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Measuring interprofessional competencies and attitudes among health professional students creating family… Wong, Eric; Leslie, Jasmine J; Soon, Judith A; Norman, Wendy V Oct 19, 2016

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RESEARCH ARTICLE Open AccessMeasuring interprofessional competenciesand attitudes among health professionalstudents creating family planning virtualpatient casesEric Wong1,2, Jasmine J. Leslie2,3, Judith A. Soon1,2 and Wendy V. Norman2,3*AbstractBackground: The Virtual Interprofessional Patients-Computer-Assisted Reproductive Health Education for Students(VIP-CARES) Project took place during the summers of 2010–2012 for eight weeks each year at the University ofBritish Columbia (UBC). Undergraduate health care students worked collaboratively to develop virtual patient case-based learning modules on the topic of family planning. The purpose of this study was to evaluate the changes inperception towards interprofessional collaboration (IPC) among the participants, before and after the project.Methods: This study utilized a mixed methods evaluation using self-assessment survey instruments, semi-structuredinterviews, and reflective essays. Pre- and post- project surveys were adapted from the Canadian Medical EducationDeterminants (CanMEDS) and Canadian Interprofessional Health Collaborative (CIHC) frameworks, as well as theMemorial University Interprofessional Attitudes (IPA) questionnaire. The survey results were analyzed as mean (M)and standard deviation (SD) on Likert scales. The non-parametric Wilcoxon signed-rank test was used to determineif any significant changes were measured between each participant’s differences in score (p ≤ 0.05). Post-projectinterview transcripts and essays were analyzed using recursive abstraction to elicit any themes.Results: Altogether, 26 students in medicine, pharmacy, nursing, midwifery, dentistry, counselling psychology, andcomputer science participated in VIP-CARES, during the three years. Student attitudes toward IPC were positivebefore and after the project. At the project’s conclusion, there was a statistically significant increase in theparticipants’ self-assessment competency scores in the CanMEDS roles of health advocate (p = 0.05), manager(p = 0.02), and medical expert (p = 0.03), as well as the CIHC domains of interprofessional communication (p = 0.04),role clarification (p = 0.01), team functioning (p = 0.05), and collaborative leadership (p = 0.01). Qualitative evaluationsyielded three major themes: communication and respect as key to team functioning, importance of role clarificationwithin the team, and existence of inherent challenges to IPC. From the reflections, students generally felt morecomfortable with their improvements in the CIHC domains of interprofessional communication, team functioning,and role clarification.(Continued on next page)* Correspondence: wendy.norman@ubc.ca2Contraception Access Research Team- Groupe de recherche surl’accessibilité à la contraception (CART/GRAC), Women’s Health ResearchInstitute, British Columbia Women’s Hospital and Health Centre, ProvincialHealth Services Authority, Vancouver, BC, Canada3Department of Family Practice, Faculty of Medicine, University of BritishColumbia, 3rd Floor, David Strangway Building, 5950 University Boulevard,Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Wong et al. BMC Medical Education  (2016) 16:273 DOI 10.1186/s12909-016-0797-8(Continued from previous page)Conclusion: After working within an interdisciplinary team developing virtual patient learning modules on familyplanning, the student participants of the VIP-CARES Project indicated general improvement in the skills necessary foreffective interprofessional collaboration. Triangulation of the overall data suggests this was especially observedwithin the areas of interprofessional communication, team functioning, and role clarification.Keywords: Sexual health education, Interprofessional, Health professional education, Medical education, Virtualpatients, Medicine, Nursing, Midwifery, Pharmacy, Canada, Mixed methods, Survey, QualitativeBackgroundIn today’s medical system, delivering high-calibre healthcare often requires that professionals from differentfields collaborate effectively [1]. Interprofessionalcollaboration (IPC) is defined as the process of develop-ing and maintaining effective interprofessional workingrelationships with learners, practitioners, families,patients, and communities to enable optimal healthoutcomes [2]. The World Health Organization hasstated that IPC is essential in order to provide care forthe people who are underserved by the medical system[3]. Furthermore, it has been recognized that this typeof collaboration must begin early in the training ofhealth care students to develop the necessary skills inthis area [4]. For example, providers who infrequentlyinteract with other disciplines during their educationand training may encounter potential challenges in fu-ture collaborative work [5]. Recent literature suggeststhat there is a general positive attitude trend amonghealth care students towards an acceptance of the prin-ciples of interprofessional education (IPE) [6, 7]. There-fore, it is beneficial to foster this type of collaborationamong health care undergraduates.The Virtual Interprofessional Patients-Computer-Assisted Reproductive Health Education for Students(VIP-CARES) Project was a student-led initiative, whichtook place during the summers of 2010–2012 for eightconsecutive weeks each year. The project was developedby a group of medical, nursing, pharmacy, and midwiferystudents at the University of British Columbia (UBC) toaddress a curricular need after noting a lack of formalteaching in the topic of family planning. The aim of theVIP-CARES Project was to recruit an interdisciplinaryteam of health care students to work collaboratively inperson on developing interactive virtual patient case-based learning modules in this area, for use in pre-licensure health professional training. Completedmodules were integrated into their respective programsto fill gaps in curricula.Currently, there is a lack of unity regarding the bestmethods to assess the professional outcomes of interdis-ciplinary learning projects [8, 9]. Despite the number ofmeasurement instruments in IPC and IPE that havebeen published, only a few apply directly to health careteams [10, 11]. However, there are well-established IPC-related frameworks within and across health care disci-plines that are often assessed. For example, the RoyalCollege of Physicians and Surgeons of Canada developeda framework of professional competencies deemed es-sential for every practicing physician: the CanMEDS[12]. The competencies are comprised of seven roles:communicator, collaborator, health advocate, manager,medical expert, professional, and scholar. Not only hasthis tool been used to evaluate Canadian physician spe-cialists in training [13], it is being used as a standard as-sessment tool to review competency in currentphysicians [14] in rural training sites [15], internationally[16, 17], and increasingly to assess a wide array of alliedhealth care professionals [9].The Canadian Interprofessional Health Collaborative(CIHC) also developed and published a framework thatis specific for measuring interprofessional health carecompetencies [2]. The CIHC has outlined six major do-mains: interprofessional communication, patient-centeredcare, role clarification, team functioning, collaborativeleadership, and interprofessional conflict resolution.There is much overlap between these domains and theCanMEDS roles. However, the CIHC framework specif-ically defines the skills and qualities necessary for effect-ive IPC, whereas the CanMEDS more broadly definesthe competencies required for overall patient care, a partof which includes IPC.In addition to personal competencies, personal atti-tudes towards working in an interprofessional group cansubstantially impact the overall successful functioning ofinterprofessional teams. To assess these qualities, re-searchers from Memorial University developed the Inter-professional Attitudes (IPA) questionnaire [18]. This IPAquestionnaire was developed by adapting three individ-ual surveys related to attitudes towards IPE, each ofwhich had previously been validated in their respectivestudies [19–21].At the time of our study, the CanMEDS and CIHCframeworks, along with the IPA questionnaire, were theonly established Canadian instruments relevant to evalu-ation of interprofessional attitudes and competencies.Wong et al. BMC Medical Education  (2016) 16:273 Page 2 of 9We utilized a combination of these three instrumentsfor learner self-assessment, aiming to measure the devel-opment of attitudes and competencies for working in in-terprofessional teams. This study presents results fromthis survey among students participating in an interpro-fessional collaborative summer project, along with richqualitative data providing depth, clarification, and sub-stantiation of the quantitative results through findingsfrom interviews and self-reflective essays. The purposeof this study is to evaluate the changes in perception to-wards interprofessional collaboration among pre-licensure health professional students, before and afterworking within an interdisciplinary team developing vir-tual patient case-based learning modules.MethodsThis mixed methods study utilized a combination ofself-assessment survey instruments to measure changesin interprofessional perceptions, including attitudes andcompetencies, before and after working on a collabora-tive, eight-week interprofessional project. Post-projectinterviews and reflective essays were completed by allparticipants. Ethics approval was obtained from the Uni-versity of British Columbia (UBC), Children’s andWomen’s Hospital Research Ethics Review Board (H10-00797) prior to the study.Each participant completed surveys combining theCanMEDS and CIHC frameworks and the MemorialUniversity IPA questionnaire (Additional file 1), tomeasure the self-assessed changes in interprofessionalattitudes and competencies of the pre-licensure healthprofessional students. The CanMEDS framework con-sists of seven roles, while the CIHC framework consistsof six domains. The original IPA questionnaire from Me-morial University is comprised of 42 questions acrossthree components [18]. For our study, the fifteen rele-vant questions were selected within the components, ‘At-titudes towards health care teams’ and ‘Attitudes towardsinterprofessional education’. Each question in the finalevaluation tool asked participants to rank their expecta-tions (pre-project) or experiences (post-project) on a 10-point Likert scale of expectations met, or on a 5-pointscale of level of agreement to a statement. In addition,demographic information was collected regarding age,gender, discipline, year of study, and prior interprofes-sional experience(s). Prior interprofessional experiencewas defined as any team collaboration involving morethan one health discipline, which took place before thestart of the VIP-CARES Project.During 2010–2012, three different cohorts (one eachsummer) of interdisciplinary health professional stu-dents from UBC worked together for eight consecutiveweeks on the VIP-CARES Project. The purpose of theVIP-CARES Project was for the students to workcollaboratively and in person on an interdisciplinaryteam to develop virtual patient case-based learningmodules on family planning topics for implementationinto their respective program curricula. Project activ-ities included conducting team interviews with commu-nity family planning health service professionals fromall project disciplines to learn about practice relevantperspectives and cases; collaborating to collect, evalu-ate, and integrate appropriate case and resource mater-ial; and utilizing the information to develop the virtualcases. Altogether, there were nine different virtual pa-tient cases developed by the students (approximatelythree cases from each cohort).The project was offered to students enrolled in any yearof a health professional pre-licensure training program atUBC (including up to one year after graduation), as a paidsummer work experience. Positions were also offered tocomputer science students for their expertise in human-computer interaction and the interfaces necessary for ef-fective online self-learning modules. There were manymore students who applied each year than there were po-sitions available; each final cohort of students was selectedthrough a panel of student interviewers who were rigor-ously involved in the early project development.Altogether, there were three different cohorts of students,each cohort combined students from the programs ofmedicine, pharmacy, nursing, midwifery, dentistry, coun-selling psychology, and computer science. The project wasapproved and funded by the UBC Teaching and LearningEnhancement Fund for each of the three years.Data collectionVIP-CARES Project students received a letter explainingthe purpose and methods of this study, and a consentform two weeks before the project began.Surveys were completed on the first and final days ofeach project. Following completion of the final survey,participants wrote a short, reflective essay of up to 500words, and completed a semi-structured interview witha trained research assistant, in which they were asked todescribe how their perceptions of IPC changed over thecourse of the VIP-CARES Project. The interviews wereaudio-recorded, professionally transcribed, and thematic-ally analyzed as detailed below. The essays and inter-views expanded upon and explored in more depth theconcepts and attitudes introduced in the quantitativemeasures for interprofessional competencies. Resultsfrom the surveys, interviews, and reflective essays werelinked to each participant, such that triangulation ofthemes and ideas could be evaluated.Statistical analysisThe results from the surveys were analyzed as mean (M)and standard deviation (SD) scored on a Likert scale fromWong et al. BMC Medical Education  (2016) 16:273 Page 3 of 91 to 5 (IPA), or from 1 to 10 (CanMEDS and CIHC). Boththe mean and the standard deviation of the differences inscore (Md, SDd) between each participant’s pre- and post-responses were also calculated. These differences wereevaluated using the non-parametric Wilcoxon signed-ranktest to determine if any significant changes were measuredbetween each participant’s differences in score (signifi-cance level p ≤ 0.05). Interview transcripts and essays wereanalyzed using recursive abstraction to elicit themes andchanges in attitudes or competencies over the course ofthe project. Themes from the qualitative data were elicitedby two research assistants, then the categories werereviewed and any discrepancies resolved by two faculty in-vestigators. Triangulation of self-assessment surveys, in-terviews, and essays within and between individualparticipants was performed to enhance the depth of un-derstanding related to feedback from each of the studentexperiences and from the participants overall.ResultsDemographicsTable 1 describes the study participants. There were atotal of 26 participants among 28 project studentsthroughout the three-year project. The two students wereexcluded from the study because they were post-graduatemedical residents who had completed their undergraduateprograms beyond one year of their project enrolment. Theaverage age of participants was 26.0 (±2.8) years old, andthe female- to- male ratio was 23- to- 3 (88 % female).About half (54 %) had ‘prior interprofessional experience’.SurveysTable 2 summarizes the analysis of the CanMEDS,CIHC, and IPA sections within the administeredsurveys.Overall, the participants responded with a positive atti-tude towards IPC in the IPA section of the survey, bothbefore and after the VIP-CARES Project. However,participants less strongly agreed with the statement: “theinterprofessional approach improves the quality of careto patients/clients.”There was a trend towards higher participant self-assessment scores for the CanMEDS competency rolesof communicator, collaborator, health advocate, man-ager, medical expert, and scholar post-project, as com-pared to baseline. Statistical significance was observedfor the roles of health advocate (p = 0.05), manager(p = 0.02), and medical expert (p = 0.03).There was a similar trend towards higher participantself-assessment scores for all six CIHC competency do-mains: interprofessional communication, patient-centeredcare, role clarification, team functioning, collaborativeleadership, and interprofessional conflict resolution post-project, as compared to baseline. Statistical significancewas observed for the domains in interprofessional commu-nication (p = 0.04), role clarification (p = 0.01), team func-tioning (p = 0.05), and collaborative leadership (p = 0.01).Qualitative findingsThe qualitative findings comprising of the semi-structured interviews and the reflective essays supportedand provided further explanation for the results fromthe surveys in most roles and domains. Most commentsreflected positively on IPC and the VIP-CARES Projectoverall. Several consistent themes emerged from thepost-project qualitative findings:Communication and respect as key to team functioningThe most significant theme which emerged is how thequalities of communication and respect are consideredto be central to successful IPC. Several participants com-mented on the importance of a committee, rather than ahierarchal structure within the group to help facilitatethese qualities. The participants agreed that this createdopen communication between team members, andallowed for the sharing of ideas in a comfortable settingTable 1 Demographic information of participants across the 3 years (2010–2012) who completed all components of the mixedmethods assessment for the interprofessional VIP-CARES ProjectTotal number of students 26Mean Age 26.0 (±2.8)Gender Female: 23 (88 %)Discipline Medicine Pharmacy Nursing Midwifery Dentistry Counselling Psychology Computer Science(n = 7) (n = 6) (n = 4) (n = 4) (n = 1) (n = 1) (n = 3)• Year 1 (2010) (9 participants) 3 2 2 2 0 0 0• Year 2 (2011) (9 participants) 2 2 2 0 1 0 2• Year 3 (2012) (8 participants) 2 2 0 2 0 1 1Proportion of program years completedper discipline (M, SD)0.36 (0.20) 0.75 (0) 0.63 (0.25) 0.38 (0.14) 0.25 (0) 1.0 (0) 1.0 (0)Students with prior inter-professionalexperience per discipline4 3 2 3 0 0 2Wong et al. BMC Medical Education  (2016) 16:273 Page 4 of 9Table 2 Pre- and post- mean scores and differences on survey scales for interprofessional collaboration and competencies amongVIP-CARES Project studentsInterprofessional (IP) Attitudes section adapted fromMemorial University Questionnaire (Five point LikertScale: 1 = Strongly Disagree, 5 = Strongly Agree)Mean score of allparticipants beforeM (SD)Mean score of allparticipants afterM (SD)Mean score differencesfor each participantMd(SDd)p-valueNumber of completed surveys n = 26 n = 26IP learning will help students to understand their own professionallimitations.4.4 (0.6) 4.5 (0.6) 0.0 (0.7) 1.00Developing an IP patient/client care plan is excessively time consuming. 2.6 (0.8) 2.3 (0.8) −0.3 (0.9) 0.11The IP approach makes the delivery of care more efficient. 4.2 (0.7) 4.2 (0.5) 0.0 (0.6) 0.74Developing a care plan with other team members avoids errors indelivering care.4.2 (0.7) 4.3 (0.7) +0.2 (0.7) 0.20Working in an IP manner unnecessarily complicates things most of the time. 1.8 (0.5) 1.8 (0.6) +0.1 (0.8) 0.44The IP approach improves the quality of care to patients/clients. 4.6 (0.5) 4.3 (0.7) −0.3 (0.7) 0.02aIn most instances, the time required for IP consultations could be betterspent in other ways.2.0 (0.7) 2.0 (0.7) −0.2 (0.9) 0.44IP approach permits health professionals to meet the needs of familycaregivers as well as patients.4.0 (0.6) 4.0 (0.7) 0.0 (0.9) 0.83Team meetings foster communication among team members from differentdisciplines.4.1 (0.6) 4.4 (0.6) +0.2 (0.9) 0.18IP learning will help students think positively about other health careprofessionals.4.3 (0.6) 4.3 (0.8) 0.0 (0.8) 0.81Clinical info can only be learned effectively when taught within one’s owndepartment.1.9 (0.9) 1.8 (0.6) −0.1 (0.7) 0.74Students in my professional group would benefit from IP small groupprojects.4.2 (0.8) 4.2 (0.7) +0.1 (0.7) 0.37It is not necessary for undergraduate health care students to learn together. 1.8 (0.7) 1.7 (0.7) −0.1 (0.6) 0.48IP work before qualification would improve working relationships afterqualification.4.2 (0.6) 4.2 (0.9) 0.0 (1.0) 0.78IP work helps undergraduates to become more effective team members. 4.3 (0.6) 4.3 (0.9) 0.0 (1.1) 0.64Competencies from the CanMEDS section (Ten point Likert Scale: 1 = Below Expections, 10 = Exceptional)Number of completed surveys n = 26 n = 26Communicator 6.4 (0.6) 6.7 (1.2) +0.3 (0.9) 0.12Collaborator 6.7 (1.2) 6.9 (1.1) +0.3 (1.0) 0.18Health Advocate 6.2 (1.2) 6.8 (1.3) +0.5 (1.1) 0.05aManager 5.6 (1.5) 6.3 (1.3) +0.6 (1.1) 0.02aMedical Expert 5.0 (1.1) 5.7 (1.4) +0.6 (1.3) 0.03aProfessional 7.3 (1.4) 7.2 (1.1) −0.1 (0.9) 0.64Scholar 6.3 (1.3) 6.8 (1.5) +0.4 (1.6) 0.19Competencies from the CIHC section (Ten point Likert Scale: 1 = Below Expections, 10 = Exceptional)Number of completed surveys n = 22 n = 26Interprofessional Communication 6.2 (1.2) 7.0 (1.2) +0.7 (1.6) 0.04aPatient Centered Care 6.5 (1.2) 6.9 (1.5) +0.4 (1.3) 0.24Role Clarification 6.0 (1.3) 7.0 (1.3) +0.9 (1.3) 0.01aTeam Functioning 6.3 (1.3) 7.2 (1.5) +0.8 (1.7) 0.05aCollaborative Leadership 5.9 (1.1) 6.9 (1.4) +0.9 (1.4) 0.01aInterprofessional Conflict Resolution 5.7 (1.5) 6.2 (1.6) +0.6 (1.5) 0.10aStatistically significant resultWong et al. BMC Medical Education  (2016) 16:273 Page 5 of 9that was conducive to collaboration. For most partici-pants, respect encompassed being receptive towardsideas which emerged within the group, regardless ofeach other’s interdisciplinary backgrounds. For example,one student spoke on the need to “respect each other’sopinions throughout the project…and wanting to learnabout each other and not having that feel [sic] like yourprofession is better than theirs.”Importance of role clarification within the teamAnother theme was the importance of role clarificationin an interprofessional setting. Most participants com-mented that the interprofessional roles of themselvesand team members were more defined following theproject. One student mentioned that “when [the rolesare] laid out, it leads to the health care providers havingmore satisfaction about what they’re doing and I think itcomes off a bit clearer for the client too.” By having anunderstanding of each other’s roles, the team membersfelt they were better able to contribute their specificareas of expertise on a particular subject, which may alsoextend into future career-related IPC. For example, amedical student commented on what she gained fromworking with a midwifery student: “if someone were toask me before the program started what exactly does amidwife do, I could sort of guess but I had no idea ofhow broad it was… [it] helps you to provide in the fu-ture…better maternity care service for patients for lettingthem know what’s out there as well.” Several participantscommented on learning about expanding scope of prac-tice for other disciplines. Where there were areas ofoverlap between disciplines, the participants perceived itas being beneficial, rather than detrimental to team col-laboration, as long as they were aware of where thisoverlap existed.Existence of inherent challenges to interprofessionalcollaborationA final theme which emerged is recognizing the poten-tial inherent challenges to IPC. One participant wrote inher reflective essay how the project “strengthened andemphasized the importance of interprofessional work inpatient management”; however, this same individual re-flectively commented on how different personalities andagendas of team members can hinder collaborative prod-uctivity, noting that “interprofessionalism is not as easyto accomplish as it sounds.” Similar sentiments werenoted by other participants, many of whom felt that adifficult personality in a team setting could hinder theprogress of collaboration.It is of interest that there were several students whowere still uncomfortable about their abilities to applythese roles in future settings. As one student mentioned,“I’m not far along enough in my training…like, to be ableto advocate for my field of health care…I just don’t knowenough about my field yet to be able to do that.” Otherstudents also commented that they expect their healthadvocacy to improve once they are out in practice. Stu-dents who commented on their change in the role ofmedical expert believed they were able to develop apatient-centered approach to decision-making and learnthe limits of their expertise. However, others believedthat they are “not familiar enough in [their own] profes-sion[s] at this stage to be considered an expert.”DiscussionThe VIP-CARES Project was undertaken during the earlydevelopment stage of interprofessional collaboration forpre-licensure health professional students in Canada.Each team of interdisciplinary students worked collab-oratively to create virtual patient case-based learningmodules over the course of eight weeks. These self-learning cases on family planning topics have since beenadapted into the health professional training curricula atUBC. In 2011, the project was also recognized with thenational Health Innovation Award by the Health Councilof Canada for the university-based practice in healthcare education most deserving to be a model for the restof Canada [22].Following the three eight-week interprofessional VIP-CARES Projects, student participants reported a self-assessed increase in competencies as measured by theframeworks of CanMEDS and CIHC. Our results showsome promising trends. The CIHC framework specific-ally defines the skills and qualities necessary for effectiveIPC. We found significantly higher post-project scoresas compared to the baseline surveys in the CIHC com-petency domains in interprofessional communication,team functioning, and role clarification, and that im-provements in these areas were supported by the themesfrom the qualitative findings. Expanding on the surveyresults, we observed among the qualitative responsesthat participants generally felt more comfortable withtheir improvements within CIHC interprofessional com-petencies, as compared to the CanMEDS individual pro-fessional competencies of health advocate, manager, andmedical expert. Similarly, for each participant, the meanscore differences in the CIHC domains were higher(close to one full point), as compared to the mean scoredifferences in individual achievement measures of theCanMEDS roles (close to half a point). This finding mayreflect the predominance of pre-licensure students earlyin their professional careers disinclined or less confidentto comment on their growth in individual professionalcompetency areas. Attitudes towards IPC were positiveamongst students before and after participating in theVIP-CARES Project. The participants’ IPA scores for atti-tudes towards interprofessional health care teams andWong et al. BMC Medical Education  (2016) 16:273 Page 6 of 9education were high at baseline. These responses did notchange significantly at the project’s conclusion.The participants identified in the post-project semi-structured interviews and reflective essays that commu-nication and respect were two important attributes tosuccessful interprofessional work. These findings areclosely associated with the CIHC competencies of inter-professional communication and team functioning, bothof which were scored significantly higher by participants,as compared to baseline. Several participants noted that“communicating and asserting themselves” with otherhealth care students was a weakness prior to starting theVIP-CARES Project. These participants later commentedon an increase in their level of confidence when commu-nicating with other team members, while remaining re-spectful of group diversity. During the project, eachgroup of students had the opportunity for extensiveinteraction on an interdisciplinary team for eight con-secutive weeks, which likely helped to facilitate IPC, asthey were working towards a shared goal. Interestingly,the results from the interviews and essays did not con-vey any major themes regarding the perceived domin-ance of a particular health care profession. This wassurprising, given that there were a disproportionatelyhigher number of students from certain programs (i.e.medicine and pharmacy), as compared to others (i.e.dentistry and counselling psychology) each year. A pos-sible explanation for this is the fact that the participantsresponded with a positive attitude towards IPC in gen-eral, both before and after the VIP-CARES Project. Al-though some participants related that there are inherentchallenges to achieving IPC, this was more in the con-text of individual personality dynamics. It should also benoted that the nature of the project required regular,daily collaborative interaction over an eight-week period,which is not necessarily indicative of all interprofessionalsettings.The responses to the CIHC section of the survey,along with the themes elicited from the reflective essays,support a general improvement in role clarificationamong the students. Participants seemed to gain a betterunderstanding of their own roles, as well as the roles ofother disciplines within the team. They reflected thatthis knowledge can be utilized to enhance patient/client/family goals, which may be especially important in fam-ily planning, as it is increasingly delivered within inter-disciplinary team settings [23]. As the VIP-CARESProject focused on developing educational tools for fam-ily planning, the role of each team member was well-defined, as required for the development of specificityand complexity within the various virtual cases. This po-tentially allowed for greater role clarity over the courseof the project, as participants were able to closely ob-serve team members modeling their respective roles.The higher scores in the CanMEDS roles of health ad-vocate, manager, and medical expert from the surveyswere generally supported by the themes from the inter-views, but this was not as closely observed with the CIHCcompetencies. The concept of the VIP-CARES Project cre-ated ample opportunities for students to make achieve-ments in these CanMEDS roles. For example, severalmodule cases were based on challenges in caring for pa-tients within at-risk or marginalized populations. In de-signing these cases, participants were guided to considerthe determinants of health, including the physical, cul-tural, and economic barriers faced by vulnerable individ-uals in these populations. These skills are encompassed inboth the CanMEDS health advocate and medical expertroles. Using information technology, as well as setting pri-orities and practicing time management skills are associ-ated with the CanMEDS manager role [12]. The majorityof the students had most recently completed the first orsecond years of their respective programs, with the excep-tion of all pharmacy students who had completed theirthird year. Thus, at the end of the project, studentsappeared to still retain a level of uncertainty about theirprofessional expertise, which appeared consistent with thecurrent progress in their respective programs.With regards to the attitudes towards interprofessionalhealth care teams and education, participants lessstrongly agreed with the statement: “the interprofessionalapproach improves the quality of care to patients/cli-ents,” at the end of the project. The mean IPA score forall participants for this question at baseline was 4.6 ± 0.5,which was resoundingly the highest baseline scorewithin this section of the survey. Considering that theattitudes were ranked on a 5-point Likert scale and themean score difference within each participant for thequestion was −0.3 ± 0.7, this level of change, althoughstatistically significant, is unlikely to represent a clinic-ally significant attitude shift. It may, however, more likelyreflect a loss of pre-project anticipatory enthusiasm.Notably, no negative opinions related to “the interprofes-sional approach improves the quality of care to patients/clients” were documented in the qualitative findings.Overall, the results of this study have various implica-tions. The current literature suggests that there is a discord-ance regarding the best methods for assessing theprofessional outcomes of interdisciplinary learning projects[8, 9]. This study is the first to combine the IPC-relatedframeworks from established Canadian instrumentsrelevant to evaluating interprofessional attitudes and com-petencies: CanMEDS, CIHC, and the IPA questionnaire. Byapplying this tool in the evaluation of the interprofessionaldevelopment of virtual patient case-based learning mod-ules, we were able to observe some meaningful results,which were supported by participant interviews and self-reflective essays. Future studies to validate this combinedWong et al. BMC Medical Education  (2016) 16:273 Page 7 of 9survey instrument are recommended. Furthermore, theVIP-CARES Project helped to further our understanding ofhow pre-licensure health professional students work collab-oratively on a project of this level of regular, daily interpro-fessional interaction. This study also fills a gap in literatureregarding the lack of interprofessional student collaborationin antenatal and postnatal care [24]. At the time, it fulfilleda curricular need at UBC, in providing more formalizedteaching in the topic of family planning. Educational tech-nology, in the form of virtual patients, is becoming morecommonly used in medical education for its role in pro-moting deep learning and enhancing clinical reasoningskills [25]. However, they are frequently developed by med-ical educators in their respective health disciplines. TheVIP-CARES Project, to our knowledge, is one of the first toallow for interdisciplinary students to work collaborativelyon developing virtual patient cases, for implementationacross multiple health care curricula.Our results have implicit limitations. First, this studyhad a small sample size of 26 participants, with no morethan 7 participants in each professional group (i.e. medi-cine). The reason for this limited size is due to the fund-ing allocated from the UBC Teaching and LearningEnhancement Fund for each of the three years. Each stu-dent also received a stipend over the summer for theirparticipation. Furthermore, the survey instrument usedself-assessment as a means of measurement, which is in-herently subjective. We noted unexpectedly high ratingsof positive interprofessional attitudes and competenciesat baseline, which likely reflected a bias in our sample.Project participants were selected from among a large,competitive group of pre-licensure health professionalstudent applicants. In general, the participants were indi-viduals who had sought out prior interprofessional op-portunities, and who had positive views of this type ofcollaboration. Seventeen of the 26 participants notedthat they had some ‘prior interprofessional experience’.Additionally, there was no blinding, as all of the partici-pants fully understood the project objectives. Surveyswere completed at the beginning and end of each sum-mer project, when awareness of teamwork and commu-nication issues was likely highest in students’ minds. Ofinterest to note is that only three males participated inthe VIP-CARES Project over the three years of this study,which could reflect a gendered preference for the topicof family planning among prospective participants. Inaddition, the disciplines involved in the project (i.e. mid-wifery, nursing, pharmacy, and medicine) may have alsocontributed to the skewed gender ratio, as all of theseprograms at UBC have a higher proportion of female en-rollment. Previous studies have also examined gender asa factor affecting attitudes towards IPC [26]. Futuresimilar studies on IPC and attitudes may wish to exploremethods to sample a more balanced gender mix.ConclusionThis mixed methods study evaluated the changes in per-ception towards interprofessional collaboration (IPC)among pre-licensure health professional students beforeand after working on the VIP-CARES Project. Studentsparticipated in an eight-week interdisciplinary team, de-veloping virtual patient case-based learning modules onthe topic of family planning. The findings from the sur-veys were supported by the themes elicited from thequalitative data. Attitudes towards IPC were positiveamongst students before and after participating in VIP-CARES. At the project’s conclusion, there was a statisti-cally significant increase in the participants’ self-assessment competency scores in the CanMEDS roles ofhealth advocate, manager, and medical expert, as well asthe CIHC domains of interprofessional communication,role clarification, team functioning, and collaborativeleadership. From the oral and written reflections, thestudents generally felt more comfortable with their im-provements in the CIHC domains of interprofessionalcommunication, team functioning, and role clarification.Additional fileAdditional file 1: Self-evaluation questionnaire: Evaluating healthprofessional interprofessional collaboration and attitudes. Thisquestionnaire is the instrument used in this study. (PDF 113 kb)AcknowledgementsThe authors wish to acknowledge the contributions of Dr. Weihong Chen,research manager for this project, and of all the health professional studentparticipants.FundingThis study was supported by the Contraception Access Research Team-Groupede recherche sur l’accessibilité à la contraception (CART-GRAC) a research teamwithin the Women’s Health Research Institute, British Columbia Women’sHospital and Health Centre, of the Provincial Health Services Authority of BritishColumbia Canada.Dr. Norman is supported as a Scholar of the Michael Smith Foundation forHealth Research (2012-5139(HSR)), and as an Applied Public Health ResearchChair by the Canadian Institutes of Health Research (CIHR) Institute of HealthServices and Policy Research, Award number CPP-329455-107837.Availability of data and materialsThe questionnaires used for this study have been included as supplementalmaterial. The dataset may be requested from the corresponding author.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsEW carried out data acquisition during the final project year and analysis ofall data; JL developed the protocol, ethics applications, measurementinstruments and guided the initial data collection, WN and JS developed theproject concept and approach and supervised all aspects of the project. JLand EW drafted the initial manuscript and EW drafted all subsequentrevisions. All authors contributed to and approved the final manuscript.Consent for publicationNot applicable.Wong et al. BMC Medical Education  (2016) 16:273 Page 8 of 9Ethical approval and consent to participateInstitutional Review Board Approval was obtained from the University ofBritish Columbia (UBC) Children’s and Women’s Hospital Research EthicsReview Board (H10-00797) prior to enrollment of participants. All participantsin this research participated in full informed consent, and a signed consentform, prior to participation.Author details1Faculty of Pharmaceutical Sciences, University of British Columbia,Vancouver, Canada. 2Contraception Access Research Team- Groupe derecherche sur l’accessibilité à la contraception (CART/GRAC), Women’s HealthResearch Institute, British Columbia Women’s Hospital and Health Centre,Provincial Health Services Authority, Vancouver, BC, Canada. 3Department ofFamily Practice, Faculty of Medicine, University of British Columbia, 3rd Floor,David Strangway Building, 5950 University Boulevard, Vancouver, BC V6T 1Z3,Canada.Received: 1 February 2016 Accepted: 8 October 2016References1. Smith T, Brown L, Cooper R. A multidisciplinary model of rural allied healthclinical-academic practice: A case study. J Allied Health. 2009;38(4):236–41.2. Canadian Interprofessional Health Collaborative [website]. A NationalInterprofessional Competency Framework. Vancouver: CanadianInterprofessional Health Collaborative; 2010. Available from: http://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf. Accessed 2015 Aug 3.3. World Health Organization [website]. Framework for action oninterprofessional education & collaborative practice. Geneva: World HealthOrganization; 2010. Available from: http://www.cihc.ca/files/Framework%20for%20Action%20on%20Interprofessional%20Education%20and%20Collaborative%20Practice.pdf. Accessed 2015 Aug 3.4. Chan AK, Wood V. Preparing tomorrow's healthcare providers forinterprofessional collaborative patient-centered practice today. UBC MedJournal. 2010;1(2):22–4.5. Meffe F, Moravac CC, Espin S. An interprofessional education pilot programin maternity care: findings from an exploratory case study of undergraduatestudents. J Interprof Care. 2012;26(3):183–8.6. Giordano C, Umland E, Lyons KJ. Attitudes of faculty and students inmedicine and the health professions toward interprofessional education.J Allied Health. 2012;41(1):21–5.7. Clark K, Congdon HB, Macmillan K, Gonzales JP, Guerra A. Changes inperceptions and attitudes of healthcare profession students pre and postacademic course experience of team-based ‘Care for the critically ill’. J ProfNurs. 2015;31(4):330–9.8. Thistlethwaite J, Moran M. Learning outcomes for interprofessional education(IPE): Literature review and synthesis. J Interprof Care. 2010;24(5):503–13.9. Verma S, Broers T, Paterson M, Schroder C, Medves JM, Morrison C. Corecompetencies: The next generation. Comparison of a common frameworkfor multiple professions. J Allied Health. 2009;38(1):47–53.10. Archibald D, Trumpower D, MacDonald CJ. Validation of theinterprofessional collaborative competency attainment survey (ICCAS).J Interprof Care. 2014;28(6):553–8.11. Thannhauser J, Russell-Mayhew S, Scott C. Measures of interprofessionaleducation and collaboration. J Interprof Care. 2010;24(4):336–49.12. Royal College of Physicians and Surgeons of Canada [website]. TheCanMEDS 2005 Physician Competency Framework. Ottawa: Royal College ofPhysicians and Surgeons of Canada; 2005. Available from: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/resources/publications/framework_full_e.pdf. Accessed 2015 Aug 3.13. Chou S, Cole G, McLaughlin K, Lockyer J. CanMEDS evaluation in Canadianpostgraduate training programmes: Tools used and programme directorsatisfaction. Med Educ. 2008;42(9):879–86.14. Jakobs OM, O’Leary EM, Cormack MF, Chong GC. A working model for theextraordinary review of clinical privileges for doctors and dentists in theAustralian Capital Territory. Aust Health Rev. 2010;34(2):170–9.15. Rourke J, Frank JR. Implementing the CanMEDS physician roles in ruralspecialist education: The multi-specialist training network. Rural RemoteHealth. 2005;5(4):406.16. Ringsted C, Hansen TL, Davis D, Scherpbier A. Are some of the challengingaspects of the CanMEDS roles valid outside Canada? Med Educ. 2006;40(8):807–15.17. Scheele F, Teunissen P, Van Luijk S, Heineman E, Fluit L, Mulder H, et al.Introducing competency-based postgraduate medical education in theNetherlands. Med Teach. 2008;30(3):248–53.18. Curran VR, Sharpe D, Forristall J. Attitudes of health sciences facultymembers towards interprofessional teamwork and education. Med Educ.2007;41(9):892–6.19. Heinemann GD, Schmitt MH, Farrell MP. Attitudes toward health care teams.In: Heinemann GD, Zeiss AM, editors. Team Performance in Health Care.New York: Kluwer Academic/Plenum Publishers; 2002. p. 155–9.20. Parsell G, Bligh J. The development of a questionnaire to assess thereadiness of health care students for interprofessional learning (RIPLS). MedEduc. 1999;33(2):95–100.21. Steinert Y. Learning together to teach together: interprofessional educationand faculty development. J Interprofessional Care. 2005;1(Suppl):60–75.22. Leung FK, Nakanishi AM, University of British Columbia [website]. VirtualPatient Teaching Tools: An Innovative Model to Enhance Canada’s HealthCare Education. Health Council of Canada, Health Innovation Award, 2011May 16. Toronto: Health Council of Canada; 2011. Available from: http://www.cbdha.nshealth.ca/IC2/Intranet/includes/secure_file.cfm?ID=484&menuID=5050. Accessed 2015 Sep 5.23. Munro S, Kornelsen J, Grzybowski S. Models of maternity care in ruralenvironments: barriers and attributes of interprofessional collaboration withmidwives. Midwifery. 2013;29(6):646–52.24. Aune I, Olufsen V. From fragmented to interdisciplinary understanding ofintegrated antenatal and postnatal care’ – An interprofessional projectbetween public health nursing students and midwifery students. Midwifery.2014;30(3):353–8.25. Berman NB, Durning SJ, Fischer MR, Huwendiek S, Triola MM. The role forvirtual patients in the future of medical education. Acad Med. 2016.Advance online publication. doi:10.1097/ACM.0000000000001146.26. Wilhelmsson M, Ponzer S, Dahlgren L, Timpka T, Faresjö T. Are female studentsin general and nursing students more ready for teamwork andinterprofessional collaboration in healthcare? BMC Med Educ. 2011;11(15):1–10.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Wong et al. BMC Medical Education  (2016) 16:273 Page 9 of 9


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