Tips for converting interprofessional education sessions from in-person to remote synchronous formats for experiential learning
Introduction
Interprofessional education (IPE) occurs most effectively with in-person modes of instruction. Small group discussions, simulation experiences, and authentic patient care situations readily enable students to learn and work together collaboratively.
In March 2020, with the spread of COVID-19 around the globe, new methods for conducting IPE were suddenly needed in which the same interprofessional objectives could be accomplished using remote, synchronous formats rather than face-to-face encounters. With short turn-around, we converted afternoon student-led, interprofessional care conferences (using authentic, hospitalized patient chart notes that were de-identified), as well as evening interprofessional teaching clinics, into remote learning experiences.
Historically, our student-led care conferences occurred monthly and involved ~25–30 learners every four weeks. Due to the global emergency, clerkships/clinicals were abruptly re-structured and IPE activities needed to be scaled up and delivered remotely for more than 600 learners. In addition, until 2020, our interprofessional teaching clinic (IPTC) activities had always involved in-person interactions with patients. However, to continue momentum with this IPE activity, we capitalized on tools that were available to host patients using virtual visit formats. Herein, key points we learned and tips are presented for conducting IPE remotely, using technologies that are widely available, including (a) a learning management system (our institution uses CANVAS [(Instructure, Salt Lake City, UT)]), (b) ZOOM (ZOOM Video Communications, Inc, San Jose, CA, USA) as a videoconferencing solution, and (c) structured Google docs for online, real-time care plan creation. It is hoped that information presented can be used as a roadmap by others faced with similar challenges.
Faculty development, prior to any IPE activity, is imperative. Logistics and session objectives need to be communicated. Faculty have reported that the most valuable training involves “hands-on” learning.1 When it comes to delivering IPE remotely, part of that practical training necessitates instruction with the digital tools and technologies that will be used during the IPE activity.2 This ensures that facilitators have been versed in the technologies prior to using for the first time during live, remote sessions with students. In addition to “traditional” faculty development sessions, we hosted multiple “technology trials” for faculty prior to the IPE sessions. After consultation with instructional design experts, we provided semi-structured events during which facilitators were introduced to the following technological features: the CHAT feature in ZOOM to tell something positive that resulted from COVID-19 (e.g. new hobby, etc); the PARTICIPANT feature of ZOOM to give a “green check mark” for a YES response or a “red X” for a NO response to a question that was posed; the annotate option of ZOOM was featured when participants were shown a picture of a tropical beach scene and invited to indicate where they would ideally like to be in the picture; the polling feature of ZOOM was used to inquire about favorite sports teams; the CHAT feature of ZOOM was used to direct individuals to a GOOGLE document where participants were invited to complete a table and share a favorite thing about their profession. Finally, we provided instructions and opportunities for individuals to log in to the learning management system, which was new to our College and most faculty/staff had not previously used it.
Since the goal of IPE is for learners from different professions to learn together, a mechanism is needed to ensure relatively equal representation of the different professions (nine professions in our case) when dispersed across small group breakout rooms. Although the ZOOM platform allows for random breakout rooms to be created in the middle of an educational event, we could not rely on random distribution of learners, since there is no way to guarantee equal representation of each profession during breakouts. Furthermore, use of pre-created and pre-assigned breakout rooms enables faculty to know, in advance, who their roster of students is and enables more efficient delivery of individual student feedback. It also provides a mechanism (one of several we used) to track student attendance. Thus, we needed to use the breakout room pre-assignment function within ZOOM. Each of four case-conference sessions included learners from as many as eleven different institutions (some of which had not used ZOOM previously as a videoconferencing platform). We learned while “practicing” with faculty during faculty development sessions that a multitude of different mechanisms exist by which ZOOM meetings can be accessed (e.g., private accounts, institutional single sign-on [SSO], downloaded apps on a variety of different devices versus using a computer browser, clicking on a URL meeting link versus joining a meeting using a meeting identifier, etc). However, since it was desirable to have ZOOM automatically direct learners to their pre-assigned, break-out rooms, we needed: (a) all learners to provide the email address tied to their ZOOM account in advance (in many cases, learners had to create ZOOM accounts for the first time; they had grown accustomed to simply clicking on a URL and had never logged in via an individual account) and (b) students needed to follow an explicit set of instructions for logging into their specific meeting event to guarantee they would end up in the proper breakout room. If a student entered an event “waiting room” as a “guest”, it was apparent that they had not followed instructions; therefore, a technology assistant messaged these students requesting them to log out, follow instructions, and log back in to the meeting. We hosted “technology trials” for students daily over the lunch hour during the week preceding the events to allow students to gain familiarity with log-in instructions and interactive features within ZOOM that were incorporated into the sessions.
Whether managing several hundred interprofessional learners participating in student-run care conferences or less than a dozen learners involved with an IPTC, having dedicated personnel to manage technology behind-the-scenes is critical. These individuals manage a variety of tasks, including: assisting learners with technological problems, allowing students to “enter” the main meeting room from the online waiting room (to decrease likelihood of “ZOOM bombing”), monitoring the CHAT box for issues that require attention, loading just-in-time documents and URLs into the “files tab” when needed, managing breakout rooms to be sure students end up in the correct small group, and even taking attendance. With dedicated personnel handling these tasks, faculty were able to focus on facilitating and instructing learners without having attention diverted.3
Use of a designated learning management system (LMS) to hold all information regarding the sessions alleviated confusion and frustrations. When hosting IPE events that involve multiple colleges and universities, it is challenging (and may even require manual entry) to get all learners into the same LMS. Nonetheless, doing so provides a central repository of information about the activity, including: log-in instructions for the online event, session objectives, expectations and rubrics for participation and engagement during the session, and pre-work (e.g., readings, chart/case notes, etc) so that all learners receive the same clear and concise information and can attend the IPE activity adequately prepared.3 The LMS was also useful for just-in-time release of additional information throughout the care conferences.
During IPE sessions, the CHAT feature was exploited during the large group sessions for several purposes. First, at the beginning of the activity, we encouraged students to use the CHAT feature to state their name, institution, and profession. This accomplished several things: (a) it was a way to demonstrate the function to learners unfamiliar with ZOOM, (b) it let students know that it was acceptable to use this feature during the activity, and (c) it was one of several mechanisms by which attendance was captured. In addition, the CHAT feature was used during the large group portion of the event by: faculty facilitators to pose questions to the learners, learners to ask questions of each other, and learners to post resources that their interprofessional colleagues had not previously known about.
Our student care conferences feature two distinct types of learning. Some sessions are based around de-identified data originating from authentic patients that are currently hospitalized in the Neuroscience Intensive Care unit within our academic medical center. Other sessions are based upon video recordings of a standardized patient, who has many social influencers of health challenges for herself and her newborn, in a scenario that unfolds over a 2 week time period. All remote care conference activities began and ended in a large group environment (e.g. ZOOM room) to introduce and debrief the activities, respectively. In addition, each activity also included multiple ZOOM breakout rooms for more intimate discussions and care plan formation by interprofessional student team members. There are a multitude of ways to keep learners engaged, even during the large group IPE activities, simply by using tools within the ZOOM videoconferencing platform. In addition to using the CHAT feature, we had students respond to embedded polling questions to gauge knowledge or experience levels during the large group portion of the events. We used the annotate function to receive feedback about pre-activity assignments. Using non-verbal feedback tools (under PARTICIPANTS), students responded to questions by raising their hand or indicating agreement (YES) or disagreement (NO) with statements. During breakout sessions, students were asked to volunteer to fill specific roles for their team (e.g. “Reader”, “Case Director”, “Researcher”, “Scribe”, etc). In addition to their profession-specific role, this gave students an additional team-specific role to take on and stay involved. Furthermore, simply setting expectations and making rubrics available, in advance, in the LMS incentivized engagement and participation during small group break-out activities since the expectations were clear.
To keep students on task and provide each learner with feedback from a faculty member, each breakout group had a minimum of one facilitator. When possible, we had two faculty assigned to co-facilitate each group.2 When partnering co-facilitators, it works well to pair individuals with complementary backgrounds or partner novice facilitators with more experienced ones for mentorship.4
As our IPE activities involve unfolding authentic patient scenarios, the LMS initially provided learners with only admission notes (e.g. inpatient interprofessional case conference) or background chart notes (outpatient interprofessional care plan) as one component of the pre-work. However, without being able to hand out additional information via paper at appropriate times, we used two different methods to release new, updated information to learners at specific times. We programmed time-release mechanisms into the LMS to activate at specified times to make new information available to students. In addition, we also used the “file upload” feature in the CHAT function of ZOOM. This assured that even students who did not have the LMS open would receive information in a timely manner (e.g. we were told that many individuals get confused when toggling back and forth between windows, and not every learner has a double monitor or a second device to view ZOOM and the LMS simultaneously). Thus, technology, used in different ways by different learners, facilitated timely collaborations between students.5
During small group break-out sessions, students took on their professional role, communicated profession-specific information, and collaborated as a team to complete a structured Google document. The Google document posed questions to guide discussions (e.g. what other information would you like to know?, what are your professions' priorities for caring for this patient?, which professions are best suited to assist? are there other professions needed?, what is your professions' role?, etc.). In addition, tables were embedded within the Google document for learners to complete as a team “deliverable”, to document the care plan that they developed for the patients, as the scenarios unfolded. The structured Google document kept students’ discussions focused and goal-oriented as they worked to develop the best plan for each patient.
We have had many years of experience running these specific IPE sessions in a face-to-face format; we know the amount of time that the sessions take when delivered via that mode. In the past, these have been 2 h sessions. However, during remote synchronous delivery of these events, the IPE activities went longer than anticipated. Extra seconds here-and-there added up quickly. Students require orientation to the tools inherent to the technology. Moreover, there is a time lag when posing a question until students respond. Others who made quick transitions from face-to-face simulations to remote delivery also report similar experiences; thus, it seems that incorporating additional time for online delivery compared to in-person sessions should be a standard consideration.6 In the future, we will allot at least 30 min extra when conducting these activities in an online format.
Recognizing that feedback is an important part of learning, we involved learners in the feedback process. To accomplish this, learners knew in advance that they would use a rubric to self-evaluate their contributions, they would give/receive feedback to/from three other learners as assigned, and they would receive feedback from their faculty facilitator(s). Feedback was formative in nature. The instrument used was a modified version of the seven-point Likert scale used by Cottrell et al., 2006 7 for peer feedback. We included only five domains instead of nine and our domains focused on professionalism/responsibility, respect, communication, teamwork, and roles/responsibilities. Valuable insight may be gained by students when they compare self-reflection ratings of their contributions with the perceptions that others had. In addition, students submitted feedback about the entire activity, including whether session objectives were accomplished and comments about their facilitator(s). Likewise, facilitators provided feedback about things that worked well or need improvement. We also asked learners to identify something that was learned and how they hoped to apply that information when they were able to re-engage in patient care activities. Historically, all feedback and evaluative information has been completed on paper-based forms (we had tried to convert to electronic data capture previously, but facilitators preferred paper). Given the current situation, all data was captured using digital tools inherent to the LMS or Qualtrics (Qualtrics, LLC, Provo, UT, USA). While this saved time in terms of manual data entry, there was still a lag time of several weeks to compile and re-distribute the feedback to learners on account of competing priorities faced by staff members during the pandemic.
Even IPTCs can be held remotely with live patients. Having a dedicated individual serving as a “host” for these virtual visits is key to mimicking a patient clinic visit. To maintain patient privacy, students and faculty participants are instructed in advance to either be alone in a quiet room or use earbuds so that the patient's voice cannot be heard by anyone in close proximity; furthermore, participants are instructed that their back must be against a wall or other backdrop such that no one can walk behind them and view their screen. In advance of the patient appointment time, all student and faculty participants log into a HIPAA-compliant ZOOM platform and are immediately directed into a breakout room by the meeting host. This enables learners and faculty to have a pre-brief huddle in advance of the patient visit. Once the patient arrives (e.g., logs into ZOOM at his/her scheduled time), all participants return to the main meeting room to interact with the patient. At this time, students lead a virtual visit and faculty mute their microphones and turn off their video to provide greater student autonomy. We have routinely had between 4 and 7 students and 4 to 5 faculty/staff on each call. Following interprofessional student assessments/interactions with the patient, students and faculty return to the breakout room for teaching points and to formulate a plan. Once a plan is established, the students and faculty return to the main meeting room to rejoin the patient and engage the patient by developing a plan that is mutually agreed upon. In total, the pre-brief lasts about 45 min; the visit with the patient runs about 60–75 min; and, it usually requires about 15–20 min to review the plan with the patient. In total, we ask students to allow for 3 h (e.g. 5–8 p.m.) and ask the patient to allow about 90 min (e.g. 6 to 7:30 p.m.). After the patient exits the ZOOM meeting room, interprofessional students jointly write a note to be communicated to the primary care provider, highlighting key findings and recommendations from the visit. Since these sessions are held in the evenings, there usually are not many competing priorities for participants. Overall, using the features of ZOOM, all the facets of a typical IPTC patient encounter can be replicated including: a pre-brief huddle, patient encounter, case presentation to faculty, faculty visit with the patient, and a post-visit summary note. Not only has this circumvented transportation difficulties, but it also supports social distancing and reduces the risk of office visits that could promote exposure to unwanted pathogens (e.g. COVID-19, influenza, etc). Although, additional coordination would be needed, it is possible that student groups could continue to follow their IPTC patients longitudinally as a team.
Section snippets
Conclusion
Now that students have returned to direct patient care responsibilities, they are slowly submitting follow-up assignments from the remote IPE activities, including highlights of how they are applying information learned to interactions with healthcare team members and patients. Student responses have been encouraging to read and demonstrate that the IPE sessions were effective, even via virtual delivery.
Certainly COVID-19 has brought challenges. Pivoting existing IPE activities to online
CRediT authorship contribution statement
Kelly Karpa: envisioned creating this manuscript as a roadmap for others, and she wrote and edited the manuscript, The IPTC is funded by HRSA 1 TOBHP30010-01-00 (Leong).
Declaration of competing interest
The authors report no declarations of interest.
Acknowledgements
These activities would not have been possible without the assistance of a cadre of facilitators, the insights of interprofessional education co-director Sol DeJesus, the assistance of Joy Bowen, and the tireless efforts of Tanya Shaw. The IPTCs are funded in part by the Health Resources and Services Administration 1 TOBHP30010-01-00.
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