Ten key elements for implementing interprofessional learning in clinical simulations
Skills Centre, Faculty of
Health Sciences, University of Limpopo (Medunsa Campus),
Soshanguwe, Polokwane, South Africa
This paper discusses 10 key elements for the design and
implementation of interprofessional education (IPE) in a skills
centre. The elements are based on published literature as well
as on the experience of an IPE initiative, simulating the
management of a multiple-traumatised patient in the acute and
rehabilitation phases, by students from 4 professions: medicine,
nursing, occupational therapy and physiotherapy. The key
elements are interrelated and include the partners involved
(learners, facilitators and patient simulator), the content,
learning resources, setting, faculty development, logistics,
learning strategies and evaluation.
Interprofessional education (IPE) refers to healthcare students learning with, from and about one another to improve collaboration and the quality of patient care.1 Successful transition of students to competently work-ready health professionals requires an ability to work in healthcare teams2 and should be addressed through IPE.
The use of IPE to facilitate effective teamwork in healthcare is not novel and has been supported for about 40 years. Despite increasing recognition of the importance of IPE3 and collaborative teamwork being a World Health Organization (WHO) priority of action,4 an international environmental scan commissioned by the WHO concluded that significant efforts are still required to ensure that IPE is designed, delivered and evaluated at a high standard. This finding was based on self-reports from 41 countries that IPE was often (i) not mandatory (88%); (ii) not based on explicit learning outcomes (34%); (iii) not assessed for what was learned (63%); (iv) not offered by trained facilitators (69%); and (v) not formally evaluated (30%).3 IPE is an important paedagogy but there are certainly challenges and barriers involved in this effort. A systematic planning, development, and implementation process should be outlined before initiating IPE.5
An IPE simulation was presented at Medunsa for students from 4 professions: medicine, nursing, occupational therapy and physiotherapy. Owing to large groups of students, the simulation was repeated 6 times. The simulation comprised 2 phases: (i) the acute phase requiring medical and nursing students to manage a multi-traumatised patient on admission to the emergency room, followed by (ii) a rehabilitation phase during which occupational therapy (OT) and physiotherapy (PT) students joined for a consultation with the patient at a clinic. We drew upon our experience of simulation as well as published literature to plan, develop and implement these IPE experiences. Seven of the 10 elements of our planning, development and implementation concur with all the elements of a Conceptual Framework for Interprofessional Education and Practice (developed by the McGill Educational Initiative on Interprofessional Collaboration).6 The elements are the partners involved (learners, facilitators and patient simulator), the content, learning resources, setting and faculty development. The remaining 3 elements are the logistics, learning strategies and evaluation. These 10 key elements for the design and implementation of IPE in a skills centre are discussed under separate headings but are interrelated, as each has an influence on the process of developing and delivering an IPE event.
The 10 key elements
Interprofessional education involves staff from different professional backgrounds learning and working together. Commitment is required of faculty to engage in shared learning and dialogue which has the potential to encourage collegial learning, change thinking and support new working relationships.7
The facilitation of IPE for a small group of students is a complex and demanding activity. Facilitators need to display a wide range of attributes and competencies to ensure that they function effectively, as would be demonstrated in commitment to IPE, positive role modelling and valuing of diversity.5 They should feel confident and secure about their knowledge base and their ability to facilitate diverse groups of interprofessional learners,5 work creatively with small groups8 and be able to plan, develop, implement, teach and evaluate IPE.5
In the absence of top-down drivers for the implementation of
IPE, lecturers committed to changing and improving healthcare
education for improved patient management and safety, could
serve as bottom-up drivers. It is advisable to include faculty
who are creative and innovative – as well as interested in
transformational change – when selecting professionals to take
part in an event that is relevant to their curricula. One of our
challenges for this initiative was similar to that reported in
the literature – that the facilitators lacked training for
teaching in an IPE environment.5 The lecturers from the 4
professions invited to join the skills centre personnel in the
planning and implementation of the IPE event were skilled
clinical facilitators, strongly motivated and enthusiastic.
It is difficult to select training that is relevant for
students from different healthcare professions; most studies
limited the complexity by including no more than 4 professional
The management of a multiple-traumatised patient, as reflected
in Table 1, was selected as content for 3 reasons: (i) the management of traumatised
patients forms part of undergraduate medical (5th year), nursing
(4th year), OT (4th year) and PT (4th year) curricula; (ii) these senior students have already
mastered the required individual clinical skills; and (iii) the skills centre is very
well-suited for trauma simulations.
The simulation matched the
5th-year medical students’ lectures on multiple trauma, and
their attendance was mandatory. Fourth-year nursing students
were invited to join, as well as OT and PT students who were
allocated to relevant clinical settings that made possible their
reallocation to the skills centre for short periods. As there
were large numbers of student and limited time, some students
observed the simulations and assessed the actions using an
assessment tool (Table 2) as a guide.
3. Patient simulators
Authenticity is an important mechanism for participants to have positive experiences; the simulation of patients by high-fidelity simulators and simulated/standardised patients (SPs) plays a big part. For the present simulation, the high-fidelity simulator was programmed to display dyspnoea with decreased breath sounds on the injured side and was manipulated to appropriately change vital signs in response to treatment or deterioration in condition. Separate low-fidelity arms were used for suturing and venous cannulation, and a pneumothorax trainer to prevent numerous invasive procedures being performed on the costly simulator.
SP encounters must not be overly different from the experience
with a real patient. For the SPs to be more believable, they
need to 'become the patient', with real emotions,
and express the needs, expectations and fears of a patient.
Appropriate moulage and dress are also important. In our
simulation, the SP was dressed in overalls, and a stab wound
with controllable bleeding was created on the right arm, at the
correct site where a penetrating wound could cause damage to the
radial nerve. Bruises and haematomas were added to improve
authenticity of the patient. Detail regarding the background,
moulage and dress were carefully planned and documented to
ensure effective SP training and accurate repetition of the
Teamwork has become a major focus in healthcare, as many of the high number of preventable medical errors are a result of dysfunctional or non-existent teamwork.9 Team-based skills such as communication and leadership are therefore vital for success in IPE events, and training in these non-technical skills is becoming a high priority.10 The choice in setting the scene and creating learning situations in planning IPE is crucial to the learning that will occur. It is difficult to select training that will be relevant for students from different healthcare professions.11 Scenarios for the simulations should be customised to facilitate team interaction. The multidisciplinary and time-sensitive nature of trauma care especially requires teamwork and communication for treating the acutely injured patient.12
Trauma and communication skills were considered as common ground for a simulation appropriate for the 4 selected students groups, since these skills are included in their various curricula. The groups, however, have different roles and, as pointed out in the literature, they have different competencies and objectives as per the various curricula.5 The content should therefore be appropriate for the stages in the curricula of students from all the participating professions.
The simulation (Table 1) comprised 3 scenarios (including
pre-hospital and initial in-hospital phases that were at a level
commensurate with the knowledge and experience of medical and
nursing students) and a rehabilitation phase for the same
patient that would be more suitable for the medical, PT and OT
5. Learning resources
The resources in the skills centre are appropriate for various simulations. The patient simulators, equipment and facility itself have a big influence on scenario planning. The flat roof of the skills centre and surrounding concrete slab made it ideal for Scenario 1 to simulate a ‘fall from a height’. The facility also provided easy access to a room fitted with video recording equipment, which was used as the ‘emergency room’ for Scenario 2. Students not taking part in the resuscitation observed and assessed the activities through a one-way mirror or on plasma screen from the observation room.
Pictures of the prepared venues and equipment were taken and
filed together with the requirements list to facilitate easy and
correct preparation for similar simulations to follow. Other
resources include the instruments necessary for planning,
implementation and evaluation of the simulation. They include an
action guide (part of which is shown in Table 2) that can be
used by the facilitator without the ‘Done’ columns, as a guide
to responses required during the simulation. It can also be used
without the responses column by the observing students and
facilitator to guide their assessments and follow-up discussions
of the performances during the reflection session.
Since teamwork needs to be learnt and practised in safe simulated settings to enhance resuscitation performance,13 the skills centre was the ideal setting for simulating the management of a multiple-traumatised patient. Every effort was made to customise the IPE so that it reflected appropriate, authentic and relevant service delivery settings, since authenticity is deemed important for a positive experience by participants.6
7. Faculty development
Becoming a skilled educator in IPE is a process. Faculty members need to have a shared understanding of the purpose and goal of IPE, and to engage in collaborative discussions. Barriers to this strategy of teaching and learning at both the individual and the organisational level can be addressed by providing individuals with the knowledge and skills needed to design and facilitate IPE.6
Staff development to enable competent and confident facilitation of IPE is a key influence on the effectiveness of IPE.6 Topics should be aimed at integrating principles of teamwork into a healthcare system5 and could include instruction on interactive teaching and learning, facilitated learning, group dynamics, technology, conflict resolution, assessment strategies for IPE5 and experiential exercises; the latter provide opportunities for sharing facilitation tips. Faculty members from various disciplines are given an opportunity to interact early in the process of initiating IPE. Sharing experience is essential for team bonding and agreeing upon optimal strategies.5
Globally, only a third of facilitators undertaking IPE have not
received any training.3 None of the facilitators in
our simulation had any formal training, but fortunately had the
attributes described in the first key point. Our experiences in
this IPE event could be useful in future faculty development to
Traditional university curricula severely limit the time that students from different professions can learn together. Apart from timetabling, formal IPE can also be restrained by factors such as space and lack of management support.3
Time: Implementing this simulation was negotiated in the medical curriculum since suitable skills training was required for the management of severely traumatised patients. The only available time was on 4 Friday afternoons in 1 month. Time was then negotiated for nursing, OT and PT students to attend the IPE events.
Groups: Owing to time limitations and despite the fact that the simulations were duplicated for each event, there were about 20 students per simulation. Although hands-on experience would have been ideal, some students could only observe. The schedule for the groups was made available well in advance.
Student preparedness should be
seen as a prerequisite for clinical IPE. The facilitators
produced a video of the scenario, which was used to orientate
the students on the expected outcomes of the event and the
skills they needed to revise. Students then had the
opportunity to indicate whether they wanted hands-on
experience of the simulation or whether they would rather
observe the process. A schedule of the facilitators’
responsibilities and roles was negotiated and made available
to all. Some facilitated the resuscitation while others
manipulated the simulators or assessed the activities of the
students by means of a checklist.
9. Learning strategy
The IPE event was based on Kolb’s Experiential Learning theory, which includes a meaningful and relevant context, experiential learning, debriefing and reflection. Students should be encouraged to actively partake and then review and reflect on their performance in order to identify their personal and professional learning requirements to achieve proficiency.14 A number of studies have explicitly documented the inclusion of team reflection as part of their design.6
The intervention for IPE should be based on shared outcomes,
relevant to all groups, provided in a realistic educational
context suitable for students with differing levels of previous
IPE and skills training experience.15 In our event, the context
was trauma as explained under the Content
heading, and the experiential
learning was reserved for only small teams of students because
of time constraints. Students were expected to take
responsibility for the management of the patient by
prioritising, making appropriate decisions, resolving their
conflicts, and performing and delegating tasks. The teams as
well as the facilitators and observing students who used a
checklist to guide their observations, took part in the
post-simulation discussion to reflect on the performance.
Feasible assessment of IPL outcomes, especially those concerning teamwork and collaborative practice skills, presents a major challenge for educators.1 Seventy per cent of respondents to the WHO review on the status of IPE used a range of methods to evaluate IPE. Student surveys were the most popular evaluation tool. Additional methods include inter alia test results and reflective journals.13
The 10 key elements cover the range of resources and processes
required to implement an IPE event aimed at providing healthcare
students with an opportunity to acquire awareness of professions
and to develop collaborative skills.
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