|ORIGINAL RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 1 | Page : 52-57
Challenges of interprofessional team training: A qualitative analysis of residents' perceptions
Sandrijn van Schaik1, Jennifer Plant2, Bridget O'Brien1
1 Department of Pediatrics, University of California, San Francisco, California, United States
2 University of California Davis, California, United States
|Date of Web Publication||31-Jul-2015|
Sandrijn van Schaik
Associate Professor of Clinical Pediatrics, Department of Pediatrics, University of California, 550 16th St, 5th floor, San Francisco CA 94158
Source of Support: None, Conflict of Interest: None
Background: Simulation-based interprofessional team training is thought to improve patient care. Participating teams often consist of both experienced providers and trainees, which likely impacts team dynamics, particularly when a resident leads the team. Although similar team composition is found in real-life, debriefing after simulations puts a spotlight on team interactions and in particular on residents in the role of team leader. The goal of the current study was to explore residents' perceptions of simulation-based interprofessional team training. Methods: This was a secondary analysis of a study of residents in the pediatric residency training program at the University of California, San Francisco (United States) leading interprofessional teams in simulated resuscitations, followed by facilitated debriefing. Residents participated in individual, semi-structured, audio-recorded interviews within one month of the simulation. The original study aimed to examine residents' self-assessment of leadership skills, and during analysis we encountered numerous comments regarding the interprofessional nature of the simulation training. We therefore performed a secondary analysis of the interview transcripts. We followed an iterative process to create a coding scheme, and used interprofessional learning and practice as sensitizing concepts to extract relevant themes. Results: 16 residents participated in the study. Residents felt that simulated resuscitations were helpful but anxiety provoking, largely due to interprofessional dynamics. They embraced the interprofessional training opportunity and appreciated hearing other healthcare providers' perspectives, but questioned the value of interprofessional debriefing. They identified the need to maintain positive relationships with colleagues in light of the teams' complex hierarchy as a barrier to candid feedback. Discussion: Pediatric residents in our study appreciated the opportunity to participate in interprofessional team training but were conflicted about the value of feedback and debriefing in this setting. These data indicate that the optimal approach to such interprofessional education activities deserves further study.
Keywords: Debriefing, feedback, interprofessional education, simulation, teamwork
|How to cite this article:|
van Schaik S, Plant J, O'Brien B. Challenges of interprofessional team training: A qualitative analysis of residents' perceptions. Educ Health 2015;28:52-7
| Background|| |
With the growing emphasis on teamwork in health care, simulation-based team training programs are increasingly instituted in the United States and elsewhere to practice teamwork skills through experiential learning in a safe setting. , It can be argued that such training should occur as interprofessional education, defined as learning from, with and about other professionals, and involve interprofessional teams as they work together in clinical practice.  Interprofessional team training can, however, be complicated if learners and providers at various levels of training or experience participate, which is often the case in teaching hospitals in the United States. While this resembles real-life in which healthcare teams often consist of both experienced providers and trainees, tensions related to hierarchical team structures and differences in experience can become more visible in simulation training. Simulation training is typically followed by debriefing, which offers opportunities for discussion and feedback that do not commonly occur in real-life. In particular, debriefing tends to put a spot light on team leaders, since team leadership tends to be seen as a major aspect of effective teamwork. , In the United States, the leadership role is often assigned to resident physicians (also referred to as residents), physicians in-training who have completed their medical school degree program and are undergoing further training in a (sub) specialty of medicine.
There is little data in the literature on the benefits of an interprofessional approach to team training.  We conducted interviews with pediatric residents at our institution, an academic healthcare center in the United States, to examine their self-assessment of team leadership skills during simulated resuscitations.  During these interviews, almost all residents commented on the interprofessional nature of the simulation sessions in relationship to their learning. We therefore performed a separate qualitative analysis of the interview data to further explore residents' attitudes toward simulation-based interprofessional team training and examine whether interprofessional team dynamics impact their perceptions regarding learning in the context of simulation.
| Methods|| |
Participants and setting
Our study was conducted in the context of UCSF Benioff Children's Hospital Mock Code Program, an interprofessional, simulation-based, team-training program for pediatric health care professionals and trainees. The program has been described in detail elsewhere;  it involves regularly scheduled simulation sessions or "mock codes" that take place in-situ on patient care units with participants who work on those specific units. The current study focused on mock codes taking place on the acute care units of our Children's Hospital, in which both nursing staff (six to eight per session) and residents (four to six per session) participate. Residents participate in the mock code program as part of their scheduled acute care rotations, and those in their second and third year of training are randomly assigned to the leadership role by mock code program leadership. Participation in the mock code program is mandatory for all nurses on at least an annual basis. In addition, clinical pharmacists, pharmacy students and medical students are invited to participate although their participation is more variable. Mock code sessions follow a structured format with two scenarios per session, each followed by a semi-structured group debriefing during which team members provide feedback on each others' performance. Trained faculty instructors (at least one RN and one MD instructor per session, trained in debriefing through formal workshops) facilitate the debriefing. Participants are assigned roles consistent with their professional roles ahead of each scenario (e.g., bedside nurse, team leader) and sessions are video recorded. All residents assigned to the leadership role in consecutive sessions during the 2009-2010 academic year were eligible for participation in the study.
The UCSF Committee on Human Research approved the study.
The original study was designed to analyze residents' self-assessment of resuscitation skills; a complete description of the tools used and procedures followed has been described elsewhere.  Residents met individually with one of the investigators (JP) for a semi-structured interview within one month of the mock code. During this audio-recorded meeting, each resident reviewed the video of the mock code, answered questions about his/her approach to self-assessment and commented on the feedback they received in the debriefing immediately after the mock code scenario. We designed interview questions to examine residents' overall experience during the mock code, their perceptions of their own performance in each of five domains of resuscitation skills, and how these perceptions compared to, and were influenced by, the feedback they received. (Appendix [Additional file 1]).
We used a general inductive approach to identify themes in the interview data and used constant comparison to refine and verify themes and sub-themes. , Two investigators (JP, SvS) independently coded the first three transcripts, compared codes and generated a preliminary coding scheme. Next, they each coded three more transcripts and finalized the coding scheme. With this scheme, both investigators coded all remaining transcripts independently and compared, discussed, and reconciled differences. Throughout the coding process, they independently generated possible themes and subthemes, identifying both confirming and disconfirming cases to ensure rigor. They reconciled and finalized the list of themes and subthemes. To further explore residents' perceptions of interprofessional team training and debriefing, one investigator (SvS) performed a secondary analysis of the transcripts with a theoretical thematic analysis approach, using interprofessional learning and practice as sensitizing concepts  and extracted themes. Because residents often use the terms interdisciplinary and multidisciplinary interchangeably with interprofessional and multiprofessional, we coded excerpts with the first two terms and verified based on the examples residents provided in their discussions that they indeed eluded to interaction with other professionals, not disciplines. A second investigator (JP) verified the theme list against the original data set, and all three investigators reviewed the theme list and verified its accuracy. We used HyperRESEARCH 2.8! to organize the qualitative data.
| Results|| |
We approached 19 eligible pediatric residents for consent and 16 participated in the study (11 PGY-2's and 5 PGY-3's). We identified three major themes related to the interprofessional context of the simulation.
Theme 1: Mock codes are helpful but anxiety provoking, in part because of interprofessional dynamics. Residents universally felt that the mock code sessions were helpful, but frequently mentioned feeling anxious and insecure. They often attributed this to performance anxiety and lack of experience with the leadership role in crisis situations. Residents recognized themselves as part of a complex hierarchical structure, in which on the one hand they were asked to be leaders, and on the other hand often they deferred to more experienced nursing staff. "You're trying to establish yourself as a person, as a care provider in this environment with people who are there all the time and you're just walking in " (R06). One resident explicitly verbalized how being in training and less experienced than the nurses affected the experience: 0"I'm uncomfortable with being younger and telling other people what to do, [it is] a strange feeling to me, when there's three expert nurses that have dealt with this for a very long time and have a lot of experience with it" (R13). Residents also realized that their performance during a mock code can impact how nurses perceive their overall competence: "I'd rather do a bad job in front of residents (…) than in front of the nurses, because I mean they run the floor (…) Maybe they don't say it, but, in their head, they [the nurses] are like, "Oh, I remember this guy from the mock code. He doesn't know what he's doing " (R16).
Theme 2: Residents appreciated the interprofessional training opportunity and hearing perspectives of other health care providers, but recognized limitations of debriefing in the interprofessional setting. Residents valued the mock codes because they provide opportunities to practice teamwork, and to hear the views of other health care providers on the team. One resident pointed out that such opportunities are rare, but helpful to address issues related to systems and team interactions: "It's the one time where we can talk through some of the systems issues, with everyone actually there, like the charge nurse, the floor nurses, the residents; talk through those things and focus on (…) the interaction between people in different roles " (R12). Several residents thought that the debriefing would be more useful if it was, at least in part, conducted in separate groups: "I think it is good to have it all as a group, but I (…) also think it is important that nurses and the residents get separated because I think we reflect on different aspects of it0" (R07). One resident mentioned not wanting to offend the nurses: "I just think that I had a hard time expressing some of my thoughts because I didn't want to offend nurses. But if I'd maybe talked about it with my fellow residents and then come back to the big group, maybe I would have had the words and I would have done that in a more effective way " (R06).
Theme 3: The interprofessional context inhibits critical feedback during debriefing because of the complex hierarchy and need to maintain positive relationships with colleagues. Fear of offending others was seen as an important barrier to critical feedback in the interprofessional setting: "I think debriefing mock codes that are multidisciplinary, and getting feedback at the same time seems to be a little challenging, because nobody wants to step on any toes" (R16). In general, residents expressed a desire for more critical feedback to help with performance improvement, and the majority felt that the debriefing after mock codes was not always conducive to this. They noted tension between the need to maintain a friendly, safe environment and creating space for constructive, useful feedback: "I think, in general, the debriefings are kind of a little nicey-nice and don't offer a lot of really solid criticism and very helpful feedback (….) nobody wants to get - like in front of the whole team, it's hard to get really focused, actually like critical criticism, but then it's also not as useful0" (R11). The potential effect on working relationships outside of the mock code setting was quoted as a reason for residents to not be critical toward nurses: " Even though as we get further along we're more in charge of decisions we're still very deferential to the nursing staff, (...) because we need stuff to get done. So I think from our perspective we can't - we don't usually give, you know, true criticism" (R10). One resident, however, saw the mock codes as an opportunity to hone the skill of giving feedback in such a way that it would not hurt relationships: "I just feel like the whole maintaining peace with your colleagues comes into play in the debriefing, (…) it's good to develop those skills - to give feedback and maintain relationships" (R04).
| Discussion|| |
Our study of pediatric residents participating in interprofessional simulation-based team training revealed that residents appreciated the opportunity but at the same time were conflicted about the benefits of conducting such training in an interprofessional manner. There is increasing evidence in the literature that team training in health care leads to decreased errors and improved patient outcomes, , but it is less clear what the impact of an interprofessional approach is on learning.
The residents in our study questioned whether the interprofessional nature facilitated effective feedback, and highlighted reasons why they themselves may be reticent to be forthcoming. Many of these reasons appeared founded in beliefs about power differentials and a desire to avoid conflict. Viewed through the lens of Raven's theoretical framework of power,  residents can be seen as having "positional power" due to their assigned role as leader of a mock code, whereas nurses tend to have more "expert power" and/or "informational power" because they often have more experience and have worked in a given setting longer than the rotating residents. Gabel has argued that physicians should be educated about different forms of power and effective use of power in order to improve physician's leadership.  While Gabel's paper does not discuss power in the context of interprofessional teams, it is clear from our study that power differentials play an important role on such teams, and the possibility that explicit education about power leads to improved interprofessional teamwork deserves further consideration.
We also see the social identity approach, which includes self-categorization theory, as a useful framework for our findings. , This framework conceptualizes human behavior as having both interpersonal and intergroup aspects, with social identity defined as a person's self-concept derived from perceived membership in a particular group. This self-categorization leads to perceptions of an "in-group" versus an "out-group," with the in-group generally receiving more favorable consideration than the out-group. Applied to teamwork in healthcare, the social identity approach helps explain tensions between professions based on factors such as stereotyping of doctors and nurses, hierarchy between professions and contextual as well as temporal changes in self-categorization.  In the team training setting, individuals can either self-categorize to the team, or to their specific professional group (e.g., physicians, nurses). This self-categorization is not static, and can be influenced by several factors, including experience, professional identity formation and perceived benefit from belonging to one group over another. Individuals who self-categorize as team members may be more open to interprofessional team training than those who self-categorize to one professional group, and residents' conflicted attitude toward mock codes and in particular team debriefing may reflect their struggle to choose between identities. As team members, they may embrace the opportunity to train together and hear from others whereas as physicians-in-training, they may feel more comfortable practicing and debriefing in their in-group.
Studies in the business literature have shown that psychological safety, defined as the shared belief that the team is safe for interpersonal risk taking, is essential for team learning.  Psychological safety enables team member to seek feedback, share information, ask for help, talk about errors, and experiment, all actions that are essential for learning in, and as, a team. Psychological safety is greater if team members have preexisting relationships with each other.  Interestingly, the residents in our study reported that their existing relationships with nurses outside of the mock code training were a deterrent to providing critical feedback. This indicates that preexisting relationships by themselves are not sufficient to create psychological safety on a team; another essential element is trust.  How trust can be fostered on healthcare teams remains to be established, and is not without challenges. The interprofessional dynamics outlined above likely play a major role in establishment of trust on healthcare teams, and may be exacerbated in different contexts and cultures where hierarchical tensions are more pronounced than in our setting. In addition, in various contexts teams may be ad-hoc or short-lived, for example, in teaching hospitals the composition of teams changes frequently due to the temporary nature of training, adding another challenge to the formation of trusting relationships.
Our study has several important limitations. First, the study population was small and confined to pediatric residents, and we did not explore perceptions of other healthcare providers, in particular of the nurses. This limits the generalizability of our findings, although the issues the residents in our study raise about hierarchy and need to avoid conflict are likely felt by other healthcare professionals and present in other settings as well. Indeed, studies by Lingard et al. in operating room settings have revealed that perceptions of power and professional identify play a major role in communication between physicians and nurses.  Second, the results presented in the current report came forth from a secondary analysis of data collected with a different study question, and we did not specifically explore residents' perceptions of interprofessional team training. While we might have been able to develop a more in-depth understanding with an a-priori study design, the fact that residents spontaneously raised concerns about the interprofessional nature of the mock codes lends authenticity to the findings and highlights how much this is on the forefront of their minds.
So where do we go from here? Reeves has suggested that simulation-based interprofessional education should pay attention to "sociological fidelity," creating scenarios to realistically reflect the sociological environment of clinical practice and taking into account factors such as hierarchy and power.  We certainly agree that sociological factors deserve attention, but are not sure that creating sociological fidelity is always feasible or desirable. In particular the desirability deserves attention: By recreating the social environment of teams in clinical practice, existing but undesirable barriers to collaborative practice may be viewed as the norm and become persistent. It might be more productive to address social factors explicitly, either prior to the simulation training, during the debriefing, or both. Acknowledging their existence and educating about forms and use of power may open up the conversation and create potential for change. It is evident that simply "creating a safe environment" as advocated in the simulation literature  is not going to be sufficient, since residents in our study equated safety to "nice" and did not achieve the psychological safety needed for constructive, useful feedback. We recognize that the open discussion approach toward interprofessional team training may be easier said than done, in particular in settings and cultures where open communication between different professions is not (yet) the norm. The idea that hierarchical differences and other interprofessional dynamics may be mitigated through interprofessional team training may be overly optimistic, and in many settings hierarchical barriers may need to be overcome before interprofessional team training is even possible. This would imply that education about interprofessional collaboration should precede interprofessional team training, as is increasingly the case in health professions education across the globe.  Lastly, it should be noted that even though residents in our study expressed interest in interprofessional feedback, it is unclear whether they would use it to inform performance improvement. Studies of multi-source feedback for physicians, including but not limited to feedback from other professionals, found few physicians used this feedback to make practice changes. , How interprofessional feedback can be used effectively to impact performance warrants further study.
In conclusion, interprofessional simulation-based team training offers an opportunity for residents to learn about, from and with other health care professionals but barriers exist that hamper its effectiveness, in particular as it pertains to "learning from". Further exploration of the social factors that affect residents' ability to learn in the interprofessional setting and a deeper understanding of ways in which interprofessional feedback can be delivered so it is acceptable and useful is needed in order to create evidence-based guidelines for interprofessional team training.
| Acknowledgments|| |
The authors are grateful to all the pediatric residents who participated in this study.
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