Innovation! Why wait for disruption?

By Bethany Robertson (@bdrclo)

Innovation! Why wait for disruption?

I am a fan of disruptive innovations.  I like change.  I always see ways of improving or trying something a different way; hence my propensity for improvement science.

Unfortunately, many people are not like me and loath change and actually go to great lengths to avoid change.  This spring I was part of a NEW Interprofessional Education (IPE) experience that had the makings of a “disruptive innovation” but really there was a disruption that led to innovation; very different indeed.

In the fall of 2019, a team of nurses and physicians received intramural funds to examine the effects of teaching Interprofessional Education Collaborative (IPEC) competencies in the clinical environment.  The students were four 3^rd year medical students and five 3^rd semester nursing students one semester away from graduation.

The students had four consecutive experiences working together on a clinical unit to address the discharge planning needs of a shared patient.  They collaborated to gather information about a patient and then presented the case during a post-conference period.  The post-conference sessions had questions unique to each session, derived from select IPEC sub-competencies.

We then asked them to complete the Nebraska Interprofessional Education Attitude Scale (NIPEAS) derived from the IPEC competencies and designed to measure attitude about Interprofessional collaboration in pre-service health professions studentsand the IPEC Self-Assessment tool, that assesses competencies related to collaborative practice at the healthcare degree level. This latter tool measures a student’s self-efficacy on items based on the 42 core competency statements developed by IPEC.

On the initial survey, the nursing students scored higher on the NIPEAS than the medical students, indicating a more positive attitude about inter-professional collaboration.  Both scored similarly on baseline scores for the IPEC questionnaire. After the program was completed, the nursing students experienced an increase in the Nebraska score, and a statistically significant median increase for the IPEC score, indicating greater self-efficacy related to IPEC competency statements. The medical students experienced a median increase in both surveys as well but did not approach statistical significance.

Several themes emerged from the qualitative results:

1. There is a need for further education on the roles nurses and medical students play in the discharge process on a unit. Doctors and nurses need to be taught what the other is concerned with.
2. Both groups liked learning about the medical perspective on the patient in the discharge process.
3. Physicians and nurse communication outside the hospital room is vital as nurses have more in-person contact
4. An artificial hierarchy exists in the medical field. Meeting individuals outside of the medical setting helps break that down.

While it is important to build in program evaluation strategies into our work, sometimes the work itself is an outcome measure.  Logistics are often cited often as the barrier to IPE, but we showed it could be done.  Our plan was to repeat this entire pilot work in the spring with 3^rd year medical students and 1^st semester nursing student

Then came the disruption: Covid-19.

In comes the innovation… How were we going to “repeat” given none of our students were allowed in the clinical environment?  The Nursing school was converting to all online, using web-based products to simulate the clinical experience.  The Medical school turned their curriculum upside down, pulling forward electives, stalling on the clinical rotations until the COVID fog lifted.

Then came two amazing emails: both from my physician colleagues looking for a willing partner to quickly implement IPE in two new electives they were putting together.  We were all reeling from the dust called “disruption” and it was catapulting us to thinking about doing things in ways we have never done before….because we had no choice.

No offense to my physician colleagues but in all my years of IPE work, I have never had medicine reach out to nursing; it is usually the other way around.

In their defense, after implementing the fall 2019 pilot project, I see why.  The medical student’s schedules are packed to the gills and there is a pervasive sense of “hurry up to get to the next thing”. Someone from the outside looking in could perceive the medical school curriculum as focused more on completing the intense schedule rather than the actual learning.  The program evaluation assistant who conducted the focus groups reported that the medical students expressed resentment for the intrusion of the IPE activity because it “took them away from their team and was one more thing in their schedule”.  I wonder why they don’t view the nursing students as part of their team? But now, that barrier had crashed to the ground and the “schedule that binds them” was no longer a thing.

So they called.  And we planned.  And it was magical.  Two School of Nursing faculty members and two School of Medicine faculty members put together a virtual IPE event with 39 students; 11 medical students and 28 nursing students! We borrowed elements from the fall pilot, focusing on select IPE competencies and again, on care transitions and discharge planning.  We hosted a Zoom session where the four faculty members set the stage for the session and then students were divided into separate Zoom classrooms, ensuring at least one medical student was in each group; they were at a premium compared to nursing students.

We equipped several students who had participated in the fall event, with facilitator guides, and they led several of the break-out Zoom sessions while the four faculty members covered the remaining groups.  As an icebreaker, each group came up with a name to help facilitate the report out session at the end of the class which sparked effective conversation, creativity, and laughter.  While our post-program evaluation methods were not as extensive as our pilot program in the clinical learning environment, it yielded some consistent themes from both nursing and medical students:

1. They liked being able to talk openly about experiences on our units and how they felt communication could improve between physicians and nurses
2. They gained a greater appreciation for how detrimental it can be to act in silos
3. They realized how variations in roles can be misunderstood between professions, leading to unclear communication with patients
4. The environment was very low pressure and it was easy to talk to the medical students.

One most poignant comment about the overall experiences was “this was a great activity but not the last week of class”.  I am not entirely sure what the respondent meant; it could mean life was way too stressful prior to graduation (nursing) to try something new but it could also mean, “Why didn’t we do this sooner?”.

Either way the point is the same; why do we wait for a disruption as drastic as COVID-19 to welcome innovation?

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