Medical students' engagement in interprofessional collaborative communication during an interprofessional observed structured clinical examination: A qualitative study

Medical students' engagement in interprofessional collaborative communication during an interprofessional observed structured clinical examination: A qualitative study

Journal of Interprofessional Education & Practice 7 (2017) 21e27 Contents lists available at ScienceDirect Journal of Interprofessional Education & ...

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Journal of Interprofessional Education & Practice 7 (2017) 21e27

Contents lists available at ScienceDirect

Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com

Medical students' engagement in interprofessional collaborative communication during an interprofessional observed structured clinical examination: A qualitative study Sandra K. Oza, MD, MA *, 1, Maria Wamsley, MD, Christy K. Boscardin, PhD, Joanne Batt, BA, Karen E. Hauer, MD, PhD Department of Medicine, University of California San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 8 September 2016 Received in revised form 20 December 2016 Accepted 6 February 2017

Background: Effective communication is essential for interprofessional collaborative practice; however, a conceptual framework of interprofessional collaborative communication (ICC) has not been proposed. Purpose: Develop and apply a conceptual framework of ICC. Methods: Literature on interprofessional collaboration and interprofessional communication informed framework development; we then applied it to analyze medical student communication with a standardized nurse (SN). We identified prototypical ways that students engaged in two of the ICC framework constructs. Nurses provided feedback on our framework. Discussion: The ICC conceptual framework consisted of four constructs. Higher rated students engaged in more bidirectional information exchange and solicited the SN's input into the care plan. Prototypes ranged from less collaborative (i.e. closed-ended) to more collaborative exchanges inviting the SN to share knowledge and suggestions. Six nurses endorsed the framework. Conclusions: Bidirectional information exchange and soliciting input into decision-making may be particularly important for ICC. This novel ICC framework can inform curriculum development and learner assessment. © 2017 Elsevier Inc. All rights reserved.

Keywords: Interprofessional collaborative practice Medial student assessment Communication

Introduction Collaboration among health care professionals is essential for high quality patient care. Interprofessional collaborative practice can improve health outcomes by reducing medical errors and enhancing patient safety.1e4 Collaboration in healthcare has been defined as “nurses and physicians cooperatively working together,

Abbreviations: ICC, interprofessional collaborative communication; OSCE, observed, structured clinical examination; SN, standardized nurse; CPX, Clinical Performance Examination. Funding: The Mini-Grant program of the Western Regional Group on Educational Affairs of the Association of American Medical Colleges provided grant funding to support this work. The funders were not involved in the study design, collection, analysis, or interpretation of data, nor in the decision to submit this manuscript for publication. * Corresponding author. 3444 Kossuth Ave, Bronx, NY 10467, USA. E-mail address: koza@montefiore.org (S.K. Oza). 1 Present and permanent address: Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, 3444 Kossuth Ave, Bronx, NY 10467, USA. http://dx.doi.org/10.1016/j.xjep.2017.02.003 2405-4526/© 2017 Elsevier Inc. All rights reserved.

sharing responsibility for solving problems, and making decisions to formulate and carry out plans for patient care”.5 Effective communication is a core competency for interprofessional collaborative practice, with benefits for both patients and providers.6,7 Conceptual frameworks of interprofessional collaboration frequently employ terminology such as sharing and partnership, interdependency and mutual respect, communication, and balance of power.6,8,9 Determinants of collaboration include systemic and organizational factors, as well as interactional dynamics such as willingness to collaborate, trust, mutual respect and communication. In particular, communication (1) conveys an understanding of the contributions of the other members of a team; (2) allows for constructive negotiations with other professionals; and (3) enables other interactional determinants of collaboration, like mutual respect, mutual trust, and sharing.10 The literature strongly supports that communication is particularly important in the realization of collaboration. We propose that ‘interprofessional collaborative communication’ (ICC) is a particular type of communication that healthcare professionals engage in that enables collaboration. To our knowledge, a conceptual framework that captures the core constructs of

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ICC has not been proposed. Such a framework would be useful in the development of curricula to teach ICC skills to health professions trainees, and to assess whether these skills have been mastered, with the ultimate goals of fostering collaboration among health professionals and improving patient care. This study proposes and applies a conceptual framework of ICC that builds upon theoretical descriptions of collaboration and empirical research on nurse-physician communication and collaboration.11e15 We applied this framework to an analysis of medical students' engagement in ICC during a simulated patient care encounter with a standardized patient (SP) and a standardized health professional (standardized nurse, SN) to provide evidence for the utility of the framework and to examine the applicability for assessment in an observed structured clinical examination (OSCE) setting. Methods Design We developed a conceptual framework of ICC and then applied this framework to an analysis of medical student communication during an interprofessional OSCE using directed qualitative content analysis.16 Subjects and setting The study population was third-year medical students at the University of California, San Francisco (UCSF) who participated in the 2012 high-stakes Clinical Performance Examination (CPX) administered at the end of the core clinical clerkships. In the CPX, each student conducted a single encounter involving both a SP and SN. All encounters were audio- and video-recorded. The institutional review board approved this study. Development of a conceptual framework of interprofessional collaborative communication We conducted a narrative review of the literature including theoretical work and empirical research in interprofessional collaboration and communication to identify key constructs,17 with particular focus on studies assessing collaboration between physicians and nurses. Two authors (SKO and KEH) conducted the search in PubMed, utilizing the following search terms: interprofessional communication, interprofessional collaboration, and nursephysician communication. Theoretical and empirical research exploring collaboration, interprofessional communication, as well as published instruments measuring these constructs were extracted for further review. The authors determined article relevance to be theoretical and/or empirical studies of collaboration or communication between nurses and physicians. One author (SKO) distilled the most frequently mentioned constructs and concepts related to interprofessional and health ‘collaboration’ and ‘communication’ from the articles, and used them to develop a new conceptual framework of ICC, incorporating these constructs. We sought consultation on the content, appropriateness and structure of the framework from several sources. First, members of the author team, including three general internists (SKO, MW, KEH) and one educational researcher (CKB), all with expertise in medical education and qualitative research, reviewed the appropriateness and scope of the framework. Second, an internationally recognized scholar on interprofessional collaboration and education reviewed the overall framework and agreed with its content and scope. Finally, after applying the framework in the study analysis, we invited six medical-surgical nurses with extensive clinical

experience with both physicians and medical trainees to participate in a focus group. The purpose of the focus group was to solicit nurses' feedback on the framework. Prior to attending the focus group, each participating nurse reviewed two transcripts of student encounters for background reference during the discussion of the conceptual framework. The focus group was audio-recorded and transcribed verbatim by a professional transcription service, and analyzed by one author (SKO) using a thematic approach. Interprofessional OSCE Three general internists and one nurse, all with expertise in medical education and experience with OSCE case development, developed the case materials.18 Case development occurred prior to the development of the ICC conceptual framework. The SP was a 55-year-old woman hospitalized for left leg cellulitis who acutely developed chest pain. The SN called the student to the bedside to evaluate the patient. The SN was present in the examination room for the first three and final 5 min of the encounter (for a total of 8 of 15 min). The student was advised at the start of the encounter to gather pertinent history from the SP and SN, perform a focused physical examination, and counsel the SP. The student was also advised to collaborate with the SN to develop a care plan. Both the SP and SN actors assessed the student's performance utilizing checklists; student performance was used in the selection of our study sample as described below. Communication items on the SN checklist The 11-item SN checklist developed for this case targets relevant core interprofessional practice competencies19 (see also Appendix A). For the six communication items, the SN assessed whether a student had (“yes”) or had not (“no”) demonstrated a particular communication skill. Performance on the checklist was defined as the percentage of items scored as “yes” (range 0e100%). Communication items on the SP checklist The 29-item SP checklist assessing student performance included one global rating item, 11 history, 5 physical examination, and 2 information-sharing items. Ten items e modeled on the SEGUE-framework20 e targeted expected physician-patient communication including listening, counseling, and respect for patient preferences. For these ten items the SP assessed whether a student had (“yes”) or had not (“no”) demonstrated a particular communication skill. Performance on the checklist was defined as the percentage of items scored as “yes” (range 0e100%). “Overall Satisfaction” item on the SN checklist The SN checklist also included one global rating item. The SN indicated her “overall satisfaction” with the student encounter by indicating her agreement with this statement: “Based on my level of satisfaction with this encounter, I would choose to work with this student doctor again,” rated from “disagree” to “strongly agree.” We used this overall satisfaction (OS) rating to group students into three categories: low OS (“disagree” response from the SN), medium OS (“agree”), and high OS (“strongly agree”). Procedures Sampling We used purposive sampling of medical student subjects based on quartiles of performance on the communication items in the SP and SN checklists. We generated a combined communication score using the SN checklist (6 items) and SP checklist (10 items). Fifteen encounters were randomly selected from each quartile of

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performance for 60 total encounters. The sample size of 60 encounters was selected to ensure sufficient examples of students' communication across a broad range of test performances. Audio recordings of these encounters were transcribed verbatim by a professional transcription service. Application of the conceptual framework of ICC to student-SN encounters Following the development of the conceptual framework, the authors used it to analyze students' communication with the SN during the encounter. Two authors (SKO, KEH) developed a coding guide based on the ICC conceptual framework. These authors read 5 transcripts and further refined the coding guide, clarifying definitions and including examples from transcripts, to the form utilized in the study (Table 1, see also Appendix B). The units of analysis were spoken exchanges between student and SN, analyzed in transcriptions of the encounters. Because the SN role was standardized and partially scripted, analyses focused on the student's utterances to the SN. All instances of two constructs of ICC in the coded data (information management and decision-making, which were both further sub-divided into two components; see Table 1) were extracted and re-reviewed to determine prototypes of these elements. Analyses Pairs of researchers (either two physicians, or a physician and an experienced research assistant) analyzed all sixty transcripts for evidence of the constructs of ICC (Table 1, see also Appendix B). Coders were blinded to the student performance rating on the checklists. We coded whether the student used each ICC element at least once during the encounter. Coders met throughout the coding process to review their coded transcripts, and reconciled discrepancies by discussion. Next, we examined the encounters according to the ‘overall satisfaction’ rating by the SN (low, medium or high, as described above). This step allowed us to answer two questions: (1) Did a student's engagement in more elements of the ICC conceptual framework correlate with greater SN-reported satisfaction working with the student? and (2) Were students who scored higher in overall satisfaction more likely to engage in certain elements of ICC than lower rated students? The overall satisfaction rating was preferred over combined communication checklist performance score, as the overall satisfaction rating derived purely from the SN encounter with the student and thus represented the nurse perspective. Finally, one author (SKO) extracted all examples of information management (which consisted of examples of the components of information-management-seeking and information-managementsharing) and decision-making (which also consisted of examples of the components of decision-making-sharing and decision-makingseeking). The researchers then reviewed these examples to identify prototypical ways that students engaged in these communicative elements. The resulting prototypes were classified as more or less collaborative through discussion among the research team, in consultation with the previously identified literature on interprofessional collaboration and communication. Results Study participants Of the sixty students selected for inclusion, communication scores were: 25th percentile cutoff score 81.25% correct; median percentile 93.75% correct, and 75th percentile and maximum score 100% correct.

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Table 1 Constructs of the conceptual framework of ICC, with a definition of what the student needed to do to engage in that element. ICC conceptual framework constructs

Defined as the student

Role identification

Introducing self to the SN and indicating his/her role on the health care team

Information management e Sharing e Seeking Decision-making e Sharing

e Seeking

Collegial exchanges

Sharing information about the SP with the SN Asking the SN for information about the SP Informing the SN of his/her thought process and/or decisions regarding next steps in the SP's diagnostic and/or therapeutic plan without seeking the SN's input Seeking input from the SN into the decision-making process, such as what should be done next in the SP's diagnostic and/or therapeutic plan Exchanging comments conveying praise, mutual respect, support

Development of a conceptual framework of ICC The conceptual framework of ICC includes four constructs (role identification, information management, decision-making, and collegial exchanges; information management and decisionmaking were subdivided into two components of sharing and seeking), which can be readily observed and measured (see definitions of these constructs in Table 1). The focus group with six nurses reinforced the salience of the conceptual framework. None of the constructs in the framework were felt to be unimportant or unworthy of inclusion in the model. One nurse, when reflecting on positive and negative experiences of ICC, stated, “… those all worked together in the positive experience and were strikingly absent in the negative experience.” Another nurse commented specifically on the foundational nature of collegial exchanges: “I find myself thinking of the top 3 [role identification, information management, decision-making] measured concepts, I don't think you can get to that. And maybe this is my soapbox of the moment, but the [collegial] exchanges sort of form a foundation. And you won't have effective other things if e whether it's decision making or information seeking and sharing or role identification e if you don't first start with a positive [collegial] exchange.” Analysis of medical students' engagement in ICC Table 2 presents data on the frequency of ICC elements in the dialogues between medical students and SN, with the data Table 2 Number and percentage of students demonstrating elements of interprofessional collaborative communication during an encounter with a standardized nurse (SN), categorized by overall satisfaction rating assigned by the SN. Constructs of the ICC conceptual framework

Overall satisfaction rating from SN Low (n ¼ 1)

Medium (n ¼ 46)

High (n ¼ 13)

Overall (n ¼ 60)

Role identification n (%)a Information management  Sharing  Seeking  Both sharing and seeking Decision-making  Sharing  Seeking  Both sharing and seeking Collegial exchanges

1 (100%)

44 (73%)

13 (100%)

58 (97%)

1 (100%) 0 (0%) 0 (0%)

24 (52%) 38 (83%) 20 (43%)

8 (62%) 12 (92%) 7 (54%)

33 (55%) 40 (67%) 27 (45%)

1 0 0 1

46 16 16 46

12 (92%) 8 (62%) 8 (62%) 13 (100%)

58 24 24 60

(100%) (0%) (0%) (100%)

(100%) (35%) (35%) (100%)

(97%) (40%) (40%) (100%)

a Percentages add to greater than 100% as students could demonstrate multiple elements.

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organized by the SN overall satisfaction rating for the student. Nearly all students (58 of 60, 97%) identified their role. All 60 students demonstrated collegial exchanges in communication with the SN. One student (2%) received an overall satisfaction score of low by the SN, 46 (76%) received a score of medium, and thirteen (22%) received a score of high. The percentage of students who (1) sought information about the SP from the SN; (2) both sought information from, and shared information with the SN about the SP; and (3) sought the SN's input into decision-making about the care plan increased linearly with the overall satisfaction rating from the SN (Table 2). Analysis of prototypes of information management and decisionmaking elements of ICC Prototypes representing the ICC elements “information management” and “decision-making” are displayed in Table 3aed, along with representative excerpts from student-SN dialogue. The prototypes are listed in order of the degree to which they foster collaboration. When the student was sharing information about the patient, or sharing suggestions about the care plan, doing so in the context of a “think aloud” in which the student explained his/her clinical reasoning was judged to be more collaborative, compared to simply sharing factual information or stating the care plan without a rationale. Instances of open-ended information seeking, and open-ended inquiries into the nurse's suggestions on the care plan were more collaborative forms of these prototypes of ICC. These findings align with the sentiments of focus group participants, who highlighted joint participation and acknowledgment of interdependency as critically important to ICC. One nurse said, “To me, that brings up what perhaps I was thinking of as the difference in communication and collaboration. And it's the explicit nature of sharing. And that we're gonna communicate about a lot of things, but part of my obligation, if I'm going to be a good collaborator, may be to share what I am thinking. And there's a lot of times there can be information pushed back and forth that, if it doesn't come with the plan that was informing that information, I wouldn't call that real collaboration.” Discussion The purpose of this study was to develop a conceptual framework of ICC and test the utility and applicability of the framework in an analysis of medical student encounters with SNs. The key findings of this study e that medical students engaged to varying degrees in all elements of the newly developed framework of ICC e support the applicability of the framework to analyses of communication in the context of interprofessional practice. The framework also discriminated a range of student performance, indicating its potential for learner assessment. Our findings contribute to an emerging body of work focused on teaching and assessing interprofessional collaborative practice skills. We focused our study on four constructs of ICC that can be readily observed and measured. Our findings that more highly rated students were more likely to engage in bidirectional information management (both seeking and sharing) and joint decisionmaking (both seeking and sharing), suggest that these elements may be particularly important for ICC. Students' uses of the SN's knowledge and expertise in formulating a care plan for the SP varied from requesting factual information, to soliciting acknowledgment of the care plan without soliciting input into the plan, to soliciting the SN's input into the plan. These findings align with those from Nair and colleagues, who utilized the validated Nurse Physician Collaboration Scale (NCPS),15 to collect data from physicians and nurses about collaborative behaviors used by nurses and

physicians. This study found that nurses most frequently cited collaborative behaviors from the sharing patient information subscale of the NCPS, highlighting the importance nurses place on information sharing.13 Other work has shown that nurses' satisfaction with the decision-making process is closely tied to perceptions of collaboration.21 In our study, additional examination of excerpts of decision-making and information management indicated that open-ended inquiries for information or input into the care plan, and the sharing of information about the patient or care plan in the context of a clinical rationale, were more collaborative, compared to closed-ended requests or statements lacking a rationale. Open-ended exchanges permitted more back-and-forth dialogue between student and SN, which, when viewed through a sense-making lens as advocated by Manojlovich,22 facilitates consensus and execution of next steps. Our findings support recommendations about the importance of facilitating mutual knowledge among team professionals to improve collaboration and sharing of clinical information.10 Further, our findings align with recommended core communication competencies for interprofessional collaborative practice, those competencies specifically focused on encouraging team members' contributions and working to ensure common understandings of information and treatment/ care decisions,19 and have implications for training health professionals in effective ICC. Students commonly employed collegial exchanges and role identification in communicating with the SN, although the utilization of these elements did not differentiate higher and lower rated students. Collegial exchanges can demonstrate mutual respect for colleagues and communicate praise and acknowledgment, and are important for effective nurseephysician communication.14 However, polite and respectful interactions alone may be insufficient to achieve a collaborative interaction, a hypothesis supported by our findings and focus group discussion. Similarly, in our study sample, all but two students engaged in “role identification” e which in this study could be achieved by introducing one's name and role as medical student caring for the patient. In the literature, “authentic role understanding” is described as an understanding and appreciation of the value of other professionals and their unique contributions to patient care; it is felt to be an important pre-requisite for collaboration.7 It would be inappropriate to conclude that all but one student in our sample possessed an authentic understanding of the nurse's role and unique contributions to patient care. More likely, students introduced themselves and their role out of habit fostered in prior “general communication skills” training. We maintain that the inclusion of role identification in the conceptual framework is appropriate, but acknowledge that our operationalization of this construct has fallen short of capturing full role understanding. Further work is needed on how best to measure authentic role understanding during ICC. In our literature review, other constructs emerged as essential for successful ICC. These included constructs such as authentic role understanding (as noted above) trust, cooperativeness, interdependency, power, willingness to collaborate, mutual respect, and collaborative problem solving.6,8,9 Some of these constructs overlap with the measured constructs in our conceptual framework, although were named differently (e.g. mutual respect can manifest through collegial exchanges, and cooperativeness and interdependency can manifest through more collaborative forms of bidirectional information management and seeking others' input into decision making). Further refinement and elaboration of this framework could seek to incorporate more of these constructs. This study has important limitations. Subjects were medical students at one medical school, and therefore findings may not

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Table 3 Prototypes of the ICC elements “information management” and “decision-making” are displayed in aed, along with representative excerpts from student-SN dialogue. The prototypes are listed in order of the degree to which they foster interprofessional collaboration. Prototype A: Information management: Sharing Less collaborative To orient SN to situation Y

Y

To report factual information to SN

Y More collaborative

To “think aloud” and display clinical reasoning/share rationale with SN

B: Information management: Seeking Less collaborative Closed-ended, factual Y

Closed-ended, to confirm or clarify

Y

Closed ended, to solicit clinical reasoning

Y More collaborative

Open-ended, to gather opinions/ Concerns/ Suggestions

C: Decision-making: Sharing Less collaborative To suggest plan without Y contextual clinical reasoning

Y Y Y

To suggest plan during a “think aloud” display of clinical reasoning

Representative excerpt Student: Hi, thank you for coming back. I just got a history right now. SN: Great Student: And we're just gonna take a quick blood pressure. SN: Okay. Student: And then do a quick physical exam Student: Yeah. So I know she's hypertensive, but she said she's pretty well controlled. SN: Last night it was 138/78. Student: 138. Okay. Student: I'm gonna have the attending take a look at this [EKG]. And depending on what we see, we may want to do some troponins or something like that. But for now, this is reassuring. I went ahead and started her on some oxygen just for comfort. SN: Mm-hmm. Student: Although I noticed that her O2 sat was pretty good. SN: Mm-hmm. Student; It's just for comfort measures. SN: Okay Student: I'll write those orders, but definitely, we'll get some troponin. Did you give her any other medications for the chest pain? SN: Hi. Student: Hi. I was wondering if she e Ms. Lyons let me know that you did an EKG. SN: Yeah. Student: I was wondering if it was possible for me to have a quick look at it? SN: Absolutely. SN: And I'm just concerned that this may be something to do with her heart, so I'd like you to evaluate the patient and then let me know what I can do to assist in the evaluation. Student: Yeah, absolutely. What, what made you think that it might be cardiac in nature? Just from what you've seen? SN: Yeah, just her symptoms and her chest pain made me wonder. Student: Okay, okay. And so did you see the patient this morning, besides chest pain has there been any other complaints or changes in her status? SN: There's been no change in her status other than her new chest pain. Student: So you just came onto her care? SN: Yes, right. We just met this morning, so. Student: Is there anything else that you've gotten from sign out, anything in the evening? SN: The only other thing that comes to mind is that she has been refusing her enoxaparin shots the last two nights. Student: So let's get her on some oxygen. SN: Sure. Student: And some aspirin. SN: Okay Student: And e SN: I think that's a great idea. For the aspirin I just need you to place the order and have it co-signed e Student: Okay SN: And then I can get back to her right away Student: Okay, I'll be happy to do that SN: Yeah Student: And then let's also give her some nitroglycerin SN: Okay. Student: Sure. Thank you, Chris. So, we were just talking, and I think that she obviously has concerns with her family history about possible heart attack, which is legitimate given the fact that she's got some chest pain now. I think things that we can do to kind of rule that out is we can get an EKG. SN: Okay, we actually did that earlier, and I got the results when I was out at the nurse's station. Student: Great. SN: Here you are. Student: Thank you. All right. The EKG looks good. It doesn't look like there's any abnormalities there. Thank you. SN: Thank you. Student: Another thing I was going to suggest that we may do just in case. We can always get some troponins, which look for any dead muscle from the heart. You were talking about some of your symptoms e some shortness of breath, getting a little bit worse when you take deeper breaths, which can make us concerned that maybe there's a pulmonary embolism coming from we talked about the veins in your legs when you're laying in bed for a while can cause basically blood clots, which can travel up to your lungs. SP: Oh, that's what the pulmonary embolism means? Student: Yeah, sorry. SP: It's okay. (continued on next page)

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26 Table 3 (continued ) Prototype

Y Y More collaborative

To obtain confirmation of the plan from the SN

D: Decision-making: Seeking Less collaborative Closed-ended, confirming Y proposed plan

Y

Open-ended, consultative to address questions/ Concerns

Y More collaborative

Open-ended, inviting input into plan

Representative excerpt Student: And, so we can e I know there was a prior study done e an ultrasound of her leg. Maybe we can repeat that. SN: Okay. Student: And see if we can get a better look. And, if another thing we can do is a D-dimer test to help rule that out if it's negative. SN: Okay. Yeah, those all sound very reasonable. If you'd like to place those orders, we can have a resident or intern co-sign. Student: Okay, okay. So we've talked about the Heparin. And then the last thing is on sending some labs, troponins to be able to see if this is actually a cardiac thing going on, although the EKG is a bit less concerning right now. SN: I was going to recommend labs. That's a very good idea. You know you will need to place the order for that as well as the repeat EKG and just get your resident to co-sign it. Student: Okay, it sounds great. Okay, well thank you for letting me know about the heparin and for getting this EKG. Is there anything else that you wanted to check on while I'm here. SN: What specifically more do you need from me? Student: Let's see, so we're going to, we're going to monitor you. We're going to monitor the vital signs more frequently. We're going to start heparin. We're going to have the ultrasound order, repeat EKG, order some labs, recheck the O2 sat. What else? Is there anything else that you wanted to add to that plan? SN: No. Just, you know I agree with your plan about the labs and repeat EKG. Sounds like a good plan. Student: Actually, something that I maybe should have done a little earlier is I'll go ahead and let my senior supervisor know what is going on with you and we'll come back and evaluate you together. Does that sound okay? SP: Okay Student: Does that sounds okay to you? SN: It does. Student: Good. Student: Okay? All right. Is there anything else that you think that I've maybe might have missed, or -? SN: I can't think of anything. So you'll go ahead and order the nitro, the aspirin, and the morphine all at once and get that co-signed, right? Student: Mm-hmm. Student: What do you think about repeating kind of the ultrasound of the lower extremities? SN: That sounds reasonable. Student: Yeah? Do you have any other questions or thoughts or suggestions? SN: Well, my concern is Ms. Lyons' heart; I would have suggested a full set of labs e cardiac enzymes. Student: Okay. I definitely think that's a great idea. Do you mind if I kind of meet with the team first and we look at the chest x-ray, and then we'll just decide which should be within the next hour. We should be meeting just shortly. SN: Yeah, just let me know. Student: Does that sound like a good plan? SN: Mm-hmm.

generalize to other students or learners at other points in training. This study was conducted in the context of a high stakes OSCE, and students may communicate differently in the workplace. Additionally, our study employed an actor trained to portray a SN; despite careful role development and actor training, the SN may have behaved differently than some actual nurses. As we only examined interactions between medical students and SNs, our model may not be generalizable to interactions with other health professionals. We did not evaluate non-verbal communication. Using the SN checklist's ‘overall satisfaction’ item to organize the findings has important advantages and disadvantages. It is intended to represent the “nurse's” opinion about working with the student, and is therefore serves to triangulate our data. However, it may not fully measure the satisfaction that an actual nurse would have derived. Additionally, it may capture other things the student did/did not do apart from collaboration. The literature review was limited to PubMed and may have failed to identify relevant research present in other databases such as CINAHL. Finally, our findings may have been biased by the researchers' prior experiences and interpretations of the literature and data, which threatens the validity of the framework. The strengths of this study include the development and testing of a conceptual framework for ICC that incorporates key constructs identified through theoretical and empirical research; our rigorous approach included refinement by an interprofessional practice expert,

endorsement by nursing professionals, and application to the study of student encounters. Conclusions This study provides evidence that a newly developed framework of ICC is a useful lens through which to examine ICC, particularly in early medical learners with developing interprofessional communication skills. Our findings demonstrate the applicability of this method of measuring students' ICC, and provide evidence that medical students do engage in ICC. Our findings can therefore be useful to medical educators studying ICC. Next steps should include further testing and refinement of the conceptual framework, and gathering evidence of validity for this approach to assessment. This study may also serve as a useful needs assessment for educators planning to develop curricula around interprofessional communication for medical students and other health professions trainees, by providing support for the importance of ICC, as well as evidence that medical students are engaging in this important skill that can be measured. Acknowledgements The authors would like to thank Scott Reeves, PhD for his consultation in the development of the conceptual framework on

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collaborative communication. Additionally, we are grateful to the nurses who participated in the study focus group. Appendix A. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.xjep.2017.02.003. References 1. National Research Council. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000. 2. National Research Council. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001. 3. National Research Council. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 2003. 4. World Health Organization (WHO). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: World Health Organization; 2010. http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf. Accessed 15 March 2012. 5. Baggs JG, Schmitt MH. Collaboration between nurses and physicians. Image J Nurs Scholarsh. 1988;20:145e149. 6. Henneman EA, Lee JL, Cohen JI. Collaboration: a concept analysis. J Adv Nurs. 1995;21:103e109. 7. Suter E, Arndt J, Arthur N, Parboosingh J, Taylor E, Deutschlander S. Role understanding and effective communication as core competencies for collaborative practice. J Interprofessional Care. 2009;23(1):41e51. 8. D’Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu M-D. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care. 2005;S1:116e131. 9. Petri L. Concept analysis of interdisciplinary collaboration. Nurs Forum. 2010;45(2):73e82.

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