Background
Preparation for Interprofessional collaborative practice
Interprofessional collaborative practice and COVID-19
Methods
Research design
Participants and setting
Agency | Type of Agency | Graduate Students | Method of Service Delivery | Impact of COVID-19 | Level of Integration |
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Agency 1 (Federally Qualified Health Center [FQHC]) | Integrated primary care with behavioral health practitioners (BHPs) delivering mental health services. | Social Work, Psychiatric Nurse Practitioner, Rehabilitation Counseling | In-person till March 19, 2020. | Students continued to see patients remotely. | Agency is fully integrated. PCPs did not always refer patients to students. |
Agency 2 (FQHC) | Integrated primary care with BHPs delivering mental health services. | Social Work, Psychiatric Nurse Practitioner, Rehabilitation Counselor | In-person till March 20, 2020. | Students continued to see patients both in-person and remotely. | Agency is fully integrated. Agency supervision sometimes lacking. |
Agency 3 (FQHC) | Integrated primary care with BHPs delivering mental health services. | Social Work, Psychiatric Nurse Practitioner, Family Nurse Practitioner | In-person till March 20, 2020. | Students provided a limited number of services remotely. | Agency is fully integrated. But students did not always have opportunities for working directly with PCPs. |
Agency 4 (Community clinic) | Integrated primary care with BHPs delivering mental health services. | Social Work, Psychiatric Nurse Practitioner, Rehabilitation Counselor, and Family Nurse Practitioner | In-person till March 20, 2020. | Students had option to provide services remotely. Agency closed in May 2020 due to COVID-19 for summer. | Early stages of integration. Students had many opportunities for providing group therapy but not individual sessions. |
Agency 5 (Community clinic) | Integrated primary care agency with drop-in center for homeless population. Offers mental health and psychosocial support. Also serves individuals with HIV. | Social Work, Rehabilitation Counseling, Psychiatric Nurse Practitioner | In-person till March 20, 2020. | Students provided a limited number of services remotely. | Agency is working toward becoming fully integrated. Students had limited opportunities for collaboration. |
Agency 6 (Community clinic) | Integrated primary care with behavioral health specialist delivering mental health services. | Social Work, Psychiatric Nurse Practitioner, Rehabilitation Counseling | In-person till March 20, 2019. | Students provided a limited number of services remotely. Clinical supervisor was reassigned, so students had to terminate with patients early. | Agency is fully integrated. Also a training facility for other mental health professionals. Thus, patient flow was limited. |
Data collection and analysis
Ethical considerations
Strategies to ensure rigor and trustworthiness
Results
“You just really have to assert yourself:” encountering difficulties acclimating to the agency and the interprofessional model
Student participants described that part of the reason why they had little to do was because PCPs and other staff members were not always willing to engage with them. As SW Student 5 remarked:Social Work (SW) Student 1: …It is funny because I taught a group [on] social skills. We talked a lot about assertiveness and, like, I know to preach it, but I don't know how to role model it … you know, the staff [at the agency] … have heavy caseloads, and they're dealing with … crises and things going on with their clients that I'm like, you just really have to assert yourself into the position or else like you're just going to be sitting in the room at the seat just like talking to random clients …
In addition to finding ways to stay involved in the work flow of the agencies, student participants reported having to acclimate to a new way of providing mental health services. More specifically, they had to move away from practicing psychotherapy or counseling as they would in an outpatient mental health setting to conducting brief sessions in the integrated care setting. As two participants explained:I don't know if the doctors fully knew why we were there and what we were doing. Like I think it would have been helpful to have a, you know, like a meeting … to introduce us. To say, … this is what they are there for; this is integrated care.
Rehabilitation Counseling (RC) Student 2: … I'm used to more of behavioral health. So, I'm used to, you know, 45-minute sessions, I'm used to, you know, getting as much information from the client as possible. I think, for me, it was adapting to the integrated care setting and shortened sessions and also working with, you know, two other people on my team. I think that was the biggest adjustment for me.
According to most student participants, acclimating to the agency became more difficult because of the lack of agency administrative supervision, making it more challenging to deal with not having enough to do or not being properly trained on using the electronic medical record. Clinical faculty instructors were hired to advocate for the students while they were at the agencies, and there were times where this helped the adjustment process:Nursing Student (NS) 3: … The background I came from … [I] like [to] see [the] patient by myself and taking maybe 45 minutes to assist them and to do the psych [evaluation] … but now having to have everybody coming [in the room to see the patient] … it was like a little [hard] for me at the beginning to really understand …
However, clinical faculty participants did not always have enough time to deal with these issues. As one clinical instructor participant pointed out:RC Instructor 2: I thought it was great. I just had to advocate a little bit in the beginning to make sure like they knew what my … interns were there for and what their role would be. But that was just like, you know, the first week and then they were like, having them work right away.
Although most student participants reported that they needed more guidance in the beginning of their experience, they reported figuring out ways to make things work for them:Nursing Instructor 2: I sometimes thought that I also ran out of time … we would be in the middle of something and the students might get called away for, for some patients, you know, interaction. … so when we were together, sometimes, you know, if we were running out of time, or the students were called away, you know, sometimes I felt that that was a little bit of a challenge.
NP Student 5: We did a lot of planning. So, we, when we were adjusting to not really having guidance, with a new [electronic medical record], we were able to figure out a way to route list of the schedules for the providers. So, we used that schedule and we would just kind of go through each chart and search for any indication that the patient has a history that needs to be addressed.
Learning to facilitate team cohesion by engaging in interprofessional communication and learning from others
Student participants viewed interprofessional communication as essential for helping them develop mutual respect for one another:We literally communicated and said … do you feel comfortable doing this? Do you feel more comfortable doing that [given that the patient] has this diagnosis … we just … made sure we were comfortable with whoever we were seeing. And if we weren't, then we brought, you know, an extra person in or the other, you know, all three of us would go in together.
In addition to developing their interpersonal communication skills, student participants acknowledged that learning from their team members also facilitated group cohesion. RC Student 2 provided an example, detailing what occurred after one of the PCPs contacted the team to inform them that a patient needed mental health services:SW Student 2: … I think communication is the biggest piece of it … we will ask each other questions. We weren't afraid to say, when we didn't know something and we also respected the fact that we can have expertise.
SW Student 4 echoed this perspective:[The] SW Student would go, and I … can also chime in and bring in some counseling skills or you know, even vocational because that's a huge thing too, in rehab counseling. And then DNP Nurse Practitioner Student would go over like medications … so like I think we each brought a little bit of our own, like disciplinary and our own learning. And I think we brought it to the table and it kind of just … meshed really well actually.
Learning was not limited to student participants just learning from one another. The clinical faculty reported that they also gained insight from their clinical faculty colleagues during the group supervision that they had with the project directors of the program. As two clinical faculty members mentioned:… It gave me a chance to understand different aspects of, you know, working with different professionals … I didn't know much of anything about rehab counseling before …. and getting to learn about, you know, what they do and … how they can be useful to me in the future with other clients that I might have ….
Nursing Instructor 1: I would agree it was very helpful to just hear what other people were doing at the same time that I was trying to do it. And I felt like I knew what was coming up next. I thought it was really important.
Nursing Instructor 2: I also thought it was really helpful, particularly hearing the experiences that others were having that that was really helpful for me.
Contending with role confusion and missed opportunities for interprofessional collaboration
In addition to experiencing challenges with agency staff members, student participants had difficulties differentiating the roles and responsibilities of each student team member. In fact, role confusion was common when it came to social work and rehabilitation counseling students at the start of the experience, as their jobs overlapped. Both were both able to provide psychosocial assessments, brief counseling, and refer patients to resources in the community. As one student participant expressed:But that's something that [my preceptors] need … to know, that, okay, it's not just about being inside the office, even though it is very important [for] a medical APN to learn [this] stuff, but [I] also need to be [able] to integrate.
Another student participant expressed a similar sentiment but was also concerned that there could be role confusion with the psychiatric nurse practitioner, too:SW Student 3: … I can see that [it] might get, you know, awkward if there is a social work student and a rehab counselor student who both want to do everything and want to do one aspect and not the other or so on.
At the same time, this participant also mentioned that this issue was easy to deal with, especially as time went on: “And then when it actually was put into play, it was just so cohesive. I think between the three of us at least.”RC Student 2: I think a lot of it for me was; we all have mental health backgrounds. And I think so much of it is like, well, we can all kind of do so many similar things. That it was like, well, what am I going to do? What is she going to do? What am I going to do? Like, I think so much of that was my worry.
Interviewer: Did you ever get an opportunity to work together on a patient …?
Student participants also mentioned they were concerned that seeing patients as a team might overwhelm them. As a result, they sometimes chose to function independently or to exclude one member of the team when meeting with the patient. As NP Student 8 stated:RC Student 5: Only once … and that's the one time I felt like people are getting together and trying to figure out a way to help the patient on a regular or routine basis … I do not think we ever like sat down and talked about the same patient.
It was expected that student concerns related to functioning as an interprofessional team would be addressed in weekly supervision. Although it was evident from the clinical faculty participants that this supervision enhanced students’ clinical skills, its benefits on ICP seemed less apparent. As a result, student participants could sometimes be left with missed opportunities for interprofessional collaboration. RC Instructor 2 remarked:I did expect it to be more of a team approach but from when we … had our patient simulation, and we all went in together and we found that that was overwhelming to the patient. I think we took from the experience that we did not need to team up to go in.
Sometimes I wish they asked me for more help. They were just so like strong in their own like skills. And, you know, the staff would ask them for advice sometimes, which was nice to see them asking interns for help, and for their input on client cases, but mostly they would ask me for help with counseling skills. So. like motivational interviewing, CBT. So we would do a lot of like, psycho education … [and] helping them with their counseling skills.
Managing the impacts of COVID-19 on interprofessional learning: uncertainty, frustration, and disappointment
This participant in particular still had to see patients in-person, even though social work and rehabilitation counseling students were prohibited from providing in-person services. An arrangement such as this one clearly prohibited an interprofessional team approach:… We were really making progress… like I remember the first Monday, when the pandemic was when things started shutting down. I had like six patients scheduled for me to see and then and I think I only saw one that day because people were not coming.
As student participants reflected on the experience, they expressed that much disappointment was caused by not being to terminate with patients as they would have if the pandemic had not occurred. As RC Student 1 stated:NP Student 5: [It] was difficult because I had to be their roles in a sense, because they were not readily available. And then if I needed anybody, it would be after the fact, you know.
At the same time, student participants expressed that they were dealing with their own personal issues related to the pandemic, while trying to manage their educational and field work experience. This led to some questioning whether they should be helping patients during this time. For instance, SW Student 5 explained:... That was kind of the biggest … disappointment for me … and then not even being able to, like do telehealth or, you know, communicate with your clients. I think that, for me was the biggest struggle because we're so used to, you know, at least in counseling, we're so used to, you know, terminate effectively and with enough time and this and that, and with a pandemic kind of, really didn't give us a chance to do that, unfortunately.
The effects of the pandemic could be even harder to manage when student participants were providing childcare. As RC Student 3 expressed: “… With all the stress and especially with my daughter being all the time like on top of me, I felt … I was not productive in helping other people.” Given the stress and anxiety that was coming up for students during the pandemic, clinical instructor participants expressed that they had to take on a counseling role:It was stressful because we were I felt like I was also dealing with my own anxiety during the whole thing and trying to talk to but I, it was for me it was a little bit stressful, but as I got more into it, it became it was helpful and I thought like patients appreciated it and I was able to help patients. So, in that aspect, it was good.
Similar to Counseling Instructor 2, others felt the need to be flexible since the student participants were dealing with high levels of stress at the beginning of the COVID-19 pandemic. There were situations when the clinical instructors did not even know how to respond to students, given how uncertain things were are the time. Thus, much of the time was spent listening and providing them with an opportunity to share their feelings and concerns. As RC Instructor 1 indicated:RC Instructor 2: I mean, one student couldn't graduate on time, so they're like a lot of tears. One lost a family member during the Coronavirus. So just being there for them really just showing empathy and you know, extending those hours just text me or call me whenever you need me.
All opportunities for learning were not lost during the pandemic, however. Four student participant teams ended up using telehealth to see patients, enabling them to provide continuity of care and continue supporting one another. As RC Student 6 commented, “[we leaned] on each other as coworkers more because, you know, no one had experienced anything like this before.” The use of telehealth also allowed these student participants to keep learning from one another. It also helped them to feel less alone when working with patients they were worried about:I definitely had a lot of one-to-one conversations with students … a lot of just hearing how they were doing and how they are feeling. And, you know, not being able to provide them with any answers as to what was going to happen. That often came up, people would often come to me looking for answers … so, you know, was really mostly about processing what they were going through. And there was a lot of emotions during that time. Yeah. So that is mostly what we did. We did a lot of zoom meetings. And, like the other [participant] said, being flexible.
NP Student 8: …. I shared [my concern] with the MSW SW Student, RC Student, and [my clinical supervisor] gave me great feedback on how good of a job I actually did, even though I was kind of beating myself up because it was telehealth … so, I did the best that I could.
Discussion
Implications for Interprofessional collaborative practice
Themes | Implications for Educators, Clinical Faculty, and Agency Supervisors Working to Improve Interprofessional Learning at Clinical Agencies |
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Encountering difficulties acclimating to the agency and interprofessional model | • Educate primary care providers (PCPs) about the purpose of the interprofessional team (i.e., to assist patients struggling with mental health and psychosocial problems) and the benefits of interprofessional collaborative practice (ICP). • Provide student opportunities for meeting PCPs and other agency staff members who can serve as referral sources. • Delineate student responsibilities and assignments from the outset, including whether students will have access to the electronic medical record. • Advocate for students to agency personnel, so they have patient contacts on a daily basis and engage in team-based learning regularly. • Bolster student confidence in their ability to transition from conducting typical 45-min psychotherapy sessions to brief, targeted counseling sessions. |
Learning to facilitate team cohesion by engaging in interprofessional communication and learning from others | • Emphasize the importance of having student teams engage in warm handoffs and huddles even in agencies where full integration does not exist. • Model effective interprofessional communication skills for students regardless of the agency’s level of integration. • Highlight the role of interpersonal communication in facilitating team cohesion. • Provide opportunities for educators, clinical faculty, and agency supervisors to process their experiences with student teams as a method for improving interprofessional learning as a whole. |
Contending with role confusion and missed opportunities for interprofessional collaboration | • Work closely with agency supervisors to orient students, so they clearly understand their professional role within the agency. • Normalize role confusion and help students understand how their roles are similar and different. • Train student teams members to recognize and address the communication barriers preventing the team from functioning properly. • Encourage students to engage in interprofessional communication and integrated treatment planning even in situations where only one student sees the patient. • Conduct weekly meetings with students to identify team strengths and solutions for addressing communication barriers. |
Managing the impacts of COVID-19 on interprofessional learning: Uncertainty, frustration and disappointment | • Help students anticipate the impact of a potential public health emergency on patient care and team-based patient care. • Develop a contingency plan that allows for students to quickly transition from providing sessions in-person to virtually. • Devote significant amount of time to teaching students how to incorporate ICP strategies in virtual environments. • Ensure there is a self-care or wellness component incorporated into student training that prepares them to manage the emotional effects of practicing during a public health emergency. |