Student-Initiated Interprofessional Case Discussions: Improving Students’ Perception of Interprofessional Education and Collaborative Practice / Studierenden-initiierte Interprofessionelle Fallbesprechungen: Verbesserung der studentischen Wahrnehmung von interprofessioneller Ausbildung und Zusammenarbeit

There remains no doubt that interprofessional collaboration (IPC) is crucial in providing high-quality patient care and that a lack thereof can result in poorer outcomes (World Health Organization, [WHO], 2010). Especially, with regard to the growing number of patients with chronic conditions, a collaborative, patient-centered approach with functioning communication between healthcare providers is essential (WHO, 2005).

Through interprofessional education (IPE), which according to the WHO “occurs when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes,” healthcare students are being prepared for effective IPC (WHO, 2010, p. 7).

While many IPE programs are in development or have recently been implemented, there remains a need for action in Switzerland and beyond, e.g., with regard to anchoring IPE in the curricula (Kaap-Fröhlich et al., 2022). A systematic metareview analyzing undergraduate IPE experiences in Europe advocates for including “IPE from the first years of undergraduate education and invest[ing] efforts into including in IPE a broader representation of professions involved in healthcare settings.” (Colonnello et al., 2023, p. 107).

This gap in implementation is noteworthy, given the fact that studies show that a “lack of student interest” rates among the least barriers for implementation (You et al., 2017, p. 671) and internationally, healthcare students are calling for more and better IPE (International Federation of Medical Students’ Associations (IFMSA) & International Pharmaceutical Students’ Federation (IPSF), 2020).

Benefits of student leadership in IPE have already been reported (Hoffman et al., 2008) and recently, student-initiated (extracurricular) IPE activities have shown to positively influence medical students’ attitudes towards IPC (Walmsley et al., 2018). Oftentimes, however, similar studies lack the use of validated assessment instruments (Trupiano et al., 2023).

In Switzerland in 2020, healthcare students founded the Swiss Health Alliance for Interprofessional Education (SHAPED, www.shaped-ip.ch) with the aim of improving IPE in healthcare. Incited by the lack of interprofessional (IP) activities in their curricula, students started to envision their own IPE learning activities, one of which came to be the Interprofessional Case Discussions (ICDs). The ICDs consist of students from different healthcare professions coming together to discuss a patient’s case, but with a twist: each participant receives a profession-specific script detailing information about the patient and their procedures, anamnesis, medications, etc. – every script contains complementary information. Inspired by the family game series “murder mystery,” participants need to exchange the information provided in their scripts and collaborate in order to solve the case (i.e., make the right diagnosis) and catch the killer (i.e., start appropriate treatment) in time.

The scripts are developed by members of SHAPED’s interprofessional ICD team, with the goal of including different professions for different ICDs. Combining their individual expertise, the ICD team works collaboratively and follows an iterative process with revision after each round of ICDs to ensure that the scripts contain all the clues and background information needed. It is this thorough background information that enables even healthcare students with little to no prior knowledge of the patient’s disease to participate and immerse in an IP learning experience from the very beginning of their studies.

Starting during the COVID-19 pandemic, the ICDs were first held online – though this use of technology access to IPE opportunities could be expanded as recommended by Willgerodt et al. (2015). However, more recently they have also been conducted in-person in the form of workshops at various IP events.

With the ICDs, SHAPED aims to improve the core IP competencies “Roles & Responsibilities,” “Teams & Teamwork,” and “Communication,” as outlined by the Interprofessional Education Collaborative (IPEC) (Interprofessional Education Collaborative, 2023). The primary goals (i.e., intended learning outcomes) of the ICDs are for students to work as an IP team, thereby discover and understand each other’s roles and competencies, and communicate in a respectful manner when solving the case. Completing the ICD during the provided time frame as well as advancing their (interprofessional) medical knowledge concerning the topic of the ICD are unintended—but naturally welcome—learning outcomes.

While developing the ICDs, the authors were guided first by the contact hypothesis as initially established by Allport (1954) and often described in relation to IPE since (Carpenter & Dickinson, 2016; Hean & Dickinson, 2005; Khalili et al., 2021). According to the contact hypothesis, prejudice between groups can be reduced by bringing the groups together in pursuit of a common goal, especially if supported by certain contact conditions (Allport, 1954). Emphasis was put on these contact variables specified by Hewstone and Brown (1986) as follows: a)

Equal status: by providing a script of a foreign profession to all participating students including the knowledge needed and by facilitating the ICDs, it was ensured that everyone was enabled to act as an equal member of the team

Second, inspiration was drawn from growing evidence in support of student leadership in IPE. Already in 2008, Hoffman et al. emphasized the benefits of student leadership in IPE and showed “with statistical significance the positive perceived benefits of student-initiated IPE and its potential effectiveness compared with the current ‘gold standard’ (i.e., traditional IPE teaching methods which include lectures from a professor).” (Hoffman et al., 2008, p. 657). Likewise, Ten Cate and Durning concluded that “specifically ‘near-peer teaching’ appears beneficial for student teachers and learners as well as for the organization” (Ten Cate & Durning, 2007, p. 591).

Since then, peer-teacher-led problem-based IP seminars have been seen to improve the perception of IPC among medical and pharmacy students (Lehrer et al., 2015). Similarly, weekly IP peer-taught discussions between pharmacy and nursing students not only enhanced the pharmacotherapy knowledge base of nursing students, but increased awareness of self-roles and roles of other healthcare professionals (Powell et al., 2020). And other IPE peer-teaching activities involving students from medicine, physiotherapy, and occupational therapy have shown to enhance awareness of professional roles and IP interactions (Dunleavy et al., 2017).

With the ICDs being designed and facilitated by the students and young healthcare professionals of SHAPED, they fit in the subcategory of student-initiated IPE, which “occurs when students lead the design and delivery of interprofessional education for their peers” (Hoffman et al., 2008, p. 657). Among other benefits, the applied near-peer teaching approach of the ICDs helps to create a safe and comfortable teaching environment for students and offers education at their own cognitive level (Ten Cate & Durning, 2007).

Third, gamification has been reported as a promising method in education and has been applied in the form of social engagement, specifically working on a team project (Dicheva et al., 2015) (i.e., solving the (murder) mystery posed by an ICD). And finally, when asked after graduation, students themselves valued those IPE experiences most highly “that involved genuine engagement and opportunities to interact with students in other professions working on a relevant problem.” (Gilligan et al., 2014, p. 1)—which is what participants in ICDs are tasked to do.

In the spring semester of 2024, in-person ICDs took place at the Department of Health of Zurich University of Applied Sciences (ZHAW). Students from five professions (nursing, midwifery, physiotherapy, occupational therapy, and health promotion & prevention) at the end of their third year participated as part of their mandatory curriculum. Additionally, students from medicine and pharmacy from the University of Zurich (UZH) and the Federal Institute of Technology Zurich (ETHZ), respectively, were invited to join outside of their curriculum via student associations’ newsletters.

Students were assigned scripts from different professions than their own fields of study to ensure equal status (cf. Theoretical Framework) and to further increase the understanding of roles and responsibilities of “foreign” professions.

There were two different ICD cases administered: one on the topic of neurology and one on obstetrics. Occupational therapy students all participated in the neurology case, and students from midwifery were placed in groups solving the obstetrics case to ensure context-specific learning.

SPICE-R was administered right before and after the completion of the in-person ICD. The data were collected anonymously via an online questionnaire. The participants were assigned an ID code to enable matching of pre- and post-answers.

A variety of quantitative assessment tools for IPE exist, but no single one is comprehensive enough to fulfill all assessment needs (Shrader et al., 2017). Additionally, most of them lack sufficient theoretical and psychometric development (Thannhauser et al., 2010).

The Student Perceptions of Interprofessional Clinical Education–Revised (SPICE-R) (Dominguez et al., 2015) is a validated instrument to evaluate the level 2 (“Modification of Attitudes and Perceptions”) of the Kirkpatrick evaluation framework (Kirkpatrick, 1993) and is useful to evaluate an IPE activity in a pre- and post-design (Shrader et al., 2017). It consists of 10 items that are each rated on a Likert-scale from 1 (strongly disagree) to 5 (strongly agree), and these 10 items can be further divided into the following three factors (i.e., subscales): a) Interprofessional Teamwork and Team-Based Practice; b) Roles/Responsibilities for Collaborative Practice, and c) Patient Outcomes from Collaborative Practice (Dominguez et al., 2015).

SPICE-R was designed not to focus on a single profession and provides information regarding the perceived benefits and appropriateness of IPE and IPC (Dominguez et al., 2015). It has been validated and is recommended for assessing students from a broad spectrum of healthcare professions, and its length of only 10 items (and thus needing little time to complete) is seen as a benefit (Dominguez et al., 2015).

Albeit not perfect (and missing the IPCE competency of “communication” as a primary goal of the ICDs), the facts of it being short (so students would fill it out), it being applicable to a broad variety of healthcare professionals (as were expected to participate in the ICDs), and it addressing two primary goals of the ICDs (the IP core competencies of “Team & Teamwork” as well as “Roles & Responsibilities”) the SPICE-R was chosen to determine whether the ICDs had an effect on its participants. Additionally, it had been shown to outrank other IPE-instruments such as the Attitudes Toward Health Care Teams Scale revised instrument (Dominguez et al., 2015). As no validated German version exists, it was administered in the original language (English).

Data were analyzed using the program R Core Team (version 2024.04.0+735). Pre- and post-questionnaires were paired via an anonymized code.

Using data from a preliminary analysis of online ICDs, presented at the All Together Better Health Conference XI in 2023 (Büsser et al., 2023), a priori power calculation showed n=16 to achieve a power of 80% with alpha-level set at 0.05.

For all participants, the overall mean and the means of the three subscales of SPICE-R pre- and post-ICD were calculated. After testing for normal distribution with the Kolmogorov-Smirnov as well as the Shapiro-Wilk test, normal distribution was assumed and a paired t-test was applied to determine a difference between overall mean of pre- versus post-ICD. The same was done for the three subscales of SPICE-R.

As the number of participants was rather small, no further analysis regarding fields of professions was deemed fruitful.

As seen in Fig. 1, a total of 117 students were meant to take part in the ICDs (including 4 medical and 3 pharmacy students). Twenty-two students were reported not to show up. From a total of 76 pre- and 45 post-surveys received, 33 could be paired with certainty.

Figure 1:

Flowchart detailing the recruitment of participants in the ICDs at ZHAW in spring semester 2024

The characteristics of these 33 students can be found in Table 1.

Internal consistency of the SPICE-R instrument was high, with Cronbach α = 0.87.

Pre-ICD, the mean score for SPICE-R was 3.86 (SD ± 0.39), with an observed post-ICD mean of 4.22 (SD ± 0.42). As shown in Fig. 2, using a paired t-test, a statistically significant difference between the overall mean of SPICE-R pre-to-post ICD could be found (t(32) = −5.18, p < .001, 95% CI [−0.50, −0.22]). Cohen’s d = 0.88 indicates a strong effect size (Cohen, 1992).

Figure 2:

Perception of IPE and collaborative practice pre- vs. post-ICD according to the overall mean of SPICE-R

Table 2 details the pre- and post-ICD means as well as the result of the paired t-test for the three subscales of SPICE-R: a) Teamwork and Team-based practice, b) Roles/Responsibilities for collaborative practice, and c) Patient Outcomes from collaborative practice. All subscales showed an increase in pre- to post-ICD means. Bonferroni correction for multiple testing decreased the alpha level to α = .0125; there remained a statistically significant increase on the subscales Teamwork and Patient outcome.