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Interprofessional infection control education using standardized patients for nursing, medical and physiotherapy students
Journal of Interprofessional Education & Practice 2 (2016) 25e31
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Interprofessional infection control education using standardized patients for nursing, medical and physiotherapy students Marian Luctkar-Flude, RN, MScN a, *, Diana Hopkins-Rosseel, BSc(PT), MSc(Rehab Sci) b, Cherie Jones-Hiscock, MD, FRCPC c, Cheryl Pulling, RN, MSN a, Jim Gauthier, MLT, CIC d, Amanda Knapp, BASc, CPHI(C), CIC e, Sheila Pinchin, BA Hons, BEd, MEd c, Cecilia A. Brown, RN, BNSc a a
School of Nursing, Queen's University, 92 Barrie Street, Kingston, ON K7L 3N6, Canada School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, ON K7L 3N6, Canada School of Medicine, Queen's University, 15 Arch Street, Kingston, ON K7L 3N6, Canada d Providence Care, 340 Union Street, Kingston, ON K7L 5A2, Canada e KFL&A Public Health, 221 Portsmouth Ave, Kingston, ON K7M 1V5, Canada b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 July 2015 Received in revised form 15 March 2016 Accepted 17 March 2016
Background: Health professions students may apply infection control principles poorly within complex clinical situations. Providing opportunities to practice these skills in simulated health care contexts may improve knowledge and transfer to improved performance in actual clinical settings. Objective: To implement an innovative approach to interprofessional infection control education using standardized patients. Methods: A convenience sample of 237 students participated in an interactive lecture and four standardized patient scenarios. Students collaborated and selected supplies and protective equipment to demonstrate the appropriate level of infection control practices for each clinical scenario. Results: Learner knowledge (p ¼ .001) and confidence (p < 0.05) performing infection control skills increased significantly. Student participants identified varying levels of comfort with interprofessional teamwork and communication, but valued both the interprofessional component and use of standardized patients in the session. Conclusions: Overall, student and facilitator feedback about learning was positive. Results will inform the structuring of future IP simulation and infection control education sessions. Crown Copyright © 2016 Published by Elsevier Inc. All rights reserved.
Keywords: Interprofessional education Infection control Health professional students Standardized patients Clinical simulation
Introduction An intermediate level interprofessional education (IPE) session focusing on infection control skills was developed and held for Faculty of Health Sciences (FHS) students. The objective was to enhance patient welfare and safety related to infection control and to prepare learners to transition to cohesive, collaborative, patientcentered practice through an innovative approach to IPE using standardized patient (SP) simulations. Collaborative practice is designed to enhance patient- and family-centered goals and values, provides mechanisms for continuous communication among care givers, optimizes participation in clinical decision making within and across disciplines, and fosters respect for the contributions of all disciplines. Increasing the number of health professionals
* Corresponding author. Tel.: þ1 613 533 6000x77383; fax: þ1 613 533 6770. E-mail address: mfl[email protected] (M. Luctkar-Flude). http://dx.doi.org/10.1016/j.xjep.2016.03.004 2405-4526/Crown Copyright © 2016 Published by Elsevier Inc. All rights reserved.
educated within this paradigm will be a key contribution to improved access and quality of all health care services. This has been underlined as an essential ingredient in primary health care reform.1 Simulation-based IPE aligns with our FHS Framework for IPE in which learners engage in a developmental process of acquiring IP competency by engaging in activities at the exposure, immersion and competence levels within their curriculum.2 Simulation-based IPE thus provides an immersion experience that helps prepare learners to work collaboratively in their professional practices. A partnership between the Schools of Nursing, Rehabilitation Therapy, and Medicine within the FHS was previously involved in the development, implementation, and evaluation of a series of innovative IPE modules using high-fidelity patient simulation.3e5 Three of the four modules (suctioning skills, obstetric and pediatric skills, and cardiac resuscitation skills) have been successfully integrated into the respective curricular programs. The fourth module on application of infection control skills within a complex
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patient care scenario was trialed with a group of senior students from the three schools.6 Although the individual schools within the FHS each have knowledge- and skills-based individual infection control education early in their programs, the results of the evaluation of this fourth IPE module suggested that health professional students needed more practice and reinforcement of infection control skills within a variety of simpler clinical practice settings, prior to progressing to the complex senior-level scenarios, and prior to the transition from student to health care professional. The current project proposed to develop, implement, and evaluate an IPE infection control module for intermediate level health sciences students using SPs.
patients have been linked to improved communication, physical assessment, health teaching and clinical skills, enriched cultural assessments and improved health screening.23e31 Standardized patients have been used successfully in nursing health assessment courses and one study demonstrated that the introduction of an SP improved learners' behavioral performance on videotaped examinations.20 The use of SPs in education has been associated with reduced learner anxiety while caring for patients in the clinical setting,32 and communication skills learned during SP scenarios have also been demonstrated to transfer across cases into different clinical situations.24,33 As well, SP scenarios provide the opportunity for IP groups of learners to share problem solving strategies and practice communicating with other health care professionals.34
Background Use of interprofessional education to practice infection control skills Use of combined simulation and interprofessional learning Core collaborative competencies such as communication and teamwork can be improved through IPE.7,8 There is evidence that IP learning is enhanced when students see a direct relevance between the educational experience and their future practice.9 Experiential learning, defined as “learning that takes place as a result of an encounter with an experience that is planned by instructors within a course, program or curriculum,”10 has been used extensively and effectively in IPE. Simulation-based education offers increased relevance of training, exposing health professional students to clinical challenges prior to being responsible for similar real-life encounters.11 Simulation in education refers to the re-creation of an event that is as close to reality as possible. Clinical scenarios may be developed, in which students must contend with the same complexity of interacting and unanticipated physiological, psychological and social variables that they do in real clinical practice. They must integrate the full range of knowledge, skills, attitudes and behaviors to respond effectively, safely, and with caring. They are also able to observe the outcomes of their clinical decisions and actions and reflect upon and learn from their mistakes, a powerful educational principle.11 The overall aim of simulation-based IPE is to improve patient safety and quality of care.12 Involving health professions students in IP simulation training allows them to act as a part of a team, and provides an opportunity to foster communication, collaboration and leadership.13,14 Research has demonstrated that IPE employing high-fidelity simulation improves team-based attitudes and competencies with retention over time.15 As well, there is growing research evidence of the transferability of competencies learned through simulation to the clinical practice setting.16e19 Use of standardized patients as a mode of simulation education The use of SPs is one form of simulation that can be used in clinical education. SPs are individuals carefully trained to present health or illness concerns in a systematic, unvarying manner. Specific role-playing instructions for the SP include standard and spontaneous response statements to possible questions the students may pose. The script is consistent with specific health concerns, as well as extraneous information to permit the student to determine appropriate care. The SP is encouraged to create necessary emotional responses to the scenario, ultimately producing a realistic patient care scenario that mimics those a learner may encounter in a realworld setting.20,21 Standardized patients have been used in the education of health professions students, mainly to teach communication and clinical skills.22 Within the health care education literature, the majority of studies reported changes in learner knowledge, attitudes and skills, and very few reported changes in learner behaviors.22 Standardized
Infection control practices are a suitable topic for an IPE module as these competencies are shared amongst all health care professionals. Hospital-acquired infections are a major cause of morbidity and mortality. Adhering to evidence-based infection control practices can prevent many of these infections, contributing to improved patient outcomes and decreased health care costs35; however, knowledge and practice deficits related to infection control practices such as hand hygiene have been documented amongst health sciences students.36,37 Health sciences students are introduced to infection control practices in their respective programs. However, as our previous infection control skills module demonstrated, students may apply infection control principles poorly within the context of a more complex clinical situation.6 Providing pre-licensure health sciences students with opportunities to practice these skills in simulated health care settings may improve their knowledge and transfer to improved performance in actual clinical settings. Purpose The purpose of this project is to enhance patient welfare and safety by creating and implementing an innovative approach to infection control education through IP simulation using SPs that will contribute to preparing learners for cohesive, collaborative, patient-centered practice. Specific learning outcomes for the IPE infection control module are the following: (1) Health sciences students will identify and/or demonstrate appropriate infection control practices and/or identify errors or breeches of infection control practices related to standardized clinical situations. (2) Health sciences students will identify and/or demonstrate respectful and appropriate IP communication and collaboration. Methods Sample A convenience sample of 237 intermediate level health sciences students participated in the session. Of these, 100 were first-year medical students, 87 were second-year nursing students, and 50 were second-year physiotherapy students. Ethics This study received approval from the Queen's University and Affiliated Teaching Hospitals Health Sciences Human Research Ethics Board. Informed consent was obtained from all participants.
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Anonymity and confidentiality was ensured during the surveying process through anonymous questionnaires.
and was administered online before and after the education sessions. The quiz consisted of seven multiple choice questions.
Design and methods
Confidence performing infection control skills A survey consisting of 8 items on a 6-point Likert Scale was developed to measure learner confidence performing infection control skills-based on course objectives. Higher scores indicated higher confidence with the associated skills. Internal consistency for the scale was good (Cronbach's alpha ¼ 0.83). Validity was established through peer review by the instructors teaching in the course.
An interprofessional (IP) group of faculty and infection control practitioners developed the IP and infection control content of the project. The session consisted of a 50 min interactive session with an infection control practitioner (ICP) in which students worked in IP groups of six to seven students. The second half of the session consisted of four 15 min SP scenarios in which IP pairs of students were required to apply infection control principles and IP collaboration to a clinical case. The remainder of the students in each group participated as family members in the simulation or as extra staff members. The four simulation scenarios were as follows: (1) transfer of a patient in a semi-private room, (2) visit of a patient with HIV in an outpatient clinic, (3) discharge of a patient with VRE, and (4) assessment of a patient with undiagnosed TB. Each scenario had a targeted, but concealed, specific infection control application and IP collaboration learning outcomes (Table 1). Debriefing took place immediately following each scenario and was included in the 15 min timeframe. The clinical scenarios took place at each of three sites: School of Medicine Clinical Simulation Centre, School of Nursing Patient Simulation Lab, and the Faculty of Health Sciences Clinical Education Centre. Descriptive mixed methods were used to assess the implementation process of the module, and the achievement of the anticipated, immediate outcomes. The quantitative evaluation of learning outcomes employed a pre-test post-test research design. A qualitative descriptive approach was employed to report feedback from participants, faculty and facilitators. Data collection Both quantitative and qualitative data were collected from participants using online questionnaires. Demographic questions were included, such as respondents' future profession, age, and sex. The pre- and post-module questionnaires consisted of the following instruments: Knowledge quiz A knowledge quiz of infection control practices was developed by the infection control practitioners based on the module content
Interprofessional teamwork and communication The Communication and Teamwork Scale of the University of the West of England, Bristol Entry Level Interprofessional Questionnaire was used in this study and involves participant selfassessment of teamwork and communication skills, and attitudes toward IP learning and IP interaction.38 The scale consists of 9 items on a 6-point Likert Scale. Negative statements were reverse scored with higher scores on each item indicating greater comfort with communication and teamwork items. Internal consistency for the scale was good (Cronbach's alpha ¼ 0.79). Satisfaction with the educational module A survey consisting of 8 items on a 6-point Likert Scale was developed to measure learner satisfaction with the components of the IPE module using SPs. Internal consistency for the scale was very good (Cronbach's alpha ¼ 0.98). Interprofessional learning A qualitative survey was developed by the project team asking students to respond to three open-ended questions related to their comfort with IP learning, challenges and benefits to IP learning, and suggestions to improve the IPE infection control module. Data analysis Quantitative data were entered into an SPSS v.21 database and verified by a second person. Pre-post-survey comparisons were conducted using Mann Whitney U tests for ordinal data. Analysis of qualitative feedback involved identifying emergent categories and patterns concerning participants' learning related to infection control practices and IP collaboration.
Table 1 Interprofessional infection control standardized patient scenarios. Scenario
Situation
Infection control component
IP collaboration component
1. Transfer of patient with right-sided stroke in hospital neurology unit. Participants: medical & physiotherapy students 2. Routine checkup of patient with HIV in HIV outpatient clinic. Participants: nursing & medical students
Patient with r-sided stroke wants to get up in wheelchair that was borrowed by roommate. Roommate's housecoat is draped on it. Young male patient with HIV is stable on meds & attending clinic for routine checkup. No complaints of symptoms. Energy level “OK.” States he has a new partner. Patient with start of a dementia and VRE is ready for discharge post hospitalization with fractured ankle.
Wash hands before & after; Clean wheelchair with “wipes”; Clean stethoscope with alcohol wipes before & after use Wash hands before & after; Clean stethoscope before & after use; Question health care professional who enters room wearing gloves & gown Wash hands before & after; Follow contact precautions: glove & gown to enter room
Collaborate on assessment; Collaborate on transfer of patient to wheelchair
Person with undiagnosed TB having recent weight loss and the following symptoms: coughing for 4 weeks with greenish sputum, fatigue, fever, night sweats, chills, & shortness of breath
Wash hands before & after; Clean stethoscope before & after use; Initiate airborne precautions
3. Discharge of patient from hospital orthopedics unit. Participants: physiotherapy & nursing students 4. Assessment of homeless patient with TB in hospital ER. Participants: medical & nursing students
Collaborate on assessment; Collaborate on health teaching related to safe sex practices Collaborate on discharge planning
Collaborate on assessment
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Results
Table 3 Comfort with interprofessional teamwork and communication survey.
Participants
Survey item
The overall pre-survey response rate was 140/237 (59.1%). Response rates by profession were 59% for medical students, 84% for nursing students and 16% for physiotherapy students. The overall post-survey response rate was 92/237 (38.8%) with a response rate by medical students of 41%, nursing students of 53%, and physiotherapy students of 10%. The majority of participants were female (70%) and aged 20e24 years (59%), whereas 25% were 25 years or older, and 16% were younger than 20 years.
Comfortable justifying recommendations and/ or advice face-to-face with more senior people Comfortable explaining an issue to people who are unfamiliar with the topic Have difficulty adapting communication style to particular situations and audiences Prefer to stay quiet when other people in a group express opinions that I don't agree with Feel comfortable working in a group Feel uncomfortable putting forward personal opinions in a group Uncomfortable taking the lead in a group Able to become quickly involved in new teams and groups Comfortable expressing opinions in a group even when I know that other people don't agree with them
Knowledge quiz Mean knowledge quiz scores increased from 84.95% (Mean ¼ 5.75; SD ¼ 1.09; n ¼ 189) for the pre-quiz to 89.34% (Mean ¼ 6.25; SD ¼ 0.81; n ¼ 106) on the post-quiz (p < 0.001). Confidence performing infection control skills On both the pre- and post-surveys, over 90% of learners indicated they were confident performing the following infection control skills: hand hygiene in the clinical setting, routine practices when caring for patients, utilizing contact precautions, and applying and removing personal protective equipment. Learner confidence improved significantly related to using airborne, droplet, and enhanced precautions following completion of the module (Table 2).
Pre-survey (n ¼ 140)
Post-survey (n ¼ 92)
Sig (ManneWhitney U)
78.8%
85.9%
0.172
97.12%
96.7%
0.697
80%
80.4%
0.690
65%
73.9%
0.074
95%
95.7%
0.471
35%
35.9%
0.554
32.9%
35.9%
0.907
88.6%
89.1%
0.730
75.7%
72.8%
0.746
Interprofessional teamwork and communication Little change between the pre- and post-survey comfort with IP teamwork and communication occurred among student participants. Learners identified mixed comfort levels with different aspects of teamwork and communication. Generally, students were comfortable justifying recommendations to more senior people, explaining issues to those unfamiliar with the topic, working in groups and agreed they could quickly become involved in new teams and groups, and expressing opinions in a group when others disagree (Table 3). However, many students identified having difficulty adapting communication styles to particular situations and Table 2 Confidence with infection control skills survey.
audiences and that they prefer to stay quiet when others express opinions they disagree with (Table 3). Satisfaction with the educational module Overall, survey results showed that students were satisfied with the IP infection control module, agreeing that they were able to meet session learning objectives (94.6%), the session was valuable to their education (87%), SP education was also valuable (96.7%), and that the session gave them a better understanding of health professional team member roles (81.5%) (Fig. 1). Interprofessional learning
Infection control skill
Pre-survey (n ¼ 140)
Post-survey (n ¼ 92)
Sig (ManneWhitney U)
Confident performing hand hygiene in the clinical setting Confident performing routine practices when caring for patients Confident utilizing contact precautions Confident utilizing airborne precautions Confident utilizing droplet precautions Confident utilizing enhanced precautions Confident applying personal protective equipment Confident removing personal protective equipment
98.6%
100%
0.902
90.7%
96.7%
0.365
93.6%
97.8%
0.328
74.3%
87%
0.009
75.7%
87%
0.027
55.7%
76%
0.001
92.1%
98.9%
0.056
92.1%
97.8%
0.145
Students valued the IP aspects of the educational session and having discussions about IP issues. They also demonstrated interest in learning about different health care team member roles. Learners suggested that the instructions given to all disciplines be clear and uniform. For example, students at the School of Medicine site suggested that all disciplines attending the session treat the module like a true patient encounter by coming to the session professionally dressed. Students at the same site recognized an imbalance in representation of the different disciplines, suggesting an interest in equal representation of the different professions to better facilitate the IP component of patient care. Planning committee and facilitator feedback
Bold indicates values that have reached statistical significance (p < .05).
The module planning committee and session facilitators provided mostly organizational and structural feedback on the IPE module. Developing the module required considerable combined effort of five designated faculty from the three schools and two infection control practitioners from the local community. Costs and
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Felt comfortable learning with students of different professions and/or levels of educa on The session should be mandatory for all nursing, medical, and rehabilita on students Be er understanding of health professional team member roles as a result of the session Would be interested in addi onal standardized pa ent programs during training Standardized pa ent educa on added value to their training Would be interested in addi onal interprofessional programs during training The interprofessional component of the session added value to their training Able to meet the learning objec ves for the session 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100% Fig. 1. Satisfaction survey results.
resources were shared in proportion to the number of students participating from each school. Challenges included scheduling planning meetings when all members could attend, and finding a block of time when students from the three schools were available and the three clinical education sites were also available. Planners suggested that any faculty who provide the Health Sciences disciplines with infection control education should be present and involved in the educational module to ensure continuity and consistency in teaching. As a structural consideration, SPs required a break between the hour-long sessions which was not included in this module. Overall, facilitators noted that students found the scenarios and the debriefing sessions valuable and there was an openness of participants to support, teach, and learn from students from other disciplines. Discussion Participants improved in their knowledge quiz scores following the scenarios as was seen in another interdisciplinary education study39; however, the same study demonstrated that knowledge retention several weeks following the program was low in a number of the participant groups. While our module shows an immediate improvement in students' knowledge of infection control practices, there may be a need for continued education and practice for acceptable retention. Having said this, as this module was building on earlier individual schools' education, we might suspect that the repetition of the content would extend the
timeframe for retention. Nurses agree that continuous education and reminders about Standard Precautions improve their compliance to infection control practices.40 In addition, participants showed marked increase in confidence using airborne, droplet, and enhanced precautions following the educational module, which is congruent with results from another infection control education intervention.39 There was IP student participation in the simulation scenarios, with other students role-playing as family members or other health practitioners. This contributed to the authenticity of the simulations and, arguably, any future transfer of the skills to practice. Student participants identified mixed levels of comfort with the IP teamwork and communication aspects of the module. Students agreed that they were comfortable justifying recommendations to more senior people while also noting they prefer to stay quiet when others express opinions they disagree with (Table 3). In the clinical setting, health sciences students have been more reluctant to report poor infection control practices,41 which suggests that discomfort present in a learning environment could be magnified in a more challenging, potentially more intimidating, clinical environment. While these students are at an intermediate level, studies show that IPE modules increase problem solving skills among the disciplines and allow students to collaborate to determine patient care, an opportunity that may be limited in the clinical setting.4,42 A limitation of the study is the low response rates of 59.1% and 38.8% for the pre- and post-surveys respectively which increases
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the potential for bias. Nonetheless, the success of this integrated IP and infection control simulation learning experience is evidenced by students' satisfaction with each aspect. Similar to other IPE projects at Queen's University, students in this module found the sessions valuable to their education and felt that course facilitators fulfilled the responsibility of preparing students for IP practice.43 The students considered the SP simulation component valuable as well, understandably, as the SPs can better prepare students for the clinical environment, improve the authenticity of the scenarios, and increase students' confidence communicating with patients.44 Faculty and learners identified several challenges and areas for improvement of the module; however, the challenges encountered during the development of the module were outweighed by the positive feedback obtained following implementation of the sessions. Similarly, Westberg and colleagues reported multiple challenges involved in designing and delivering an IP activity using SPs for pharmacy, nursing and medical students.45 These challenges should be considered when developing IPE activities; however our experience indicates that IPE scenarios using SPs are both feasible and beneficial to learners. Recommendations Possible solutions to eliminate or lessen the effect of the nonresponse bias seen in this project, should a similarly structured module be evaluated in research, would be to administer written surveys to be completed during the sessions, providing more frequent reminders and/or providing an incentive for completing the surveys. Results from the evaluation of this IPE infection control module demonstrate the combination of IP exposure, infection control skills practice, and the SP simulation mode were effective in improving students' knowledge and confidence using proper infection control techniques, and increasing comfort in IP teamwork. However, ongoing IP and infection control education are necessary for improving team collaboration skills and compliance to infection control standards. Suggestions include bringing feedback from this study to each school's Curriculum Committee to help build a thematic thread around patient safety, infection control practices, and collaborative learning. The planning committee recommendations for an improved module include: training of faculty instructors by ICPs prior to sessions or recruiting more ICPs to facilitate sessions, increasing session length to allow breaks between groups, and coordinating with the Office of Interprofessional Education and Practice regarding timing of other IP sessions for students' convenience. Additionally, the committee recommended that health sciences schools hold a mandatory IP pre-clinical interactive session on infection control practices taught by ICPs. Furthermore, to enhance the continuity of students' education, efficient and uniform information delivery could be achieved through IP sessions during which all health sciences students are exposed to the same, evidence-based, best practice protocols for infection control. This module will inform the ongoing structuring of future IP simulations as well as infection control education. The schools plan to continue the intermediate level sessions next academic year incorporating changes that are feasible. References 1. Romanow R. Final Report: Building on Values: The Future of Health Care in Canada; 2002. Retrieved from http://www.cbc.ca/healthcare/final_report.pdf. 2. Office of Interprofessional Education and Practice. IPE Framework for Queen's Faculty of Health Science; 2013. Retrieved from https://healthsci.queensu.ca/ education/oipep/ipe_framework_for_fhs.
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39. Wagner D, Parker C, Mavis B, Smith M. An interdisciplinary infection control education intervention: necessary but not sufficient. J Grad Med Educ. 2011;3(2):203e210. 40. Efstathiou G, Papasavrou E, Raftopoulos V, Merkouris A. Factors influencing nurses' compliance with standard precautions in order to avoid occupational exposure to microorganisms: a focus group study. BMC Nurs. 2011;10(1):1e12. 41. Ward DJ. Infection control in clinical placements: experiences of nursing and midwifery students. J Adv Nurs. 2010;66(7):1533e1542. 42. Titzer JL, Swenty CF, Hoehn WG. An interprofessional simulation promoting collaboration and problem solving among nursing and allied health professional students. Clin Simul Nurs. 2012;8(8):e325ee333. 43. O'Riordan A, Peterson J, Murphy S, et al. Collaboration in action: health care education. Acad Exch Q. 2011;15(4):94e99. 44. Rep MA. Standardized patients in education. Radiol Technol. 2012;83(5):503e506. 45. Westberg SM, Adams J, Thiede K, Stratton T, Bumgardner MA. An interprofessional activity using standardized patients. Am J Pharm Educ. 2006;70(2):34.
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Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Interprofessional infection control education using standardized patients for nursing, medical and physiotherapy students Marian Luctkar-Flude, RN, MScN a, *, Diana Hopkins-Rosseel, BSc(PT), MSc(Rehab Sci) b, Cherie Jones-Hiscock, MD, FRCPC c, Cheryl Pulling, RN, MSN a, Jim Gauthier, MLT, CIC d, Amanda Knapp, BASc, CPHI(C), CIC e, Sheila Pinchin, BA Hons, BEd, MEd c, Cecilia A. Brown, RN, BNSc a a
School of Nursing, Queen's University, 92 Barrie Street, Kingston, ON K7L 3N6, Canada School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, ON K7L 3N6, Canada School of Medicine, Queen's University, 15 Arch Street, Kingston, ON K7L 3N6, Canada d Providence Care, 340 Union Street, Kingston, ON K7L 5A2, Canada e KFL&A Public Health, 221 Portsmouth Ave, Kingston, ON K7M 1V5, Canada b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 July 2015 Received in revised form 15 March 2016 Accepted 17 March 2016
Background: Health professions students may apply infection control principles poorly within complex clinical situations. Providing opportunities to practice these skills in simulated health care contexts may improve knowledge and transfer to improved performance in actual clinical settings. Objective: To implement an innovative approach to interprofessional infection control education using standardized patients. Methods: A convenience sample of 237 students participated in an interactive lecture and four standardized patient scenarios. Students collaborated and selected supplies and protective equipment to demonstrate the appropriate level of infection control practices for each clinical scenario. Results: Learner knowledge (p ¼ .001) and confidence (p < 0.05) performing infection control skills increased significantly. Student participants identified varying levels of comfort with interprofessional teamwork and communication, but valued both the interprofessional component and use of standardized patients in the session. Conclusions: Overall, student and facilitator feedback about learning was positive. Results will inform the structuring of future IP simulation and infection control education sessions. Crown Copyright © 2016 Published by Elsevier Inc. All rights reserved.
Keywords: Interprofessional education Infection control Health professional students Standardized patients Clinical simulation
Introduction An intermediate level interprofessional education (IPE) session focusing on infection control skills was developed and held for Faculty of Health Sciences (FHS) students. The objective was to enhance patient welfare and safety related to infection control and to prepare learners to transition to cohesive, collaborative, patientcentered practice through an innovative approach to IPE using standardized patient (SP) simulations. Collaborative practice is designed to enhance patient- and family-centered goals and values, provides mechanisms for continuous communication among care givers, optimizes participation in clinical decision making within and across disciplines, and fosters respect for the contributions of all disciplines. Increasing the number of health professionals
* Corresponding author. Tel.: þ1 613 533 6000x77383; fax: þ1 613 533 6770. E-mail address: mfl[email protected] (M. Luctkar-Flude). http://dx.doi.org/10.1016/j.xjep.2016.03.004 2405-4526/Crown Copyright © 2016 Published by Elsevier Inc. All rights reserved.
educated within this paradigm will be a key contribution to improved access and quality of all health care services. This has been underlined as an essential ingredient in primary health care reform.1 Simulation-based IPE aligns with our FHS Framework for IPE in which learners engage in a developmental process of acquiring IP competency by engaging in activities at the exposure, immersion and competence levels within their curriculum.2 Simulation-based IPE thus provides an immersion experience that helps prepare learners to work collaboratively in their professional practices. A partnership between the Schools of Nursing, Rehabilitation Therapy, and Medicine within the FHS was previously involved in the development, implementation, and evaluation of a series of innovative IPE modules using high-fidelity patient simulation.3e5 Three of the four modules (suctioning skills, obstetric and pediatric skills, and cardiac resuscitation skills) have been successfully integrated into the respective curricular programs. The fourth module on application of infection control skills within a complex
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patient care scenario was trialed with a group of senior students from the three schools.6 Although the individual schools within the FHS each have knowledge- and skills-based individual infection control education early in their programs, the results of the evaluation of this fourth IPE module suggested that health professional students needed more practice and reinforcement of infection control skills within a variety of simpler clinical practice settings, prior to progressing to the complex senior-level scenarios, and prior to the transition from student to health care professional. The current project proposed to develop, implement, and evaluate an IPE infection control module for intermediate level health sciences students using SPs.
patients have been linked to improved communication, physical assessment, health teaching and clinical skills, enriched cultural assessments and improved health screening.23e31 Standardized patients have been used successfully in nursing health assessment courses and one study demonstrated that the introduction of an SP improved learners' behavioral performance on videotaped examinations.20 The use of SPs in education has been associated with reduced learner anxiety while caring for patients in the clinical setting,32 and communication skills learned during SP scenarios have also been demonstrated to transfer across cases into different clinical situations.24,33 As well, SP scenarios provide the opportunity for IP groups of learners to share problem solving strategies and practice communicating with other health care professionals.34
Background Use of interprofessional education to practice infection control skills Use of combined simulation and interprofessional learning Core collaborative competencies such as communication and teamwork can be improved through IPE.7,8 There is evidence that IP learning is enhanced when students see a direct relevance between the educational experience and their future practice.9 Experiential learning, defined as “learning that takes place as a result of an encounter with an experience that is planned by instructors within a course, program or curriculum,”10 has been used extensively and effectively in IPE. Simulation-based education offers increased relevance of training, exposing health professional students to clinical challenges prior to being responsible for similar real-life encounters.11 Simulation in education refers to the re-creation of an event that is as close to reality as possible. Clinical scenarios may be developed, in which students must contend with the same complexity of interacting and unanticipated physiological, psychological and social variables that they do in real clinical practice. They must integrate the full range of knowledge, skills, attitudes and behaviors to respond effectively, safely, and with caring. They are also able to observe the outcomes of their clinical decisions and actions and reflect upon and learn from their mistakes, a powerful educational principle.11 The overall aim of simulation-based IPE is to improve patient safety and quality of care.12 Involving health professions students in IP simulation training allows them to act as a part of a team, and provides an opportunity to foster communication, collaboration and leadership.13,14 Research has demonstrated that IPE employing high-fidelity simulation improves team-based attitudes and competencies with retention over time.15 As well, there is growing research evidence of the transferability of competencies learned through simulation to the clinical practice setting.16e19 Use of standardized patients as a mode of simulation education The use of SPs is one form of simulation that can be used in clinical education. SPs are individuals carefully trained to present health or illness concerns in a systematic, unvarying manner. Specific role-playing instructions for the SP include standard and spontaneous response statements to possible questions the students may pose. The script is consistent with specific health concerns, as well as extraneous information to permit the student to determine appropriate care. The SP is encouraged to create necessary emotional responses to the scenario, ultimately producing a realistic patient care scenario that mimics those a learner may encounter in a realworld setting.20,21 Standardized patients have been used in the education of health professions students, mainly to teach communication and clinical skills.22 Within the health care education literature, the majority of studies reported changes in learner knowledge, attitudes and skills, and very few reported changes in learner behaviors.22 Standardized
Infection control practices are a suitable topic for an IPE module as these competencies are shared amongst all health care professionals. Hospital-acquired infections are a major cause of morbidity and mortality. Adhering to evidence-based infection control practices can prevent many of these infections, contributing to improved patient outcomes and decreased health care costs35; however, knowledge and practice deficits related to infection control practices such as hand hygiene have been documented amongst health sciences students.36,37 Health sciences students are introduced to infection control practices in their respective programs. However, as our previous infection control skills module demonstrated, students may apply infection control principles poorly within the context of a more complex clinical situation.6 Providing pre-licensure health sciences students with opportunities to practice these skills in simulated health care settings may improve their knowledge and transfer to improved performance in actual clinical settings. Purpose The purpose of this project is to enhance patient welfare and safety by creating and implementing an innovative approach to infection control education through IP simulation using SPs that will contribute to preparing learners for cohesive, collaborative, patient-centered practice. Specific learning outcomes for the IPE infection control module are the following: (1) Health sciences students will identify and/or demonstrate appropriate infection control practices and/or identify errors or breeches of infection control practices related to standardized clinical situations. (2) Health sciences students will identify and/or demonstrate respectful and appropriate IP communication and collaboration. Methods Sample A convenience sample of 237 intermediate level health sciences students participated in the session. Of these, 100 were first-year medical students, 87 were second-year nursing students, and 50 were second-year physiotherapy students. Ethics This study received approval from the Queen's University and Affiliated Teaching Hospitals Health Sciences Human Research Ethics Board. Informed consent was obtained from all participants.
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Anonymity and confidentiality was ensured during the surveying process through anonymous questionnaires.
and was administered online before and after the education sessions. The quiz consisted of seven multiple choice questions.
Design and methods
Confidence performing infection control skills A survey consisting of 8 items on a 6-point Likert Scale was developed to measure learner confidence performing infection control skills-based on course objectives. Higher scores indicated higher confidence with the associated skills. Internal consistency for the scale was good (Cronbach's alpha ¼ 0.83). Validity was established through peer review by the instructors teaching in the course.
An interprofessional (IP) group of faculty and infection control practitioners developed the IP and infection control content of the project. The session consisted of a 50 min interactive session with an infection control practitioner (ICP) in which students worked in IP groups of six to seven students. The second half of the session consisted of four 15 min SP scenarios in which IP pairs of students were required to apply infection control principles and IP collaboration to a clinical case. The remainder of the students in each group participated as family members in the simulation or as extra staff members. The four simulation scenarios were as follows: (1) transfer of a patient in a semi-private room, (2) visit of a patient with HIV in an outpatient clinic, (3) discharge of a patient with VRE, and (4) assessment of a patient with undiagnosed TB. Each scenario had a targeted, but concealed, specific infection control application and IP collaboration learning outcomes (Table 1). Debriefing took place immediately following each scenario and was included in the 15 min timeframe. The clinical scenarios took place at each of three sites: School of Medicine Clinical Simulation Centre, School of Nursing Patient Simulation Lab, and the Faculty of Health Sciences Clinical Education Centre. Descriptive mixed methods were used to assess the implementation process of the module, and the achievement of the anticipated, immediate outcomes. The quantitative evaluation of learning outcomes employed a pre-test post-test research design. A qualitative descriptive approach was employed to report feedback from participants, faculty and facilitators. Data collection Both quantitative and qualitative data were collected from participants using online questionnaires. Demographic questions were included, such as respondents' future profession, age, and sex. The pre- and post-module questionnaires consisted of the following instruments: Knowledge quiz A knowledge quiz of infection control practices was developed by the infection control practitioners based on the module content
Interprofessional teamwork and communication The Communication and Teamwork Scale of the University of the West of England, Bristol Entry Level Interprofessional Questionnaire was used in this study and involves participant selfassessment of teamwork and communication skills, and attitudes toward IP learning and IP interaction.38 The scale consists of 9 items on a 6-point Likert Scale. Negative statements were reverse scored with higher scores on each item indicating greater comfort with communication and teamwork items. Internal consistency for the scale was good (Cronbach's alpha ¼ 0.79). Satisfaction with the educational module A survey consisting of 8 items on a 6-point Likert Scale was developed to measure learner satisfaction with the components of the IPE module using SPs. Internal consistency for the scale was very good (Cronbach's alpha ¼ 0.98). Interprofessional learning A qualitative survey was developed by the project team asking students to respond to three open-ended questions related to their comfort with IP learning, challenges and benefits to IP learning, and suggestions to improve the IPE infection control module. Data analysis Quantitative data were entered into an SPSS v.21 database and verified by a second person. Pre-post-survey comparisons were conducted using Mann Whitney U tests for ordinal data. Analysis of qualitative feedback involved identifying emergent categories and patterns concerning participants' learning related to infection control practices and IP collaboration.
Table 1 Interprofessional infection control standardized patient scenarios. Scenario
Situation
Infection control component
IP collaboration component
1. Transfer of patient with right-sided stroke in hospital neurology unit. Participants: medical & physiotherapy students 2. Routine checkup of patient with HIV in HIV outpatient clinic. Participants: nursing & medical students
Patient with r-sided stroke wants to get up in wheelchair that was borrowed by roommate. Roommate's housecoat is draped on it. Young male patient with HIV is stable on meds & attending clinic for routine checkup. No complaints of symptoms. Energy level “OK.” States he has a new partner. Patient with start of a dementia and VRE is ready for discharge post hospitalization with fractured ankle.
Wash hands before & after; Clean wheelchair with “wipes”; Clean stethoscope with alcohol wipes before & after use Wash hands before & after; Clean stethoscope before & after use; Question health care professional who enters room wearing gloves & gown Wash hands before & after; Follow contact precautions: glove & gown to enter room
Collaborate on assessment; Collaborate on transfer of patient to wheelchair
Person with undiagnosed TB having recent weight loss and the following symptoms: coughing for 4 weeks with greenish sputum, fatigue, fever, night sweats, chills, & shortness of breath
Wash hands before & after; Clean stethoscope before & after use; Initiate airborne precautions
3. Discharge of patient from hospital orthopedics unit. Participants: physiotherapy & nursing students 4. Assessment of homeless patient with TB in hospital ER. Participants: medical & nursing students
Collaborate on assessment; Collaborate on health teaching related to safe sex practices Collaborate on discharge planning
Collaborate on assessment
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Results
Table 3 Comfort with interprofessional teamwork and communication survey.
Participants
Survey item
The overall pre-survey response rate was 140/237 (59.1%). Response rates by profession were 59% for medical students, 84% for nursing students and 16% for physiotherapy students. The overall post-survey response rate was 92/237 (38.8%) with a response rate by medical students of 41%, nursing students of 53%, and physiotherapy students of 10%. The majority of participants were female (70%) and aged 20e24 years (59%), whereas 25% were 25 years or older, and 16% were younger than 20 years.
Comfortable justifying recommendations and/ or advice face-to-face with more senior people Comfortable explaining an issue to people who are unfamiliar with the topic Have difficulty adapting communication style to particular situations and audiences Prefer to stay quiet when other people in a group express opinions that I don't agree with Feel comfortable working in a group Feel uncomfortable putting forward personal opinions in a group Uncomfortable taking the lead in a group Able to become quickly involved in new teams and groups Comfortable expressing opinions in a group even when I know that other people don't agree with them
Knowledge quiz Mean knowledge quiz scores increased from 84.95% (Mean ¼ 5.75; SD ¼ 1.09; n ¼ 189) for the pre-quiz to 89.34% (Mean ¼ 6.25; SD ¼ 0.81; n ¼ 106) on the post-quiz (p < 0.001). Confidence performing infection control skills On both the pre- and post-surveys, over 90% of learners indicated they were confident performing the following infection control skills: hand hygiene in the clinical setting, routine practices when caring for patients, utilizing contact precautions, and applying and removing personal protective equipment. Learner confidence improved significantly related to using airborne, droplet, and enhanced precautions following completion of the module (Table 2).
Pre-survey (n ¼ 140)
Post-survey (n ¼ 92)
Sig (ManneWhitney U)
78.8%
85.9%
0.172
97.12%
96.7%
0.697
80%
80.4%
0.690
65%
73.9%
0.074
95%
95.7%
0.471
35%
35.9%
0.554
32.9%
35.9%
0.907
88.6%
89.1%
0.730
75.7%
72.8%
0.746
Interprofessional teamwork and communication Little change between the pre- and post-survey comfort with IP teamwork and communication occurred among student participants. Learners identified mixed comfort levels with different aspects of teamwork and communication. Generally, students were comfortable justifying recommendations to more senior people, explaining issues to those unfamiliar with the topic, working in groups and agreed they could quickly become involved in new teams and groups, and expressing opinions in a group when others disagree (Table 3). However, many students identified having difficulty adapting communication styles to particular situations and Table 2 Confidence with infection control skills survey.
audiences and that they prefer to stay quiet when others express opinions they disagree with (Table 3). Satisfaction with the educational module Overall, survey results showed that students were satisfied with the IP infection control module, agreeing that they were able to meet session learning objectives (94.6%), the session was valuable to their education (87%), SP education was also valuable (96.7%), and that the session gave them a better understanding of health professional team member roles (81.5%) (Fig. 1). Interprofessional learning
Infection control skill
Pre-survey (n ¼ 140)
Post-survey (n ¼ 92)
Sig (ManneWhitney U)
Confident performing hand hygiene in the clinical setting Confident performing routine practices when caring for patients Confident utilizing contact precautions Confident utilizing airborne precautions Confident utilizing droplet precautions Confident utilizing enhanced precautions Confident applying personal protective equipment Confident removing personal protective equipment
98.6%
100%
0.902
90.7%
96.7%
0.365
93.6%
97.8%
0.328
74.3%
87%
0.009
75.7%
87%
0.027
55.7%
76%
0.001
92.1%
98.9%
0.056
92.1%
97.8%
0.145
Students valued the IP aspects of the educational session and having discussions about IP issues. They also demonstrated interest in learning about different health care team member roles. Learners suggested that the instructions given to all disciplines be clear and uniform. For example, students at the School of Medicine site suggested that all disciplines attending the session treat the module like a true patient encounter by coming to the session professionally dressed. Students at the same site recognized an imbalance in representation of the different disciplines, suggesting an interest in equal representation of the different professions to better facilitate the IP component of patient care. Planning committee and facilitator feedback
Bold indicates values that have reached statistical significance (p < .05).
The module planning committee and session facilitators provided mostly organizational and structural feedback on the IPE module. Developing the module required considerable combined effort of five designated faculty from the three schools and two infection control practitioners from the local community. Costs and
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Felt comfortable learning with students of different professions and/or levels of educa on The session should be mandatory for all nursing, medical, and rehabilita on students Be er understanding of health professional team member roles as a result of the session Would be interested in addi onal standardized pa ent programs during training Standardized pa ent educa on added value to their training Would be interested in addi onal interprofessional programs during training The interprofessional component of the session added value to their training Able to meet the learning objec ves for the session 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100% Fig. 1. Satisfaction survey results.
resources were shared in proportion to the number of students participating from each school. Challenges included scheduling planning meetings when all members could attend, and finding a block of time when students from the three schools were available and the three clinical education sites were also available. Planners suggested that any faculty who provide the Health Sciences disciplines with infection control education should be present and involved in the educational module to ensure continuity and consistency in teaching. As a structural consideration, SPs required a break between the hour-long sessions which was not included in this module. Overall, facilitators noted that students found the scenarios and the debriefing sessions valuable and there was an openness of participants to support, teach, and learn from students from other disciplines. Discussion Participants improved in their knowledge quiz scores following the scenarios as was seen in another interdisciplinary education study39; however, the same study demonstrated that knowledge retention several weeks following the program was low in a number of the participant groups. While our module shows an immediate improvement in students' knowledge of infection control practices, there may be a need for continued education and practice for acceptable retention. Having said this, as this module was building on earlier individual schools' education, we might suspect that the repetition of the content would extend the
timeframe for retention. Nurses agree that continuous education and reminders about Standard Precautions improve their compliance to infection control practices.40 In addition, participants showed marked increase in confidence using airborne, droplet, and enhanced precautions following the educational module, which is congruent with results from another infection control education intervention.39 There was IP student participation in the simulation scenarios, with other students role-playing as family members or other health practitioners. This contributed to the authenticity of the simulations and, arguably, any future transfer of the skills to practice. Student participants identified mixed levels of comfort with the IP teamwork and communication aspects of the module. Students agreed that they were comfortable justifying recommendations to more senior people while also noting they prefer to stay quiet when others express opinions they disagree with (Table 3). In the clinical setting, health sciences students have been more reluctant to report poor infection control practices,41 which suggests that discomfort present in a learning environment could be magnified in a more challenging, potentially more intimidating, clinical environment. While these students are at an intermediate level, studies show that IPE modules increase problem solving skills among the disciplines and allow students to collaborate to determine patient care, an opportunity that may be limited in the clinical setting.4,42 A limitation of the study is the low response rates of 59.1% and 38.8% for the pre- and post-surveys respectively which increases
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the potential for bias. Nonetheless, the success of this integrated IP and infection control simulation learning experience is evidenced by students' satisfaction with each aspect. Similar to other IPE projects at Queen's University, students in this module found the sessions valuable to their education and felt that course facilitators fulfilled the responsibility of preparing students for IP practice.43 The students considered the SP simulation component valuable as well, understandably, as the SPs can better prepare students for the clinical environment, improve the authenticity of the scenarios, and increase students' confidence communicating with patients.44 Faculty and learners identified several challenges and areas for improvement of the module; however, the challenges encountered during the development of the module were outweighed by the positive feedback obtained following implementation of the sessions. Similarly, Westberg and colleagues reported multiple challenges involved in designing and delivering an IP activity using SPs for pharmacy, nursing and medical students.45 These challenges should be considered when developing IPE activities; however our experience indicates that IPE scenarios using SPs are both feasible and beneficial to learners. Recommendations Possible solutions to eliminate or lessen the effect of the nonresponse bias seen in this project, should a similarly structured module be evaluated in research, would be to administer written surveys to be completed during the sessions, providing more frequent reminders and/or providing an incentive for completing the surveys. Results from the evaluation of this IPE infection control module demonstrate the combination of IP exposure, infection control skills practice, and the SP simulation mode were effective in improving students' knowledge and confidence using proper infection control techniques, and increasing comfort in IP teamwork. However, ongoing IP and infection control education are necessary for improving team collaboration skills and compliance to infection control standards. Suggestions include bringing feedback from this study to each school's Curriculum Committee to help build a thematic thread around patient safety, infection control practices, and collaborative learning. The planning committee recommendations for an improved module include: training of faculty instructors by ICPs prior to sessions or recruiting more ICPs to facilitate sessions, increasing session length to allow breaks between groups, and coordinating with the Office of Interprofessional Education and Practice regarding timing of other IP sessions for students' convenience. Additionally, the committee recommended that health sciences schools hold a mandatory IP pre-clinical interactive session on infection control practices taught by ICPs. Furthermore, to enhance the continuity of students' education, efficient and uniform information delivery could be achieved through IP sessions during which all health sciences students are exposed to the same, evidence-based, best practice protocols for infection control. This module will inform the ongoing structuring of future IP simulations as well as infection control education. The schools plan to continue the intermediate level sessions next academic year incorporating changes that are feasible. References 1. Romanow R. Final Report: Building on Values: The Future of Health Care in Canada; 2002. Retrieved from http://www.cbc.ca/healthcare/final_report.pdf. 2. Office of Interprofessional Education and Practice. IPE Framework for Queen's Faculty of Health Science; 2013. Retrieved from https://healthsci.queensu.ca/ education/oipep/ipe_framework_for_fhs.
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