Perceptions Regarding Interdisciplinary Collaboration
of Graduate Students in Health-Related Programs
Presented by: Kelly Baird RD, LD B.S. Health and Sports Studies, Miami University
Master of Public Health Candidate, 2012 University of Cincinnati
November 5, 2012
Committee: William Mase Dr.PH, MPH, MA, Chair
Kelley Carameli Dr.PH, MS
Overview
• Purpose
• Overview of the Literature
• Study Design and Research Methods
• Findings
• Discussion
• Conclusion
• Questions
Purpose of the Study
• Purpose: • To explore the perceived concerns of graduate students in health-
related programs at the University of Cincinnati regarding the strengths and challenges of working with an interdisciplinary health care team
• Research Aims: • Primary:
• To discover areas of success and areas of improvement in educational efforts to prepare graduate students to work effectively in interdisciplinary teams
• Secondary: • To determine if student perceptions are consistent with current
research pertaining to interdisciplinary practices in health care
Overview of the Literature: Interdisciplinary Collaboration
• Interdisciplinary collaboration is defined as a partnership between two or more health care disciplines that facilitates the achievement of goals optimizing the knowledge, the skills and the perspectives of each team member
(Bronstein, 2002; Jansen, 2007)
• While the importance of teamwork in a health care setting is recognized, effective collaboration across disciplines is not yet a reality
(Institute of Medicine, 2001)
Overview of the Literature: Motivation to Change
• Institute of Medicine (IOM) • Crossing the Quality Chasm: A New Health System for the 21st Century
(2001) • Health Professions Education: A Bridge to Quality (2003)
• Joint Commission • Advancing Effective Communication, Cultural Competence, and Patient-
and Family-Centered Care: A Roadmap for Hospitals
• Department of Health and Human Services (DHHS) • DHHS’s strategic plan
• Patient Protection and Affordable Care Act (PPACA) • Patient Centered Medical Homes (PCMH)
Overview of the Literature: Benefits of Interdisciplinary Collaboration
• Increased Cost Savings • High-cost patient populations
• Improved Patient Care • Patient safety • Creative/innovative solutions • The better the relationship of the team, the lower the risk- adjusted
length of stay (Shortell et al., 1994)
• Increased Job Satisfaction • Organizational commitment (Proenca, 2007)
• Less turnover (Shortell et al., 1994)
Overview of the Literature: Factors that Influence Interdisciplinary Collaboration
Bronstein’s Model of Interdisciplinary Collaboration • Interdependence
• Role understanding; depend on others for success
• Newly Created Professional Activities • Creativity and innovation
• Flexibility • Autonomy and ‘role blurring’
• Collective Ownership of Goals • Celebrate successes and failures as a team; goal development
• Reflection on the Process • Feedback • Discussing individual/team needs
Overview of the Literature: Factors that Influence Interdisciplinary Collaboration
Influences that Promote or Hinder Collaboration • Professional Roles
• Understanding of each disciplines’ roles
• Structural Characteristics • Caseload • Company culture • Administrative support • Time/space for collaboration
• Personal Characteristics • Values
• History of Collaboration
Bronstein, 2003
Overview of the Literature: Factors that Influence Interdisciplinary Collaboration
Overview of the Literature: Current Health Care Practices
• Not embedded in current health education system
• Lack of opportunities for interprofessional collaboration in the educational setting
• Lack of evidence-based methods for instruction
Hall and Weaver, 2001; Greiner & Knebel, 2003
Overview of the Literature: Challenges and Barriers to Change
The 2003 IOM report
Health Professions Education: A Bridge to Quality
“The health care system can hardly be called a system, [but] rather it is a dizzying array of highly decentralized sections"
Overview of the Literature: Challenges and Barriers to Change
• Institutional Barriers • Finance • Apathetic faculty • Structural and environmental • Policy/laws • Calendar/time
• Cultural Barriers • Discipline-specific philosophies • Language/values • Social structure (hierarchy)
• Research-Related Barriers • Lack of evidence-based methods • When? How? What?
Overview of the Literature: Opportunities for Improvement
• There is an established need for health education reform • Education will shape the future of health care
• Positive exposure produces positive mindset
• Current federal/organizational level push for interdisciplinary collaboration • Window of opportunity to improve the health education
system
Research Methods: Study Overview
• Purpose • Determine graduate student perceptions regarding
interdisciplinary collaboration
• Structure • Bronstein’s Model of Interdisciplinary Collaboration • Five components (domains)
• Methodology • Qualitative, exploratory study • Inductive analysis (Thomas, 2006)
• Institutional Review Board (IRB) approval obtained
Research Methods: Population
• The Population of Interest • Graduate students training to become future health care
professionals
• Criteria for Eligibility • Age eighteen years old or older
• Currently enrolled part-time or full-time in a health-related graduate program on-site at the University of Cincinnati for the academic year 2012-2013
• Fluent in the English language
• No prior experience working as a professional in their current field of study
• Open to all genders, races, ethnicities and backgrounds
Research Methods: Population
• Study Recruitment • Graduate students at the University of Cincinnati
• College of Medicine (medicine) • College of Nursing (nursing) • College of Pharmacy (pharmacy) • College of Allied Health Sciences (physical therapy, nutritional science,
social work, communication sciences and disorders)
• Two Part Recruitment • Program directors/coordinators • Interested students respond to recruitment • Up to two (2) students from each program eligible
• Possible total of fourteen (14) study participants • Accepted on a first-come, first-serve basis
Research Methods: Sample Demographics
Student Discipline Year of Study Gender
1 Medicine Third Female
2 Medicine First Female
3 Nutritional Science First Female
4 Nutritional Science Fourth Female
5 Physical Therapy Third Female
6 Physical Therapy Second Female
7 Social Work Second Female
8 Social Work First Female
Age Mean: 31.9 years Median: 27.5 years Range: 22-51 years
Student Status Part-time: 1 Full-time: 7
Research Methods: Instrument and Metrics
Dr. Laura Bronstein’s Index of Interdisciplinary Collaboration
• This questionnaire was utilized to develop this study's interview
structure
• Extended to capture general beliefs and current practices within each discipline’s graduate program
• Due to one-hour allotted time frame, original questionnaire was narrowed down to meet time restraints
Research Methods: Metrics
Domain Description
Interdependence
• The occurrence and reliance on interactions among professionals, with each dependent on the other for accomplishing established goals
• Clear understanding of the distinction between their role and other professionals' roles
Newly Created Professional Activities
• Collaborative acts, programs, and structures can achieve more than what could be achieved by the same professional acting independently
• Maximizing the expertise of each team member
Flexibility • Deliberate 'role blurring' allowing for productive compromises
Collective Ownership of Goals
• Shared responsibility in the process of developing and achieving goals • Each professional takes responsibility for his/her part in the successes and
failures of the team
Reflection on the Process
• Collaborators' thinking and talking about working relationships and the process of feedback to strengthen collaborative relationships and effectiveness
Five Domains of Bronstein's Model of Interdisciplinary Collaboration
Research Methods: Instrument and Metrics
Domain Selected Question
Introductory Exploratory Questions
1. What are your thoughts on interdisciplinary team work in health care? 2. What do you feel are the benefits of teamwork in a health care setting? 3. What do you feel are the risks of teamwork in a health care setting? 4. Would you be willing to work on an interdisciplinary team in the future?
a. If yes, what do you hope to gain from this experience? b. If no, what are your main concerns?
Interdependence 1. What concerns do you have about other professionals understanding your role as a health care professional in a team environment? Do you feel graduate students in different disciplines have a clear understanding of the roles they will play as future health care professionals?
2. How do you feel about giving feedback to other professionals in an interdisciplinary team?
Newly Created Professional Activities
1. How do you feel about the notion that interdisciplinary work improves the development of innovative new programs? Agree? Disagree?
2. Reflect on this statement: “Working with colleagues from other disciplines will lead to outcomes that we would not be able to achieve alone.” Do you agree? Disagree? Why?
Research Methods: Instrument and Metrics
Domain Selected Question
Flexibility 1. What is your understanding of other health care discipline’s role in a team environment? 2. How do you feel about sacrificing a degree of autonomy to support collaborative problem
solving?
Collective Ownership of Goals
1. How do you feel about colleagues form other disciplines collectively participating in patient treatment plans?
2. What thoughts or ideas do you have about professionals from your discipline and other disciplines’ commitment to working together as a collective unit?
Reflection on the Process
1. What are your thoughts on colleagues from other disciplines and yourself, talking together about professional similarities and differences, including role competencies and stereotypes?
2. How do you feel about colleagues from other health care professions evaluating your future work?
Current Educational Practices
1. Do you feel your current graduate program has prepared you for a future of interdisciplinary collaboration?
a. If yes: i. Please describe courses/experiences your program has provided to prepare you.
b. If no: i. What do you think is missing from your program? ii. What would you like to see added to your program to prepare you, according to your
current concerns?
Research Methods: Data Collection
• Face-to-face, audio recorded interviews • On campus
• Academic year 2012-2013, third week of October 2012
• Interviews occurred separately, at a time/date/location selected by each study participant
• Consent obtained prior to the interview
• One-hour time frame
• Transcribed, study ID assigned
Research Methods: Data Analysis
• General Inductive Approach (Thomas, 2006) 1. Preparation of audio recordings to raw data text files
2. Close reading of the text multiple times
3. Creation of general level categories
4. Creation of major (salient) themes as developed from overlap of the general level categories
5. Discovery of contradictory points of view and new insight
6. Examples of text then utilized to illustrate the points made and support the researchers findings
Research Methods: Data Analysis
• The purpose of using an inductive approach (Thomas, 2006)
• Identify commonly reported patterns in the data • Establish clear links between the research objectives and the summary findings
from the raw data • To develop a model or theory about the underlying experiences or processes
which are evident in the raw data • Justification: general inductive approach is commonly used in health and social
science research and evaluation
• Analysis • Within domains using frames of analysis
• General (phenomenological) themes • Across domains:
• Major (thematic) themes
• Trustworthiness • Member checking
Research Methods: Data Analysis
Frames of Analysis
Findings:
Phenomenological Findings • Interdisciplinary Team Collaboration
• Innovative solutions • "The process of teamwork, I think it brings answers more quickly. I
think it allows for outside the box thinking where answers can be discovered that might not be discovered before." (Social Work Student)
• Enhanced patient care • "I also think it serves the patient better, if, different ideas can be
brought, it communicates to the patient that you’re doing everything you can do." (Social Work Student)
• Expansion of professional knowledge • "...I think it’s good for our professional development, because we pick
up tips and tricks…that we don’t get in school... it just makes us look at the patient as a whole." (Physical Therapy Student)
Findings:
Phenomenological Findings • Interdependence
• Professional Application: • Not comfortable giving feedback to other disciplines
• “I think that’s a tough one, if.... it’s something like...an extreme mistake where they need feedback or if they’re causing harm to the patient then I feel like it would be important, but at the same time... I didn’t go to nursing school, I didn’t go to PT school, I don’t know... all the things that they know.” (Medical Student)
• Misunderstanding of roles • Contingent on leadership
• Education • Lack of exposure in education setting results in minimal knowledge on
educational components of other disciplines • Current curriculum is heavy with discipline-specific content
Findings:
Phenomenological Findings • Newly Created Professional Activities
• Professional Application: • Interdisciplinary collaboration leads to creative and innovative
solutions • “…anytime you collaborate with someone else, if you’re open to their ideas
and they’re open to your ideas and you can sit and discuss them, lots of things can happen.” (Social Work Student)
• Younger professionals more open to new ideas
• Education: • No trends detected
Findings: Phenomenological Findings
• Flexibility • Professional Application:
• Loss of autonomy necessary for patient care; however expressed with caution and hesitation • "I think when it comes to nutrition stuff they should put their input and
then...the dietitian makes the call. Or...a physical therapist...we say well from my perspective this is what we think this person needs, but the physical therapist ends up being the one that makes the, the call on the care.” (Nutritional Science Student)
• Lessens the burden of patient care on each profession • Younger professionals more open to ‘role blurring’ than older
professionals • Education:
• Lack of understanding of professional roles • Need for greater professional and social exposure to other disciplines • What exposure did occur was outside the education system
• Friends/family
Findings: Phenomenological Findings
• Collective Ownership of Goals • Professional Application
• Uncertain of other disciplines’ commitment to interprofessional collaboration • "I feel like hopefully in the best interest of the patient they would want to
[work collaboratively], but I don't know if all areas necessarily do..." (Medical Student)
• Working together (establishing goals, treatment plans) produces better results and better patient care
• Education • Exposure during the educational experience shapes ability to collectively
own goals • Field of medicine still lacking in preparing physicians for
interdisciplinary collaboration • "...doctors are a little bit more solo...I think that as far as like other therapy
goes, speech therapy and occupational therapy, I think that we’re all used to kind of working as a team and so we appreciate that we’re doing one part of this whole....” (Physical Therapy Student)
Findings: Phenomenological Findings
• Reflection on the Process • Professional Application
• Feedback from others outside each discipline accepted, but with caution
• Concerns with scope of practice • "As long as the comments that are being made are…coming from your
area of expertise then it can be...perfectly fine. Then when you kind of jump into what other people are doing, then...there can be some issues." (Medical Student)
• Time
• Education • Due to lack of time in the professional setting, the educational
setting should be used to develop this domain
Findings: Phenomenological Findings
• Current Graduate Program Preparation for Interdisciplinary Collaboration • Quick to state confidence in program’s preparation regarding
interdisciplinary collaboration; however contradicted this notion with further discussion • "...I think we definitely have a lot of small group work within our
medical class, but I do think...I'm not 100% informed on this, but I feel like we might be lacking in some interdisciplinary stuff...outside the medical school." (Medical Student)
• Opportunities are voluntary, not mandatory • "I think there are certainly opportunities through the program to be
exposed to it, I don’t know that we’re specifically, (pause) required to be exposed to it." (Social Work Student)
• Ideas for improvement • Additional class time dedicated to understanding other disciplines' roles,
workshops and modules on interdisciplinary collaboration, and greater exposure to faculty working with other disciplines.
Findings:
Thematic Findings
Major Themes
Interdisciplinary Collaboration
Professional Application
• Work environment • Personality vs. Profession • Role Uncertainty • Generational Differences • Patient-Centered Approach
Education • Gaps in education
Findings Across Domains
Findings: Thematic Findings
• Gaps in Pre-Professional Education • Voluntary vs. mandatory
• Curriculum conflicts • Discipline-specific vs. interdisciplinary collaboration
• Mindset develops early, while in the educational setting
• Ideas for exposure • Time and Frequency
• “…you end up being a better member of the team the earlier you get exposed to it, the more often you’re exposed to it.” (Medical Student)
• Modules, panels, job shadowing, provision of job description, collaborative faculty involvement, and workshops
Findings: Thematic Findings
Category Examples
Voluntary vs. Mandatory
"...we don’t see them [other disciplines], in the schools we don’t really collaborate that much...I think down the road we will have a lot more opportunity to talk to other colleagues, and it’s happening now, it’s just...not as embedded in our program" (Social Work Student)
Curriculum Conflicts “We’re so busy with our nutrition specific classes...so I just spend my time doing all of that...we don’t have any...assignments to collaborate with any other graduate students or anything like that.” (Nutritional Science Student)
Mindset
"...in everyone’s graduate program or professional program...as you go along you kind of fall into that mindset that they’ve...cast upon you...nurses start thinking a certain way after a couple years of their training, I’m sure dietitians start thinking a certain way, and I know for sure med students, they get, you change a lot in your training...” (Medical Student)
Exception: Social Work
Gaps in Pre-Professional Education
Findings: Thematic Findings
• Interdisciplinary Team Role Uncertainty • Concerns with trust
• “We need to understand how much people actually know... I think you just don’t trust them because you don’t know how they were educated, that’s a big problem." (Medical Student)
• Linked to gaps in pre-professional education • Confusion with scope of practice • Concerns with providing feedback to other disciplines
• "I think I would be very quick to give positive feedback and I don’t think that I would ever criticize a nurse on the way she handled a situation, because I am not a nurse and I…don’t understand the ins and outs of what led into that...decision." (Nutritional Science Student)
Findings: Thematic Findings
• Generational Differences • Younger professionals experience greater exposure during education • Current progressing toward a interdisciplinary team model
• “...I think it’s always going to be around, but I think its definitely changing...you can kind of tell with...younger professionals entering into the field that there is a little bit more collaboration…I think some of that stuff is going to be kind of phased out as people retire” (Nutritional Science Student)
• Expressed across all five domains • Younger professions are more likely to be open to:
• Depend on other disciplines • Accept innovative ideas from other disciplines • Allow greater flexibility with scope of practice • Collectively develop goals with other professionals • Provide/allow feedback
Findings: Thematic Findings
• Personality vs. Profession • The desire to work in teams, the ability to hear and accept
feedback, the desire to hear others’ opinions, and the desire to take time for a collaborative approached was thought to be based on an individual’s personality, not the discipline in which they worked
• Exception: Field of Medicine • “…doctors are a little bit more solo, they know that they need the
help of others but what they say goes…” (Physical Therapy Study)
• “…I mean you’re taught you’re the doctor this is your (emphasis on “your”) patient, you’re managing this…” (Medical Student)
Findings: Thematic Findings
Category Concepts
Leadership • The physician is the recognized leader of the team • If the leader of the team accepts collaborative practice, the team will function effectively • Creativity and innovation depend on the leadership of the team to promote or hinder the
collaborative approach Facility • Organizational values either promote or hinder interdisciplinary collaboration
Team Members
• All team members must be respectful and open to hearing other’s ideas, not just the leader of the team
• Team members must be able to accept constructive criticism and feedback • All team members must give their input and speak up
Leadership: " If the person at the top of the chain is in any way hesitant to involve other people, the teamwork thing will breakdown, and it will cause stress on all levels.” (Physical Therapy Student) Team Members:“…anytime you collaborate with someone else, if you’re open to their ideas and they’re open to your ideas and you can sit and discuss them, lots of things can happen.” (Social Work Student)
Work Environment
Findings: Thematic Findings
• Patient-Centered Approach • Willing to allow a personally uncomfortable situation to occur if it is in
the best interest of the patient • “...ultimately your goal is the best for the patient, so if you know something
that they don’t know, then its...what needs to be done I guess. So I think if it needed to be done I could do it.” (Physical Therapy Student)
• Would surrender a degree of autonomy • “I mean if it’s, if it’s for the good of the patient, and, and they really do have
better ideas…” (Physical Therapy Student)
• Patient-centered thinking was stated to be a catalyst for effective teamwork
• Consistent across all domains
• Listed as a primary reason for desiring to work with an interprofessional team in the future
Discussion
• Supportive of current literature
• Bronstein’s (2002) Model of Interdisciplinary Collaboration • All five components justified
• Bronstein’s (2002) Influences on Interdisciplinary Collaboration • Understanding of professional roles
• (Role understanding; Gaps in pre-professional education) • Personal characteristics
• (Work environment-team member mindset; Generational differences) • Organizational/structural characteristics
• (Work environment) • History of interdisciplinary collaboration
• (Gaps in pre-professional health education; Generational differences)
Discussion
• Supportive of current literature • Gaps in pre-professional education
• Hall & Weaver (2001)
• Discipline-specific curriculum vs. interdisciplinary collaboration curriculum (time) • Gardner (2002); Greiner & Knebel (2003); Rafter et al. (2006)
• Extension to current literature • Student perceptions
• Student recommendations for improvements to the health education system • Brings new ideas forward with minimal cost
Discussion
• Education system provides a window of opportunity to shape and mold student minds on collaboration
• Concept (trust) and model (education) developed from study findings as a means to improve the current health education system
Discussion
• Information obtained from this study suggests an imperative need to develop trust amongst health care disciplines
• The development of fears concerning collaboration may be directly bound to the idea of trust
• Examination of study findings shows trust will likely increase from: • Exposure to other disciplines skills and abilities • A comprehensive understanding of educational backgrounds
for each discipline • An understanding of roles for each team member
Discussion
Discussion
Discussion: Limitations
• Sample • Gender bias • Size • Exclusive to the University of Cincinnati • Does not reflect all disciplines (only four represented)
• Interviewer’s Background
• Voluntary study • Those who responded to recruitment may have a greater
interest in interdisciplinary team collaboration, as compared to the general student population
Discussion: Future Research
• Further development and study of innovative methods/educational approach to pre-professional health education • Pilot programs
• Further examination of the effectiveness of current practices • Detect areas of weakness; opportunities for improvement
• Further examination of trust development in pre-professional education
Conclusion In order to produce a future health care workforce with positive perceptions on interdisciplinary collaboration, fundamental understanding and acceptance of other disciplines must begin at the base: the educational level.
Questions
References
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Thank You!
• Dr. Mase and Dr. Carameli
• Petra Weaver
• University of Cincinnati’s Public Health Program
• University of Cincinnati’s health education programs • College of Medicine, College of Nursing, College of
Pharmacy, College of Allied Health
• Family and friends
• Co-workers at CCHMC School Intervention Program
