Education Research: Qualitative Thematic Analysis of Interprofessional Student Reflections Following Simulated Virtual Care Conferences of Neurology Patients

In brief, interprofessional student-led educational care conferences included medical students completing a required neurology clerkship, along with nursing, pharmacy, physician assistant, physical therapy, respiratory therapy, social work, law, and chaplain learners from programs that were not affiliated with our college of medicine. Participation was a requirement for medical students; other learners were recruited from colleges/programs by sending emails to program directors at other institutions. Some of these allied health programs required participation for their students; other programs allowed voluntary participation. Each program determined the appropriate educational level for the students that they required/allowed to participate based on whether students had requisite knowledge/skills to care for patients in acute care settings. Thus, data collected were drawn from a convenience sample of participants and were coded such that analysis included reflections from all learners who participated over 9 consecutive months. Before each monthly session, a neurologist (S.D.J.) with protected time for IPE instruction identified a patient hospitalized in the neurology intensive care unit who had a diagnosis/history deemed appropriate for interprofessional teaching. The neurologist deidentified patient chart data and prepared a document for learners detailing an admission note that included laboratory and imaging results, medications, physical/neurologic examination results, and vital signs.^9,10 Before each session, learners reviewed the admission note, which was posted in the LMS.

Learning objectives were based on communication and teamwork, 2 of the 4 interprofessional education collaborative (IPEC) competencies, and included the following: (1) communicate as a member of an interprofessional team in the care of an acutely ill patient; (2) use skills and knowledge of all team members to develop an interprofessional care plan for an acutely ill patient; (3) integrate knowledge and experiences of health care team members to inform care discussions across the continuum from patient admission to postdischarge; and (4) after the event, in the context of patient care, apply behaviors that support collaborative practice and document how this affects patient outcomes or team function.¹⁴

During the interprofessional care conference, learners met through Zoom breakout rooms. Interprofessional peer-to-peer teaching regarding information contained in the admission notes occurred as students developed a team-based assessment and plan based on information known at the time of admission.

Midway through the online educational session, additional patient progress notes were made available to learners in the LMS outlining details of subsequent days of the patient's admission. Guided by prompts in a team Google Doc, students discussed the following: the parts of the chart that held the most significant information for their profession, whether new chart information supported or contradicted initial thoughts about the patient's admission, new information about the patient's condition and the significance of that information to their profession, additional information they needed, and next steps/goals/likely discharge disposition for the patient. Each small group of students (n = ∼7) was led by 2 cofacilitators from different professions who used facilitator guides (created by S.D.J. and K.K.) that were specific for each patient case to emphasize clinical and/or interprofessional points.^9,10

Toward the end of the session, all teams reconvened for a large group debrief, at which time clinical faculty, aware of case details, provided additional context about the treatment teams' plans and patient outcomes. This large group debrief allowed students to compare and contrast their plan (and interpretation of clinical data) with that of the patient's actual care team.

At the end of the session, students were asked 2 questions through the LMS. First, they were asked what they learned from interprofessional collaboration that they would not have learned if the activity had been done only with others from their own profession. Second, they were asked to reflect on something they learned that they could put into practice immediately to enhance collaborative care.

Four weeks later, all students were reminded through the LMS to respond to additional prompts that challenged them to reflect on what transpired when they instituted the behavior they indicated they would change. They were asked whether they made the behavior change and what the outcomes or barriers were to making that change. Medical students were required to submit their reflections before the end of their neurology clerkship; all other learners were sent reminders on a monthly basis until the end of the semester because most of the allied health participants were enrolled in semester-long courses.

Student submissions were deidentified, and text-based responses were analyzed using an inductive thematic analysis to detect themes and patterns without constraint imposed by pre-existing IPE frameworks; this provided deeper insight into participants' experiences, thoughts, and perspectives. Rigor and trustworthiness were accomplished through data source triangulation comprising reflections from students that represented different professions/courses/academic levels, who submitted reflections after participating in 9 different case discussions across 9 different time points. Credibility was addressed by reviewing and coding reflections from all students to assure that findings would resonate with the broadest audience in different contexts. Furthermore, thick description and prolonged engagement were used as a means of follow-up in which learners described not only what they had learned but also how they applied their experiences in different health care contexts after the IPE session concluded. Dependability of the data was assured by tracking coding decisions. Confirmability was addressed since 3 investigators (K.K., T.G., and G.W.) independently reviewed each text-based response and assigned 1 or more thematic codes to every student comment. Each item was discussed by the group until consensus was reached and/or a new code was added. Coding occurred over a period of several months, with each time point providing an opportunity for code-recode review to assure consistency in the coding processes; verbatim quotes from students about their learning experiences illustrate key themes and provide evidence for the interpretations that were made. Transferability is a function of the wide selection of participants from different backgrounds, disparate professional programs, and numerous colleges that learners represented as well as comparing the data with those obtained from a smaller sample of learners when the educational case conference sessions had been conducted in person.⁹ Our research team consists of individuals with varying levels of experience in education, patient care, and research. Although some members of the team served as (co)-directors of IPE, these individuals were not in a position to influence any course grades, nor were any students penalized for not submitting reflections. Our proximity to IPE may have led us to emphasize particular aspects of reflections, and to mitigate bias, we included 2 coders from outside institutions who had no involvement with the educational exercise.

This programmatic evaluation was determined to be exempt from oversight by the Human Subject Protections Office at the Penn State College of Medicine (STUDY00015528).

Anonymous data not provided because of space limitations may be shared with any qualified investigator for purposes of replicating procedures and results.

In 2021, a total of 293 students representing 9 professions (Figure) participated in 9 educational case discussion sessions held monthly between March and December. During any given month, between 25 and 46 learners attended and were split into smaller teams, with each team containing 6 or 7 students in Zoom breakout rooms.

Of the participants, 276 learners (94%) (Figure) responded to a follow-up question immediately after the activity that asked them to reflect on, “What did you learn today that you would not have learned if this activity had been done only with others from your own profession?” Given the demographics of participants, most responses were obtained from medical and nursing students. Eight students said that they had not learned anything; however, cumulative comments from all other respondents fell into 6 areas:

The new knowledge theme was further subcategorized into 6 areas: roles, treatments, skills (a common skill mentioned pertained to new methods of communication), barriers, pathophysiology, and rounding/intensive care unit procedures.

Regarding new knowledge about the roles of other professions, 29 medical students and 12 nursing students provided comments related to gaining a new understanding of chaplains' roles; few students had previously interacted with chaplains before the event. Thirty-two medical students also indicated learning new information about nursing roles.

There was considerable overlap between medical and nursing students regarding the 6 overall themes, but a few differences were noted. Medical students were more likely to reflect on newly learned strategies for intentionally including other professions into patient care discussions/decisions, whereas nursing students most frequently commented how they learned new knowledge about pathophysiology and rounding/intensive care unit policies. Nursing students also frequently commented about feeling more confident and empowered to speak up in clinical settings as a result of the contributions they were able to make during the IPE session. Examples of student comments pertaining to learning that occurred are summarized in the Table.

A second question was posed to students immediately after the session: “What did you learn today, that you can put into practice immediately—during your clerkships, clinicals, field experiences—that will enhance collaborative care?” 271 of the 276 respondents (98%) indicated something specific that they could do. Students were informed, “You will be asked at the end of the course whether or not you had the opportunity to utilize something you learned today and put it into practice. You will also be asked what the outcomes or barriers were to doing so.”

At the conclusion of their course/clerkship, 218 students responded to a question inquiring whether they had implemented the behavior. Of the 218 respondents, 189 (87%) indicated that they had implemented the behavior (Table); 29 students (14%) had not made a behavior change. Some of the behaviors that were changed were unique to a single individual (e.g., n = 34); however, most of the behaviors cited by students fit into 1 of 6 areas:

Based on the outcomes students cited when they enacted a behavioral change, we attempted to categorize each comment based on whether the change resulted in improved quality of care or improved patient safety. Ninety-five of the outcomes described by students were deemed likely to have improved the patients' quality of care (e.g., improved teamwork/communication due to intentionality of seeking out nursing for prerounds and rounds). Forty of the outcomes were deemed likely to have improved patient safety, such as avoiding complications, drug interactions, and medication adverse effects: “One of the patients I was assigned to was started on Sinemet…Overnight, she had … emesis that she had forgotten to mention…which I found out by specifically asking the nurse working with her. During my presentation to my attending physician, I was able to mention this fact, which encouraged my attending to lower the patient's dose of Sinemet,” shared 1 medical student.

If students were unable to make the change that they had identified, they were asked to indicate barriers they encountered. The most common barrier cited was simply not being involved with direct patient care due to being removed from clerkship/clinicals on account of coronavirus disease 2019. A few students indicated that they had not had an opportunity to practice a new behavior because of end-of-semester timing. Other reasons for not making a change included being on hospital services where collaborative practice was deeply embedded and already happening (e.g., “I was working on a service that encouraged participation from other healthcare professionals and had active discussions with them… This included not only telling them their plans for the patient, but asking what the other members thought the plan should be and how they could better help the patient. In the end, I noticed that this team was more engaged in getting care givers involved, which I believe led to less communication problems compared to teams I've been on in the past that did not implement this strategy,” said 1 medical student). In addition, a minority of students indicated that they had already been practicing collaboratively before the IPE event: “I have been interacting with care coordinators, social workers, and nurses since the start of my rotation so this was not something new for me. I spend time getting to know my patients during morning pre-rounds, develop rapport with them and find out what things they need help with. For instance, I connected a patient with social work and I also recommended music therapy for a patient,” stated a medical student.