous evaluation. Finally, the data were only collected at one midwestern university. Expanding data collection to various types of institutions and a larger number of health disciplines could help differentiate how IPE is valued across diverse institutional types.