Running head: DEVELOPING TEAM SKILLS AND ATTITUDES

Developing Team Skills and Attitudes through Interprofessional Leadership Competencies
Heidi Sanborn
Arizona State University

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Abstract
The health care industry increasingly recognizes interprofessional collaboration (IPC) as
the key to optimizing delivery of care, and interprofessional education (IPE) has been the
foundational method for building IPC. When IPC is examined, leadership skills of the
practitioners are often seen as a positive force for optimizing team performance. This project
aimed to deliver an education session sharing interprofessional leadership (IPL) competencies
and the effect they may have on attitudes toward IPC. A pilot was designed for a single site, a
student run clinic in a large city in the Southwest United States, which serves as a learning
laboratory to help future health practitioners grow IPC skills through effective and innovative
IPE. A search of the available evidence supporting this project revealed that educational
activities delivered to practitioners can build the leadership skills seen in effective IPC. During
the Fall 2017 semester, the education sessions were delivered to student practitioners at the clinic
during their semester-long rotation. The University of the West of England Interprofessional
Questionnaire, designed to measure self-assessment of attitudes toward collaborative learning
and collaborative working, was deployed at the beginning and end of a semester-long rotation to
all students working at the clinic to look for changes. A low sample size limited results to
assessment of clinical significance, but showed some changes that could be significant if the
project continues. Clinically significant changes show an increase in students’ rating of their own
skills and preferences toward interprofessional practice. In keeping with the learning laboratory
model at the clinic, these outcomes support continued delivery and examination of the education
model with subsequent clinic rotations to strengthen the conclusions being drawn from the
results.

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Interprofessional Leadership: Minding the Gap between Education and Practice
Since the introduction of the interprofessional education (IPE) core competencies
(Interprofessional Education Collaborative Expert Panel [IECEP], 2011) and subsequent update
incorporating interprofessional collaboration (IPC; Interprofessional Education Collaborative
[IEC], 2016), the interprofessional community has worked to bridge the gap between IPE and
IPC to ensure accessible and efficient population-focused care. This gap is a primary focus of an
interprofessional practice, education, and research center within a large public research
university in the Southwestern United States (the Center). It is also one of two major goals in a
grant from the National Center for Interprofessional Practice and Education (National Center)
titled Interprofessional by Design™: Meeting at the Crossroads to Accelerate Leadership
Competency and Readiness for Transition to Interprofessional Practice awarded to the Center.
This part of the grant aims to provide innovative leadership training integrated with the core
competencies (IEC, 2016) to health profession students at a student run clinic in a large city in
the Southwest United States (the clinic). Students who complete experiences in this clinic are
introduced to skills that have been demonstrated to help interprofessional teams meet the Triple
Aim of improving population health, value, and the experience of health care (Institute for
Healthcare Improvement [IHI], 2016). There is a growing body of evidence supporting the
impact IPE has on clinical practice (Reeves, Perrier, Goldman, Freeth & Zwarenstein, 2013) with
recent studies exploring strategies for teaching and applying these skills in the clinical setting
(Gordon, Rees, Ker, and Cleland, 2016; Margolis, Rosenberg, Umble, & Chewning, 2013).
Examined summarily, the evidence indicates that inclusion of leadership skills training within
IPE will help close the gap between the classroom and clinical practice.
Background and Significance

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Epidemiology
The health care industry has long sought to educate future practitioners to provide
efficient and safe patient care. Despite this focus, practitioners from all disciplines experience
lack of coordination, collaboration and communication leading to medication errors (Institute of
Medicine [IOM], 2000; IOM, 2007), inefficiencies in patient care (IOM, 2001; Williams et al.,
2007), and poor clinical outcomes (Freeth, Ayida, Berridge, Sadler, & Strachan, 2006;
Kvarnström, 2008; Reeves, 2016; World Health Organization [WHO], 2010). One solution has
been the adoption of IPE that is defined as students from two or more disciplines learning from,
about, and with each other (WHO, 2010). In 2012, a public-private partnership between the
Health Resources and Services Administration, the United States Department of Health and
Human Services, The University of Minnesota, and several private foundations led to creation of
the National Center to advance both IPE and IPC (National Center for Interprofessional Practice
and Education, 2017). The National Center has become the place where education and practice
leaders have come together to share ideas, promote research, and develop innovative practices to
meet the Triple Aim goals of improving the patient experience, health of populations, and per
capita cost of health care (IHI, 2016). Continued work is needed to establish a firm link between
IPE and improved patient outcomes (IOM, 2015; Reeves et al., 2013), but one proposed solution
is teaching leadership competencies to help future practitioners guide interprofessional teams
more effectively (Margolis et al., 2013).
Shifting Focus
Current research has focused on the characteristics of IPE delivery to determine the
effectiveness of the timing, setting, and educational outcomes (IOM, 2015). A search of evidence
shows little work has been done to teach clinicians leadership skills consistent with

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interprofessional competencies to better prepare them for transition to interprofessional practice
(IPP). Traditionally, leadership is considered a business skill, and health care professionals are
beginning to focus on leadership competencies as an essential component of successful clinical
practice (Heckman et al., 2014; Kanste, Halme, & Perälä, 2016; Lawrence, & Whyte, 2012;
Levy, Gentry, & Klesges, 2015). More recent work shows that leadership theory is increasingly
invoked to guide health care delivery models (Brewer, Flavell, Trede, & Smith, 2016). This shift
should compel health care educators to continue closing the gap through teaching application of
leadership skills to the interprofessional practitioner. Incorporation of this growing focus on
leadership in the clinical setting provides a strong foundation to inform the work at the clinic as
part of the ongoing focus on IPE and IPC.
Interprofessional Education
IPE is not a new concept; it has been an increasing focus of innovative health education
for many decades (Reeves, 2016). A renewed call to action in 2000 championed IPE as a viable
solution to the fragmentation of global health care delivery. The end goal is to “better utilize
interprofessional education and collaborative practice strategies to strengthen health system
performance and improve health outcomes” (WHO, 2010, p. 14) as displayed in Figure 1. To
meet this challenge, the evidence provides guidance on how best to design and implement IPE.
IPE addresses the complex nature of health care delivery, fostering collaboration as a cornerstone
to promoting coordinated care (Reeves, 2016; IOM, 2013). Many efforts in IPE have
incorporated the nationally-adopted Interprofessional Education Collaborative (IPEC) core
competency domains of values and ethics, roles and responsibilities, communication, teams and
teamwork (IECEP, 2011) and collaboration (IEC, 2016). These competencies serve as an
important guide for developing meaningful IPE; but the evidence also supports teaching health

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profession students to drive collaborative care by incorporating team leadership competencies.

Figure 1. The relationship between interprofessional education and collaboration (WHO, 2010)
Leadership Competencies
Leadership skills are readily identifiable, and many industries have embraced them to
help guide educators and practitioners alike. The literature shows consistent leadership behaviors
across cultures (Posner, 2013) and similar competencies among diverse professions including
nursing, social work, public health, and business with common themes of open communication,
ethical behavior, client/community relations and advocacy, influence, and flexibility (American
Organization of Nurse Executives [AONE], 2015; Giles, 2016; Wimpfheimer, 2004; Wright et
al., 2000). These competencies are mirrored in studies identifying characteristics of
interprofessional teamwork (Nancarrow et al., 2013), supporting the importance of leadership
competencies within the overarching topic of IPC. In fact, there is increasing agreement that
leadership education can build interprofessional skill in the clinical setting (Senn, 2014; Willems
et al., 2013; Wright et al., 2000) which highlights a need to define and deliver the knowledge,
skills, and attitudes necessary for leadership competence through IPE experiences.

DEVELOPING TEAM SKILLS AND ATTITUDES
Internal Evidence
The clinic is used to train health profession students through a student-run, IPP model.
Current IPE at the clinic focuses on the clinical skills of an interprofessional team rather than
team leadership competencies of the individual practitioner. As such, students are not
intentionally prepared to embody known leadership skills that align with interprofessional
competencies, both which espouse themes of effective communication, respect for other
disciplines, building team consensus, and honoring the values of others (AONE, 2015; Giles,
2016; IECEP, 2011, MCH Leadership Competencies Workgroup, 2009; Wimpfheimer, 2004).
These leadership skills are needed so future practitioners can guide interprofessional teams to
effectively collaborate (Pittenger, Fierke, Kostka, & Jardine, 2016; Reeves et al., 2013). This
aims to improve clinical outcomes, thereby meeting the Triple Aim goals of improving the
patient experience, health of populations, and per capita cost of health care (IHI, 2016). This
project will support the development of leadership training for students at the clinic to meet this
gap in IPL education.
Problem Statement
Efforts to fully understand the influence of leadership-focused IPE on IPC led to
development of the PICOT question, “how does teaching health discipline students at a student
run clinic (P) interprofessional leadership competencies (I) compared to the existing
interprofessional education model (C) affect leadership competencies (O)?” This clinical
question guided a systematic search of evidence to support leadership content within IPE. See
Appendix A for a flow diagram of how the literature search was conducted.
Search Strategy

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An exhaustive literature search was completed via PubMed, CINAHL, ProQuest, Web of
Science, Cochrane, and ABI/Inform databases. The target databases were chosen to examine
approaches to leadership education and IPP / IPC across the disciplines of nursing, medicine, and
business. The search used MeSH terms and keywords to capture all iterations of the main
concepts examined: education, interprofessional, competency, collaboration, health care, and
leadership. Terms were expanded to include all known uses of these key terms to accommodate
for discipline-specific language. The search strategy was designed to capture evidence
supporting both leadership training regardless of industry, and interprofessional competency in
the health care arena regardless of discipline. Limits were placed on all searches to capture only
articles written in English. Because the link between efforts to build leadership competencies and
IPE is new, searches were also limited to studies published between January 1, 2012 to January
1, 2017 to further limit the yield.
Search Yields
The yields for each database search are displayed in Appendix A. The initial screening of
articles was done by a scan of the abstracts. The remaining articles were read in detail, including
an ancestry search of relevant reference articles. A total of 366 articles were reviewed during this
process, leading to the exclusion of 344 articles that were duplicates, or unrelated to the topic. A
rapid critical appraisal was conducted on the remaining 22 articles, which led to the final
selection of 10 studies to form the evidentiary base for this project.
Critical Appraisal and Synthesis of Evidence
Creating evidence-based innovation within the complex health care system relies on
changes often occurring along the outer edges of the available evidence (Lalley & Clouthier,
2017). Synthesizing research on effective IPE and leadership competencies involves chunking

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heterogeneous constructs to create new practice that exists between the foundations of evidence
and the upper reaches of innovation. Recommendations for practice change should rely equally
on real-world phenomena and research outcomes. This is certainly the case for this project,
which aims to merge the disparate concepts of leadership and IPE into one cohesive and
innovative context.
Analysis of data uncovered in the literature search for this project laid the foundation for
the project design. The supporting evidence was analyzed for level of evidence (Melnyk &
Fineout-Overholt, 2011), quality, rigor, project design, and outcomes, as displayed in the
synthesis table (Appendix B). The heterogeneity of studies limits the degree of generalizability,
impacting both validity and reliability of the results. Despite the difficulties in analyzing
scientific consonance among the evidence, there are conclusions to be drawn that support the
direction of leadership-focused IPE. Many studies (88.9%) focused on a practitioner population,
providing a good fit with the intent to develop leadership training for student practitioners at the
clinic. In addition, most studies (89.3%) incorporated an interprofessional mix of learners in the
interventions. Another important similarity among studies is that IPE was articulated most
commonly as didactic instruction (82.1%) rather than experiential (25.0%), although some
programs used a combination of both (10.7%). This indicates that IPE is most easily delivered
using classroom-based learning in the form of focus groups, workshops, or case-based exercises.
The evidence also provides direction on the outcomes of IPE that could guide the aims
for an intervention at the clinic. Measurement focused more on patient or clinical outcomes
(60.7%) with a less common emphasis on team or practitioner competencies (39.3%). Specific
phenomena of interest within the studies include leadership (21.4%), communication (14.3%),
IPP / IPC (57.1%), teamwork (25.0%), and emotional intelligence (3.6%). Although IPP and IPC

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are broad concepts, these outcomes focused on the overarching theme of effective collaboration
by an interprofessional team.
A final analysis of the evidence includes an assessment of the feasibility of replication of
the study, as well as overall goodness of fit for the clinic environment. Most of the studies would
be replicable in future interventions (89.3%). However, this did not necessarily correlate with a
determination of goodness of fit for the clinic (32.1%). This was based on author judgments
regarding environmental characteristics, student practitioner availability, and scheduling
limitations, all of which must be met to best fit the existing IPE model of the clinic.
Conclusion and Discussion of Findings
Despite the heterogeneity of the studies, synthesis of the data provided guidance on how
best to structure leadership-based IPE at the clinic. The body of evidence shows that IPE is most
often directed at practitioners using a didactic modality of teaching (Gaskell & Beaton, 2015;
Margolis et al., 2013; Nancarrow et al., 2013; Reeves et al., 2013; Shanta & Gargiulo, 2014;
Sunderji, Waddell, Gupta, Soklaridis, & Steinberg, 2016; Willems et al., 2013; Zwarenstein,
Goldman, & Reeves, 2009), which would be a good fit for future IPE design for the students at
the clinic. In addition, the study outcomes were predominately focused on the individual
competency of the practitioner rather than patient outcomes (Gaskell & Beaton, 2015; Gordon et
al., 2016, Margolis et al., 2013; Nancarrow et al., 2013; Nicksa, Anderson, Fidler, & Stewart,
2015; Reeves et al., 2013; Shanta & Gargiulo, 2014; Sunderji et al., 2016; Willems et al., 2013).
This highlights a need to design future programs that can verify a more explicit link between IPE
and clinical outcome data, which is a well-known gap in IPE research (Reeves et al., 2013).
When examined summarily, the included evidence and synthesis supports the project, which was
designed to develop and deliver leadership-focused IPE education at the clinic.

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The most frequent outcome of interest that supported this project is practitioner attitudes
toward collaborative working and learning (Gaskell & Beaton, 2015; Gordon et al., 2016,
Margolis et al., 2013; Nancarrow et al., 2013; Nicksa et al., 2015; Reeves et al., 2013; Shanta &
Gargiulo, 2014; Sunderji et al., 2016; Willems et al., 2013). The synthesis of evidence across
health and business disciplines supports providing education to interprofessional practitioners to
develop the leadership skills needed to positively impact IPC. By delivering an educational
program grounded in the literature and resulting evidence synthesis, and measuring changes in
attitudes using a self-assessment tool with significant validity and reliability data, the results of
the project will help guide the dissemination of this innovative educational model to other
clinical sites and IPE offerings at stakeholder organizations. The outcome of this project
highlighted the impact of a new IPE module that explored leadership skills within the context of
IPP and IPC. The implication of this work was the creation of innovative practice that resides
upon the foundations of evidence.
Purpose Statement
Education at the clinic currently does not include any learning material explaining either
interprofessional or leadership competencies. This is an intentional gap so that students would
enter the clinic without any outside influences on their innate practice style. This has led to
students naturally sharing team leadership based on the experiences they have with patients at the
clinic. While this strategy has allowed IPL to evolve, there is no unifying structure to ensure that
students understand how their behaviors meet these competencies. This project took place at the
student-run clinic which was founded upon an interprofessional philosophy. The student-run
model has been shown to be an effective vehicle for improving care delivery and outcomes
(Liberman et al., 2011; Meah, Smith, & Thomas, 2009), and enhancing the experience to

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incorporate IPL competencies will add to the learning that already occurs.
Guiding Theory
Evidence Based Practice Model Guiding Project Design
The Iowa Model (Sanares-Carrean & Heliker, 2017; Titler, 2010) is effective for change
projects in large, complex systems, featuring key decision points that move from problem
identification through monitoring outcomes and dissemination of results (see Appendix C). The
articulation of this project closely followed the key milestones within the Iowa Model.
Implementation of the innovative IPE design began with the identification of both
knowledge- and problem-focused triggers with the clinic. Due to the changing focus within the
IPE realm to include leadership competencies, this project was a priority for the clinic leadership
and the clinic stakeholders, leading to broad support for this project. The Iowa model includes
identification of the stakeholder team (Sanares-Carrean & Heliker, 2017), relying on a
multidisciplinary team approach to improving health outcomes (Titler, 2010). The model guides
change at both the system and individual level (Bondmass, 2014). For this project, the
stakeholders included education, community, organizational, and national partners (Figure 2), all
of whom were increasingly aware of the gap between IPP and IPL. The next steps in the model
were accomplished with the systematic search of evidence, and synthesis and critique of the
relevant data. The model also guided definition of the project outcomes, collection of existing
benchmark data, creation of the EBP guidelines for the IPE design, implementation of a pilot of
the new IPL learning module, and evaluation of both the process and outcomes. Outcomes will
provide the basis to modify existing IPE guidelines, guiding full implementation of the new
practice at all sister clinics and partner sites.

DEVELOPING TEAM SKILLS AND ATTITUDES

Education
Partners
• Three large
Southwestern
universities
•Nursing
•Social work
•Physical therapy
•Medicine
•Speech therapy
•Occupational
therapy
•Health innovation

Community
Partners
• Student-run
clinic site
•Urban campus
•Provides care for
homeless and
substance use
disorders

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Organizational
Partners
• University-based
interprofessional
practice,
education, and
research center
• Sate action
coalition

National Partners
• National Center
for
Interprofesional
Practice and
Education
• Robert Wood
Johnson
Foundation
• The John A.
Hartford
Foundation
• Gordon and
Betty Moore
Foundation

Figure 2. Project stakeholders
Theoretical Model Guiding Intervention
Avedis Donabedian, a pioneer of quality issues within healthcare (Anderson, 2015), has
been influential to the improvement of health services through a focus on quality of care
delivery. His work led to development of the Structure-Process-Outcome (SPO) Model
(Ayanian, & Markel, 2016) which was chosen as the theoretical framework for this project. The
SPO has served as the foundation for the Institute of Medicine reports, including the six aims for
improving quality as outlined in Crossing the Quality Chasm (Ayanian, & Markel, 2016). These
aims, including safety, effectiveness, and efficiency (IOM, 2001), are all directly related to how
well interprofessional teams work together through cooperation, transparency, and knowledgesharing (IOM, 2001). This focus on improving delivery of patient-centered care made this the
ideal theory for guiding the implementation of new, IPL-focused IPE at the clinic.

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According to Donabedian, quality improvement efforts should aim to find the most
efficient and valid processes that lead to optimal patient care. These processes are the goal of all
IPE experiences at the clinic, as they bring benefit to the patient and improve cost of care
delivery (Anderson, 2015, Donabedian, 2003). The SPO Model is a stepwise framework that
defines the characteristics of the setting (structure), an understanding of what will be done
(process), and how it will affect the patients (outcome). By identifying each of these
characteristics within the clinic, the theory helped articulate how an educational module could be
used to influence student attitudes toward collaborative practice that can improve patient
outcomes as students translate this knowledge into their future professional roles. This project
established an evidence-based lesson plan (process) for teaching IPL skills at the clinic
(structure) that can improve IPP / IPC (outcome).
Project Methods
The project implemented a new education session aimed at introducing students to both
interprofessional and leadership competencies based on available evidence. Student practitioner
groups rotate through the clinic every Saturday of each 16-week semester, with each of four
groups assigned four specific rotation dates. The education was delivered on the second of the
four rotation days at the clinic, from September 23 through October 14, 2017. The education
sessions were delivered during morning huddles, offering minimal interruption to the typical
schedule of the clinic operations. The benefits extend beyond the students to include
practitioners, student clinic leadership, and faculty preceptors, most of whom have never been
introduced to this content. By understanding the skills needed for effective IPL, faculty and
students will have the knowledge needed to adjust their practice, which can lead to improved IPC
and patient experiences.

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Ethical Considerations
A non-random sampling process was used to recruit students to participate in this project.
The project was approved through the academic Institutional Review Board (IRB), receiving
exempted status as an educational project (STUDY00006834). All students participating in a
clinic rotation during the Fall 2017 semester were sent an email by the clinic student leadership
team, which included a recruitment script and consent. Immediately prior to delivery of the
education, consents were obtained from those students willing to share their data with this study.
The education was delivered to all those present at the huddle, including student leaders and
preceptors, regardless if they provided consent.
Innovation Leadership
This project was facilitated through collaboration with many stakeholders. The student
leaders of the clinic supported the time needed to implement the project, providing the access
and communication structures needed to recruit student participants. The educational and
organizational partners also fully supported this project through sharing of data, access to
resources, and scholarly guidance and support to ensure the project met the needs of all
interested parties. The project is an articulation of innovation leadership concepts that provide
the framework for implementing change within a complex system. Specifically, this project
harnesses reflexivity; this concept speaks to the dynamic interplay between a clinician, the
surrounding environment, and the background evidence (Lalley & Clouthier, 2017). This project
was designed to help student practitioners build their own knowledge based on reflection of their
practice experiences and the literature supporting this project. This may lead to shifts in practice
that incorporate interprofessional leadership with the aim of influencing IPC.
Implementation

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The educational intervention was delivered during the morning huddles at the clinic,
which is located in a county-run homeless health clinic complex in an urban southwest location.
The clinic site was chosen not only for the student-led, learning laboratory model, but also for
the organizational philosophy supporting innovations in IPE. The education included a
discussion of both IPE and leadership competencies that came from the evidence in the literature
and the results of previous research based on student interviews conducted at the clinic. In
addition, students were asked to identify interprofessional leadership skills, and reflect on how
leadership competencies could impact their practice.
Data Collection
To assess whether this education model impacted self-assessment of interprofessional
collaboration, a paired pre- and post-test design using the University of the West of England
Interprofessional Questionnaire (UWE-IQ) survey tools (Appendix D) was used. The pre- and
post- surveys were administered to all students who participate in the semester-long clinic
rotation. The surveys are managed using REDCap electronic data capture tools. REDCap
(Research Electronic Data Capture) is a secure, web-based application designed to support data
capture for research studies (Harris et al, 2009).
The UWE-IQ survey tool began with construction of three scales aimed at measuring
attitudes of students toward collaborative learning (Pollard et al., 2004). The three scales were
developed using exploratory factor analysis, revealing a statement load > 0.35 to only one factor
with strong correlation with one another (Pollard et al., 2004; Pollard, Miers & Gilchrist, 2005).
The Communication and Teamwork Scale has 9 items that allows students to assess their own
communication and teamwork skills using a 4-point Likert scale; the Interprofessional Learning
Scale has 9 items exploring student attitudes toward interprofessional learning using a 5-point

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Likert scale; the Interprofessional Interaction Scale has 9 items for students to rate their
perceptions of interactions between various health professionals using a 5-point Likert scale. A
fourth Interprofessional Relationships Scale features 8 items assessing students’ perceptions of
their relationships with interprofessional colleagues using a 5-point Likert scale (Pollard et al.,
2005). Pearson’s correlations coefficients for scores on all scaled confirmed strong correlations,
and internal consistency was established with Cronbach’s alpha coefficients for all four scales:
Communication and Teamwork Scale (r = 0.78, P < 0.001, α = .76), Interprofessional Learning
Scale (r = 0.86, P < 0.001, α = .84), Interprofessional Interaction Scale (r = 0.77, P < 0.001, α =
.82), and Interprofessional Relationships Scale (r = 0.95, p < 0.001, α = .71).
Outcome Measures
Students already take the UWE-IW surveys at the beginning and end of the clinic
semester rotation as part of the learning laboratory model. The survey uses Likert Scale
questions, asking students to self-assess their attitudes toward interprofessional collaboration.
The items in the UWE-IQ survey contain ratings of the respondent’s values, judgements of
observed behaviors, preferences for specific practices, and skill statements where respondents
rate their own ability to exhibit interprofessional behavior. Examples of each type of item
include:
•

Learning with students from other health and social care professions is likely to
improve the service for patient/client (Value);

•

All members of health and social care professions have equal respect for each
discipline (Judgement);

•

I would enjoy the opportunity to learn with students from other health and social care
professions (Preference); and,

DEVELOPING TEAM SKILLS AND ATTITUDES
•

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I feel comfortable working in a group (Skill).

Project Costs
The cost to implement this project were minimal, requiring printing of materials,
purchase of materials (books) as resources for the project lead, and incentive gifts for
participants as approve by IRB. The project lead was granted a $1000 Scholarship Award
through the Sigma Theta Tau International Honor Society of Nursing. The project expenses were
specifically budgeted to stay within the award amount (see Table 1)
Table 1
Expenses Related to the Project Design, Implementation and Evaluation
Item
Books to guide the design,
implementation and
evaluation of the project

Details

Printing of materials used
during implementation of
education sessions

6 pages x 120 color copies ($0.42/page)

$302.40

Incentive gifts for
participants as approved by
IRB

• Food for four huddles
• Gift cards for student leaders

$392.16

• Qualitative research methods ($17.22)
• Statistics guides ($118.12)
• DNP project resources ($191.55)

Cost
$326.89

Total Cost $1,021.45
Outcomes and Results
The total number of students across four cohort groups assigned a clinic rotation was 87,
with 40 (45.9%) consenting to participate in this project (see Table 2). Of the 40 students who
consented, four (4) completed both the pre- and post-surveys that were used for analysis.
Inferential statistics were not run due to the small sample size, and statistically significant
changes in participant attitudes cannot be determined. However, the data was examined for
potential clinical significance and there are some conclusions that can be drawn from the data.
Table 2

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Composition of the project sample

Date
09/23/2017
09/30/2017
10/07/2017
10/14/2017

Cohort
group
A
B
C
D
Total

Total
Students in
Attendance
15
19
30
23
87

Students
Consented
to Project
11
7
14
8
40

Demographics
Of the four (4) students who completed the pre- and post- UWE-IQ surveys, all (100%)
were female, Caucasian, and native English-speaking. The students all attended a single
university, with only one (1) reporting their specific program of study: Speech and Language
Pathology. The students were a mix of undergraduate (75%) and graduate (25%), and were
evenly split between Hispanic/Latino (50%) and non-Hispanic/Latino (50%). The age of the
students were unevenly distributed across US Census age categories, with 75% falling in the 20
to 24 year-old category, and 25% in the 40-44 year-old category. While the small sample size
precludes any conclusions about the distribution of the sample, these demographics are in line
with similar characteristics of the nursing profession. The latest National Nursing Workforce
Study data shows the majority of working nurses to be female (85.9%) and Caucasian (80.5%;
National Council of State Boards of Nursing & The Forum of State Nursing Workforce Centers,
2015). Analogous workforce data does not exist for other health profession students so similar
comparison to this project sample could not be made.
Data Analysis and Clinical Significance
Data analysis was performed using IBM® SPSS® Statistics 23 software. The primary,
short-term study question was looking for changes in attitudes toward collaborative learning and
practice after implementation of the IPL competency learning module. Due to the low sample

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size, analysis was completed by calculating the standard deviations and comparing means of the
pre- and post- survey item responses (see Appendix E). If the difference in means was > 0.5, the
assumption by the project lead is that a larger sample size and inferential analysis of the paired
samples may show a significant change. Nine (9) items showed large changes in means between
pre- and post-evaluation. However, only three (3) items showed an increase in means (item 5 in
the Communication and Teamwork Scale, item 12 in the Interprofessional Learning Scale, and
item 34 in the Interprofessional Relationship scale). The remaining six (6) items showed a
decrease in means: item 1 in the Communication and Teamwork Scale; items 23 and 24 in
Interprofessional Interaction Scale; and items 30, 31 and 33 in the Interprofessional Relationship
Scale. The same method was used to compare the means for each of the four scales, which
showed no clinically significant shifts.
When looking at changes in means during the post-evaluation, it is important to consider
the meaning of the shift. For the three items that showed a clinically significant increase in mean
scores, the respondents were rating their own skills and preferences. Results showed that after
the experience, respondents felt more comfortable putting forward personal opinions (item 6),
have an increased preference for learning with peers from other professions (item 12), and have
increased confidence when working with other disciplines (item 34). The decreased mean scores
in the post test focused on both an assessment of skill, and judgement of observed behaviors.
After the rotation, respondents indicated they: felt less comfortable justifying their
recommendations face-to-face with more senior colleagues (item 1); have a reduced
understanding of the roles of difference professionals (item 30); and, are less confident in their
relationship with other disciplines (item 31). They also judged situations less positively,
indicating reduced confidence that: members of health professions have equal respect for each

DEVELOPING TEAM SKILLS AND ATTITUDES

21

discipline (item 23); it is easy to communicate openly with other disciplines (item 24); and they
feel respected by people from other disciplines (item 33).
The items with positive shifts highlight areas of growth that occurred during the clinic
rotation. In addition, the areas showing decreased scores after the rotation can guide the clinic
leadership and stakeholders when designing future learning activities for the rotation. There were
more items showing large drops in mean scores, but all significant changes offer opportunities
for deeper reflection. Negative changes in scores could be the result of students experiencing
IPP, and the barriers commonly associated with IPC, for the first time during the rotation.
Working with other disciplines and overcoming the challenges of power differentials between
disciplines can be difficult for novice practitioners to navigate. Despite this, the items with mean
increases indicate that the respondents viewed the experience as a positive one that has led to
growth in the skills and abilities necessary for effective IPC.
Discussion
Project Impact
This project was the first iteration of a new IPE experience that can be refined and
expanded over time. The intent of this pilot was to support the learning laboratory model through
the design and deployment of innovative learning opportunities that can have a collective impact
on longer-term outcomes aimed at improving IPP and IPC. This project examined changes in
student attitudes about collaboration. Over time, continued examination of outcomes and
refinement of the learning module can lead to lasting and positive changes to the student
experience at the clinic. These changes in attitudes can be carried forward with graduates into the
professional health care environment, helping to shift the health care culture to a more
cooperative approach to care delivery that has been shown to improve patient care outcomes.

DEVELOPING TEAM SKILLS AND ATTITUDES

22

Looking at the clinical significance of these results highlights some initial conclusions that can
help guide revisions to the learning module moving forward.
Project Sustainability
This project was designed through a strong collaboration between the project lead and the
education partner stakeholders. There is growing interest in ways to develop IPL competence as
part of the IPE experience at the clinic, and this project provided a starting point for this work.
The intention is that this project will continue to expand, sharing IPL competencies in a
meaningful way across a variety of student-run clinics and IPE venues. One strategy that has
been proposed is the development of an online learning module that could be deployed to
students as part of the clinic rotation without the need for dedicated faculty trained to deliver the
content consistently from semester to semester. The cost to develop an online module would be a
one-time expense paid using faculty workload that could have lasting impacts on student
learning moving forward.
Strengths
The project was designed to evaluate the effectiveness of a learning module to share the
newly created IPL competencies as part of the student rotation at the clinic. Because the clinic is
considered a learning laboratory, the leadership and faculty preceptors are always looking for
strategies to enhance student learning about IPP and IPC. Student practitioners, clinic leadership,
and faculty preceptors were receptive to the IPL competencies, and how they might influence
collaboration. While the number of participants was not sufficient to determine statistical
significance, the opportunity for students to reflect on their own leadership practice as a member
of the interprofessional team is an important first step to developing this competence.
Limitations

DEVELOPING TEAM SKILLS AND ATTITUDES

23

Limitations of this project included a small sample size, confounding factors within the
clinic environment, and known potential for inflation of self-scoring on pre-survey scores,
impacting the conclusions drawn about the data. The sample size of this initial project was
insufficient run inferential statistics to establish the efficacy of the intervention. The response
rate for students rotating through the clinic has been historically low for all evaluation tools in
use. This could be due to many reasons, including the multiple demands placed on students, and
survey fatigue due to the volume of surveys used both at the clinic and through the college
experience.
Because the IPL competency education was delivered as part of a 4-session, semesterlong clinical rotation, it is hard to isolate and one element of the experience for analysis of
effectiveness. The project was designed to enhance the existing experience but is not something
that can be disaggregated from the results given the chosen method of evaluation. It is the hope
of the clinic leadership and project lead that this will continue to evolve in coming semesters,
allowing for a more robust sample and statistical analysis of survey scores to continue to refine
the learning module over time.
In addition to the limited sample, there is another confounding factor that must be
considered when analyzing subjective data ranking interprofessional attitudes among students.
According to Levinson, Gordon, and Skeff (1990), pre-/post-evaluation of self-perceptions more
accurately reflects a change in understanding of the phenomena of interest rather than a shift in
knowledge or attitudes of the subject completing the evaluation. Future efforts to study the
impact of IPL competency education at the clinic would benefit from a retrospective pre-/postevaluation to account for this effect (Sanborn, Cole, Kennedy, & Saewert, 2018).
Conclusion

DEVELOPING TEAM SKILLS AND ATTITUDES

24

While IPE is not a new concept, intentional inclusion of IPL competencies in learning
experiences with health profession students is gaining attention as one possible way to close the
gap between IPE and IPP. Current work in IPE has focused on the nationally-adopted IPEC
competency domains of values and ethics, roles and responsibilities, communication, teams and
teamwork. Yet, evidence shows that leadership of interprofessional teams is needed to drive
collaborative care to meet the Triple Aim goals of improving the patient experience, health of
populations, and per capita cost of health care. This effort must begin with a broad census of
leadership competencies, which have been defined across many disciplines, and can help build
interprofessional skill of health practitioners. The clinic stakeholders are interested in this
growing emphasis on leadership skills, setting the stage for this project to explore new ways of
incorporating IPL into the clinic rotation.
This pilot has set the stage for continued development of the learning module guided by
continued measurement of the outcomes. Improving leadership abilities, according to the
evidence, can promote the ability for health practitioners to improve the quality of patient care
delivery. Preliminary conclusions show that the clinic experience, including the IPL competency
education, does impact student self-assessments of the values, skills, and behaviors central to
effective collaboration. While the results of the semester-long experience cannot be
disaggregated to highlight any one learning experience over another, there is value in continuing
this education module as a complement to the other learning experiences that make up the clinic
rotation. This is a simple and cost-effective learning activity that could be modified for
deployment in an online format for students to reflect upon the leadership skills that influence
IPP and IPC. Evidence shows a growing association between leadership competence and IPP,

DEVELOPING TEAM SKILLS AND ATTITUDES
and this would be a sustainable complement to the current IPE experiences at the clinic to
solidify this correlation.

25

DEVELOPING TEAM SKILLS AND ATTITUDES

26

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DEVELOPING TEAM SKILLS AND ATTITUDES
Appendix A
Literature Search Flow Diagram

34

DEVELOPING TEAM SKILLS AND ATTITUDES

35

Appendix B
Table C1

1

6

X

X

X

Zwarenstein et al.,
2009 (SR)

4

Willems et al.,
2013

X

6

Sunderji et al.,
2016

X

Shanta &
Gargiulo, 2014

4

Reeves et al, 2013
(SR)

Margolis et al.,
2013

6

Nicksa et al., 2015

Gordon et al., 2016

6

Nancarrow et al.,
2013

Gaskell & Beaton,
2015

Synthesis Table

4

6

1

X

5

–
++
–

+
+
–

+
+++
–

X

X
X

5
5

X

X

Level of Evidence
Data and Measurement
Study Design
Quantitative
Qualitative
Mixed-methods
Use of validated tool
Estimate of external reliability
Internal validity established
Identified bias
Population
Students
Practitioners
Interprofessional mix of subjects
IPE Design
Didactic
Focus group / interview
Classroom / workshop
Experiential
Simulation
Clinical / practice-based
Study Outcomes
Outcome Type
Patient or clinical outcome
Practitioner or team competencies
IP Variables of Interest
Leadership
Communication
IPP / IPC
Teamwork
Emotional Intelligence
Applicability
Feasibility to replicate
Goodness of fit for project design

X
X

X
X

–
+
–

+
+
–

++
++
–

++
+
–

X
X

X
X

X
X

X

X

X

++
+++
–

–
+++
–

–
+++
–
X

X

1
14
15**

15

X

X

X

2

X
X

X

X

X

X

X

3*

X

X

X

X

X
X

X
X

X

12
3

3
5
X

X

X

X

X
X

2
9
4

5
X
X

–
–

+
+

–
+

–
+

+
+

+
–

+
––

+
–

++
–

Table Key
* = 3 studies included a combination of a workshop and clinical-based education; ** = All studies included interprofessional
learners, with only one aimed at students versus practitioners; IPC = Interprofessional Collaboration; IPP = Interprofessional
Practice; SR = Systematic review (number of results reported for each study in review)

+
+

DEVELOPING TEAM SKILLS AND ATTITUDES

36

Appendix C
Iowa Model of Research-Based Practice

(Titler, 2010).

DEVELOPING TEAM SKILLS AND ATTITUDES
Appendix D
UWE-IQ Survey Questions and Scoring Guidelines

37

DEVELOPING TEAM SKILLS AND ATTITUDES

38

DEVELOPING TEAM SKILLS AND ATTITUDES

39

DEVELOPING TEAM SKILLS AND ATTITUDES
Appendix F
Table F1
Comparison of Pre-/Post- Survey Responses
Pre-evaluation
Post-evaluation
Comparison
Item
Mean
Std. Deviation
Mean
Std.
Mean **
number
Deviation
Communication
1
2.50
0.58
1.75
0.50
-0.75
and Teamwork
2
2.00
0.00
1.75
0.50
-0.25
3*
2.25
0.50
2.50
0.58
0.25
4*
2.25
0.50
2.25
0.50
0.00
5
1.75
0.50
1.75
0.50
0.00
6*
2.00
0.82
2.50
0.58
0.50
7*
2.25
0.50
2.25
0.50
0.00
8
2.00
0.00
2.00
0.82
0.00
9
2.25
0.50
2.00
0.82
-0.25
Scale Means
2.14
2.08
-0.06
Interprofessional
10
1.50
0.58
1.75
0.96
0.25
Learning
11
1.50
0.58
1.75
0.96
0.25
12 *
1.75
0.96
2.25
1.50
0.50
13
1.75
0.50
1.75
0.96
0.00
14
2.25
1.26
2.25
0.96
0.00
15
1.50
0.58
1.75
0.96
0.25
16
1.75
0.50
2.00
0.82
0.25
17
1.50
0.58
1.75
0.96
0.25
18
1.50
0.58
1.75
0.96
0.25
Scale Means
1.67
1.89
0.22
Interprofessional
19 *
4.00
0.00
4.00
0.00
0.00
Interaction
20
3.00
0.00
2.67
0.58
-0.33
21 *
3.25
0.50
3.67
0.58
0.42
22 *
3.75
0.50
4.00
0.00
0.25
23
3.50
0.58
3.00
1.00
-0.50
24
3.00
0.00
2.00
0.00
-1.00
25
2.50
0.58
2.33
0.58
-0.17
26 *
3.25
0.50
3.67
0.58
0.42
27 *
3.25
0.50
3.67
0.58
0.42
Scale Means
3.28
3.22
-0.06
Interprofessional
28
2.25
0.96
2.00
0.82
-0.25
Relationship
29
1.75
0.50
2.00
0.82
0.25
30
3.00
0.00
2.00
0.82
-1.00
31
2.25
0.50
1.75
0.50
-0.50
32
2.00
0.00
2.25
1.26
0.25
33
3.00
0.00
1.75
0.50
-1.25
34 *
3.00
0.82
4.00
0.82
1.00
35
2.00
0.82
1.75
0.50
-0.25
Scale Means
2.41
2.19
-0.22
* These items have been reverse coded
** Differences in means > 0.5 (bolded) were deemed by the author to be clinically significant
Scale

40