Abstract
Health care professions are emphasizing the importance of well-functioning teams to improve health outcomes. Educating students in professional silos has been the tradition in higher education, but this separate approach has come under scrutiny for creating barriers to addressing the complexity of today’s health care system in the United States. Collaborative problem solving is necessary to end health disparities and medical error. The authors discuss an interprofessional internship using multiple approaches to interprofessional education that embrace interactive learning, and explore educational opportunities from the students’ point of view. The authors highlight observations about reluctance within the student interprofessional teams to make mistakes or to explain miscommunication supporting research evidence, suggesting that students harbor fears of disrupting hierarchy and the status quo.
Keywords: error; social work; interprofessional; SDOH
Introduction
This article highlights observations made by two MSW students as part of their interprofessional (IPE) field experience. An internship was created and directed by social work faculty (and co-author) to provide unique interdisciplinary experiences in community settings serving economically vulnerable clients. MSW interns were provided an opportunity for leadership experience on student medical teams as part of interprofessional internship interventions. The three interprofessional internship settings were chosen because the locations provided opportunities to practice intentional communication, to raise awareness about the social determinants of health (SDOH), and to develop programming that worked toward reducing health care disparities and medical error, which is the third leading cause of death in the United States (Makary & Daniel, 2016). The student interns learned to analyze health care disparity problems at the interpersonal, organizational, and community levels. This article looks at the current conversation about the importance of adding interprofessional components to the curriculum, and explores how a variety of interprofessional interventions by social workers can be helpful in raising a team’s awareness of interactions, attitudes, and behaviors contributing to health disparities.
Literature Review
Interprofessional education ideally includes developing a professional identity while also learning about other professional roles. Interprofessional education also stresses the importance of team identity and collaboration (Bridges, et al., 2011; Lingard et al., 2015). Interprofessional collaboration occurs when people trained for different professions work together to achieve a goal. Definitions of interprofessional collaboration also include the importance of making the patient the focal point of treatment (Liberati et al., 2015). In addition, patient-centered teams take patients’ values and beliefs into consideration in treatment. Liberati, et al. (2015) comment that “in fact, encouraging patients’ and caregivers’ inputs to innovate health care services as well as ensuring providers’ commitment with patient-centered values are considered crucial elements of compassionate care” (pp. 46–47). While it is evident that interprofessional collaboration during training to be a health care professional is important in decreasing health care disparities, interactive and interprofessional approaches are not widely available in the United States (Murray-Litchman & Levine, 2019).
“Interprofessional” is used in this article instead of terms such as “interdisciplinary” and “multidisciplinary” as an intentional choice by the educators developing IPE curriculum at the institution where the internships were created. As members of the Interprofessional Education Collaborative (IPEC), educators adhered to the definition laid out by IPEC. Interprofessional education is conceptualized as students from two or more professions learning about, with, and from each other (Interprofessional Education Collaborative, 2020). IPE involves training students to be professionals in a health care setting. The word “discipline” is used to describe academic disciplines. Interdisciplinary education is also important to teaching cultural understanding and empathy, but is not a focus of this article (Sloane, 2017).
IPE can be conducted in different formats, such as in student-run free clinics for local communities or in seminars for multidisciplinary students aspiring to work in health care. For example, Wang and Bhakta (2013) studied the Case Western Reserve University Student-Run Free Clinic educators’ utilization of a model of care involving equal rankings among professions using medical students and nursing students in pairs. Chan et al. (2009), however, studied nursing students’ and social work students’ ethical decision making through a variety of interdisciplinary seminars. These researchers in particular found that various interdisciplinary seminars helped educate nursing students and social work students about professions other than their own.
Student perspective and input on the design of interprofessional education has been seen as crucial. According to Rosenfield et al. (2011), students are a helpful and necessary part of internship and pedagogical design. Much like patient-centered concerns for compassionate care, involving student perspectives when creating interprofessional education interventions is vital in seeing what works to insure early, positive interprofessional interactions that counter negative stereotypes of professions and interprofessional teams (Tunstall-Pedoe et al., 2003). Other students have given their perspectives on the values of interprofessional training (Lumague et al., 2006). This article adds additional insight.
This article makes a unique contribution to Field Education because it prioritizes student observations about their field experience as being valuable to the design of interprofessional curricula. This article also adds to the consideration of interprofessional internships as quality internship opportunities for social work students (Poole et al., 2017). Learning about, with, and from students from other health and mental health professions opens up possibilities for education that prepare students for the reality of complex work environments.
Interprofessional Education Internship
Two MSW students, co-authors of this article, were engaged in three separate interprofessional initiatives as part of their advanced MSW internship. The internship included experiences with mock student teams in a highly interactive class that included interprofessional faculty from social work, medicine, nursing, pharmacy, physical therapy, occupational therapy, speech-language pathology, public health, physician assistant, and respiratory therapy programs. This class was organized by the School for the Advancement of Interprofessional Education on the medical campus, and was housed in the state-of-the-art Interprofessional Immersive Simulation Center. The students participating in this class had the benefit of learning from simulations and standardized patients (actors trained to perform as patient).
The interns also developed and facilitated interprofessional creative writing mentoring groups. The high school creative writing program is a unique medical humanities intervention that creates opportunities for empathy and social connection between high school and college students who would otherwise rarely encounter each other. The high school is part of the city public school system, in which the students are predominantly African American. The undergraduate and graduate students involved in this program are predominantly white and from middle-class, suburban areas. The mentors and mentees write together about their life stories, and share and give strengths-based feedback based on the Amherst Writers and Artists method (Schneider, 2003).
The third internship site was at the Student-Run Free Clinic (Clinic). This Clinic is one of the largest of its type in the United States (see https://www.utoledo.edu/med/studentaffairs/organizations/ccc.html). The Clinic’s main mission is to provide free, quality health care for individuals without health insurance and to raise awareness about health care challenges for the uninsured in the city. Volunteers at the Clinic are able to learn about societal issues and practice principles of public health in an interprofessional manner, as well as have an overall positive effect on, and facilitate change in, the greater metropolitan area. The Clinic operates weekly on Thursday nights. The majority of students who operate the facility are from the medical and pharmacy programs. However, there are social work and other allied health students present. There are many different stations involved at the Clinic, but the majority of patients are taken through the Clinic as though they are at a doctor’s office: undergoing intake/triage; seeing a medical student who conducts a physical exam; being given a prescription/medication (free of charge) if needed; and finally seeing a social work student for any additional resources they may need after their visit.
The social work services are fairly new to the Clinic. Because of this, the role of social work is still being established, but as of right now, the social work volunteers mainly complete discharges, which involves completing a survey for patients about the care they received, and connecting the patients to resources if needed.
Student Exploration
Both students were weekly participants in the IPE class (fall semester only), the Clinic, and the creative-writing mentoring program, completing over 500 hours of field experience. Students wrote freely about the dynamics at the sites that stood out to them each week in weekly reflections on their experiences in the field settings. A total of 60 reflections was collected from the students. Students also participated in weekly individual and group supervision. The student reflections were discussed individually and again in group supervision. The regular written reflections were read closely by the faculty supervisor (a co-author of this article) for themes using a literary analysis method that looks closely at power dynamics and implicit bias (Said, 1993, pp. 80–97; Sloane & Petra, 2019). Areas of interest based on the analysis were highlighted by the faculty supervisor. Looking closely at the highlighted areas of each reflection, the themes of empathy, collaboration, achievement-centeredness, and professional respect were discussed in supervision. Toward the end of the internship, the highlighted writing was reviewed again by all three writers to reconsider these themes from the students’ experiences. Student experiences of these interprofessional education interventions allowed for a deeper exploration of thoughts and feelings about collaboration and interprofessionalism.
A comparison of the different IPE approaches was also discussed by the writers of this article at the end of the internship. On top of gaining micro, mezzo, and macro (i.e., clinical practice, community practice, and policy; see Singer & Sage, 2015) health experiences, this internship allowed for the consideration of a variety of approaches to IPE and of ways to improve collaboration and teaming from the perspective of students. Both students were able to build interpersonal skills with clients and colleagues, learned ways in which communication can improve the outcomes of an agency, and were involved in the creation of education interventions that disrupt implicit bias.
Excerpts of student reflections are used within this article as representations of themes discovered in this process. The authors’ perspectives on what constituted proper interprofessional and collaborative work shifted or changed throughout the internship experience, and included a careful consideration of what it means to demonstrate social work professional humility. After the inductive gathering of themes, the authors take the main themes (empathy, collaboration, achievement-centeredness, and professional respect) and explore the current conversations on these topics in the social work and interprofessional literature. Authors focus on what worked and did not work in the settings, keeping in mind how social work students could take on leadership, particularly in avoiding medical error and confronting health disparities.
Themes
Empathy and Collaboration
It was at the creative writing mentoring site that the students wrote mostly about collaboration, self-awareness, and empathy:
We were able to have a good discussion about mental health, gender, and sexuality. While we talked about these subjects, the students [both high school and IPE university] appeared receptive to what we, the facilitators [social work interns], were saying, and it appeared that while we spoke, they truly listened and took in each word that we said to them. I think that in all, this will be enlightening for them to hear, especially the mental health talk, because a lot of times there is taboo when it comes to talking about mental health. I think opening the door to these subjects allows the group to realize that it’s a safe space for all of them to talk with one another and us, as well as learn more about subjects that are not always talked about in high school.
The interprofessional university students and the high school students in the mentoring program wrote together creatively as equal writers. All were expected to write, share, and give regular, strengths-based feedback. This setting was the only setting where the interprofessional students were in the community and not in a university or clinic setting. The university students became a part of the high school culture, which serves as a community hub. The creative writing topics were led by the high school students and not the interprofessional students. The focus was not on diagnosis or having the correct recommendation, but rather on learning how to better understand self and community members by sharing thoughts, emotions, and creativity. The conscious effort to remove hierarchy and to treat the “patient” and the “practitioners” as equal participants allowed for a different level of respect and collaboration.
Including in the three interprofessional experiences one setting that emphasized interacting with community members as expert collaborators was important to seeing how successful understanding and empathy can be to overall health outcomes, on par with understanding diagnosis and treatment. The mentoring experience raised awareness of how easy it is to make assumptions about people based on age, race, gender, sexuality, and economics. Implicit bias (unconscious “isms”) became more evident in an environment where feedback was a normal aspect of the group communication. This experience led the social work students to question how aspects of the mentoring program could be brought to the IPE class and the Clinic to disrupt medical error as well as behaviors and attitudes that support health disparities.
In regard to empathy, we discussed the importance of empathy not only for the patients but for team members. Throughout the process we brought up the importance of modeling moments of collaboration and empathy as social workers on an interprofessional team. Here is an example of an observation of successful empathy on the part of a team at the Clinic:
The two medical students left for a moment while the young female patient spoke with the social work student. I could overhear slightly the patient speak about times of anxiety, particularly with tests at school, but it appeared she was overall anxious. The social work student listened to her speak, and nodded when appropriate, and had a look of empathy on her face. The medical students returned, and I could see the demeanor of the patient change from what was more open around the social work student, to more closed and frightened around the medical students. She got up from the chairs and they walked over to the examination room. Later in the evening, I saw a medical student come out with a teddy bear for this young patient. I think it was comforting for the young patient to have something to squeeze and hold during anxious times.
In this example it was close observation of the social work interaction with the patient that modeled empathy for the team, and created room for another team member to reach out emotionally to the patient experiencing anxiety.
Overall, what was not working with the interprofessional teams was mentioned more often than what was working. However, positive examples of collaboration and empathy were also evident in the student observations. For example, regarding an IPE class that included a standardized patient:
A physical therapy [PT] student and a medical student recovered from a team members’ lack of empathy by ending the interview [with the standardized patient] and worked together to address the patient’s requests. The physical therapy student was very patient-centered in her approach, starting with reintroducing her role on this team and how physical therapy can help her. She was expressive with empowering the patient and said “it is your choice what you want to do,” and the medical student backed her [the PT student] up by telling the patient that “your comfort and safety is our main concern.” I felt that this collaboration between the medical student and physical therapy student empowered the client, while providing accurate information and empathy for her [the patient’s] desires.
Examples of impactful collaboration were seen not just between teammates but also with the patient:
Observing from afar, I see a first-year medical student walking side by side in casual conversation with an elderly male patient using a walker. The other two teammates walk far ahead at their regular pace, leaving their patient behind and not looking back. The contrast of personality and engagement is evident between the two students who are strides ahead, versus the single student who takes his time to make sure the patient is comfortable.
For this social work student, taking time with the patient to provide comfort, match the patient’s pace, gain a better understanding of what a clinic visit means to the patient, and notice how the patient feels about his care are a good use of time, not a waste of time. Overall, the students discussed how public encouragement and recognition of these moments of connection and empathy would be a demonstration of social work leadership.
Empathy is discussed in the IPE literature as important to team communication and collaboration (Adamson et al., 2018). Interprofessional empathy, when demonstrated between health care team members, allows for professionals to see issues from multiple perspectives and frameworks. This deeper level of understanding helps to shift attitudes and build relationships. Health care teams can be taught to demonstrate collective empathy for the patient, and it is this emotional understanding that leads to improved care outcomes (Sur, 2020). From the students’ examples of successful interprofessional empathy it appears that opportunities for personal expression with hierarchies dissolved, as in the creative writing intervention, allow for deeper team understanding and competency in modeling empathy for patients.
Achievement-Centeredness
Both students made repeated observations about the interprofessional teams being task centered instead of patient centered. The emphasis on getting tasks completed correctly by the interprofessional teams was particularly evident in the IPE class and the Clinic setting. The standardized patients in the IPE class and the actual patients at the Clinic were often treated as puzzles that needed to be solved within a short time frame. For example, one of the social work students observed,
The end of the evening appears to be the change in atmosphere at the Clinic. Where students who have been buzzing with cheer and patience begin to drop charts off to tables to relieve themselves of their duties tied to the patient. The rush of getting the tasks at hand completed becomes the priority, instead of realizing those tasks to be completed are human beings.
The social work students noted that even though the emphasis in the IPE class and in the Clinic was to learn to work better as a team, the value of approaching problems as a team was rarely apparent in simulated or actual patient interactions. Both students recognized individual achievement as valued over teamwork in these cases. The newly learned value for teamwork did not override the long-standing pressure experienced by students to do well in front of peers and professors. The key goal of the interprofessional teams often appeared to the MSW students to be getting the patient tasks done, rather than building rapport and learning from the patient as a team. Much as in group projects in school, many individual IPE team members were more focused on their individual achievement, rather than on the team outcome and on understanding the patient.
For students new to their careers, an inability to apply what has been learned in the fall IPE class to the Clinic seemed particularly frustrating. In the case of the treatment of a patient at the Clinic with an intellectual disability, a student wrote:
I had one patient today who was anxious and did not understand the directions from the doctor. I asked the group of medical students who saw her to maybe try and explain once more what the diagnosis was. As they explained, they were very impatient with her, and kept just reassuring her that she was okay, and that her results were in normal range. However, she still felt confused, and I could tell, based on some of her body language and mannerisms, that she might have some sort of developmental delay. This frustrated me that the medical students could not just be patient with her as they tried to explain what was happening.
The end goal for the interprofessional teams in both of these cases tended to be the correct diagnosis or the correct recommendation for treatment, not the proclaimed IPE goal of collaborating with the patient and team for the best possible communication, empathy, and overall outcome. In this example, the patient made it difficult for the team to be right and competent since she appeared to the team to be questioning their efforts. The questions were due to her confusion and fear, not in the team’s ability to diagnose, but to understand this would take the team empathizing and being willing to see the difficulty and complexity of the case as a welcome challenge instead of a personal mistake.
The social work student points out the disconnect between what was perceived as a successful interaction for the patient and what was a successful interaction for the students. Repeated questions would result in better understanding by the patient, but for the student team, questions by the patient pointed out where the team may be incompetent. The students’ not being able to answer a question correctly created stress. The MSW students began to consider what their role was in empathizing with their IPE peers to facilitate an adjustment from a focus on individual achievement to a focus on patient-centered outcomes, and noticed how this transition appeared to cause discomfort for the students on the IPE team.
Professional Respect
The MSW students reported frequent experiences of a lack of professional respect within the interprofessional student teams, particularly in the IPE class and the Clinic. One of the social work students observed during an IPE simulation,
As the medical student started the interview, he/she dismissed the patient’s wants and spoke for him/her team, saying “as a team, we recommend an in-patient rehabilitation center.” Although I was unable to witness how the team decided to proceed with the interview of the patient, I wondered why the medical student was given the lead for this interview, as well as how he/she was given the voice to speak for the team as a whole. The nursing student on the team paraphrased his/her response to this patient by letting the patient know she would not be able to go home because “it doesn’t work out that way and (she) is not quite there yet.”
The social work student’s perception of this interaction was that the other team members were not involved in the design or implementation of the interview. The assumption was that the medical student would take the lead without consulting or honoring a team process that applied to all aspects of patient interaction, in this case regarding who would lead the interview.
There were differences in how teams chose to make decisions. For example, when moving to a different IPE group in the IPE class, one of the students observed,
I was with a different group because I was making up the session, it still seemed like a group more accepting of social work than the one that I’m assigned. It was a lot easier to advocate for the patient during the interview, and they actually appreciated and wanted me to ask questions during the process instead of them simply taking over. I guess that this would be the case in real-life scenarios as well; people will try to take over the show and think of how they can get better, when in reality they are not thinking of the patient or client at all.
The social work student saw a similarity in how the social worker and patient were treated by a team, both of them passively participating in the power dynamics.
When discussing the results of the reflective writing, there arose regular consideration and conversation on the role of social workers in leading the team toward patient-centered care versus achievement-centered clinical interactions, and on how to approach these interprofessional moments with empathy. There was also consideration of how to actively interrupt occurrences of lack of professional respect instead of passively accepting traditional hierarchies, and on how to reflect on moments when social work students based decisions on negative stereotypes of other professions. When asked, the students did not feel comfortable speaking up about the moments that they witnessed that could lead to error. The social work students assumed they would not be respected or listened to by the other student professionals. The risk of causing discomfort and the risk of being wrong overwhelmed the ethical obligation to communicate to the team. Even with encouragement, and after discussion about obligations to the patient and the team, there was still resistance to be assertive and interject the social work perspective into the team communication.
Fear and Stress
We investigated what was being said about error and professional respect in the interprofessional literature, and it turns out that creating an interprofessional education culture that explicitly discusses commonly held student fears and common mistakes is considered important to disrupting current patterns of error and implicit bias (Murray-Litchman & Levine, 2019; Salas et al., 2008). Early practice at analyzing decision making can prevent interactions that create disparities in care. Salas et al.’s (2008) suggestion of using beginning and ending team debriefings to add regular feedback about how decisions are being made by interprofessional teams seems promising. The authors further suggest that regular modeling of discussions that address what is and what is not working for the team creates a culture in which it is expected that teams will consider what causes error and how to learn from mistakes.
Ironically, fear of error in medical education settings is more likely to cause error than otherwise (Baldwin et al., 1998; Kempainen et al., 2003; Parascandola, 2010). Students can learn explicitly that mistakes are more likely during times of uncertainty and time pressure, and when non-empirical solutions are required. Moments which tend to cause discomfort for the practitioner increase chances for error (Baldwin et al., 1998). To reduce anxiety about errors, it is suggested that students learn to monitor how they are making decisions.
Looking to the literature, the MSW students’ experiences of powerlessness and of not feeling valued on the team are similar to social workers working on IPE teams (Kobayashi & Fitzgerald, 2017). Social workers are often the only representative of their profession on a team, an so require high levels of confidence and competence to voice concerns. Negative stereotypes about other health professionals are also common (Tunstall-Pedoe et al., 2003). Social work students are as likely to make assumptions about medical students as medical students are to make assumptions about social work students. Social workers are often criticized by teams for insisting on anti-oppressive practice. Social work’s commitment to mezzo and macro social justice can be seen as disruptive of the micro practice concerns of other health professions (Ambrose-Miller & Ashcroft, 2016). This reality can make it challenging for social workers to lead shifts toward patient-centered care and professional respect. Keeping these unique challenges to social work students in mind, the fear of error and mistakes on the part of students in medical settings may be intensified for social work students on IPE student teams.
Discussion
Fear/stress and empathy are often conceptualized as opposite sides of an emotional tug of war. Fear of mistakes and the stress of maintaining professional territory are emotions that get in the way of empathy. The noise of stress can interrupt students’ ability to listen carefully and understand others. For the student authors, stress was experienced from achievement-centered instead of patient-centered care. Thoughts of what could go wrong in surviving as a student created a real barrier to applying newly learned skills of patient-centered care. Taking the time to understand illness from the patient’s perspective was not made a priority. Decreasing perceived stress has shown to increase student capacity to empathize (Beddoe & Murphy, 2004; van Vliet et al., 2017). At the end of this experience, the students had just started to consider what their role as social work leaders on interprofessional teams could be to encourage the use of newer skills.
One of the limitations of this study was that it looked at social work students only in the context of an interprofessional team. Investigating the actual value of social work students on interprofessional student teams as perceived by team members from other professions, rather than only as perceived by the social work students, could prove helpful to better understanding moments when social workers tend to stay silent on an interprofessional team when in fact their perspective is important and valued by the team. Further research exploring whether other professions have similar perceived stress, and if they value demonstrations of empathy and collaboration just as much as the social work students, would be helpful to encouraging explicit conversations about how fear/stress can get in the way of empathy and collaboration. It is possible that a majority of students from varying professions share a similar vision for empathy and collaboration, and are unaware of how stress and fear get in their way of their doing just that.
Due to these insights on the part of social work students, our recommendation for students and faculty educators in interprofessional internships is to openly discuss moments where students do not feel valued or feel resistant to sharing observations with their team. These moments provide rich clues to achieving better understanding on the team. Attention needs to be paid also to explicit discussions of empathy, and to how stress and fear can get in the way of collaboration. Social work students were sensitive to teammates’ fears and stress. Lack of communication on a team is not just a matter of power dynamics. As social work field educators, holding discussions about the commonly experienced fears and concerns of students on IPE teams could be a first step in preparing social work students to be leaders in disrupting systemic injustice on medical teams. The implication for field education is that regularly including students in the evaluation of the curriculum, and in the design and redesign of interprofessional social work internships, is crucial.
Conclusion
The social work program involved in this study has been a part of the joint campus (main and medical) IPE initiatives in some capacity only for the last four years. As new members of the team, social work students and faculty have been recognized as leaders in understanding cultural difference, bringing knowledge of the social determinants of health, and encouraging the consideration of ways the health care teams can tackle disparities on interpersonal, organizational, and community levels.
According to Murray-Lichtman & Levine (2019), social work internships should include ways of “recognizing and dismantling injustice” (p. 1). For the authors of this article, it was important to be a part of recognizing the injustice of medical error and health disparities, and to lead the team into patient-centered care with empathy and collaboration as the catalyst for a more just approach to health care. Through regular reflection writing and supervisory discussion, we were able to uncover what was and was not working in accomplishing our vision as members of interprofessional teams. This included our strengths as social workers on the team and also moments when we were contributing to achievement-centered care and lack of professional respect. Reviewing where there was stress and fear on the team allowed us to consider ways to increase understanding and collaboration.
Faculty are encouraged to model a culture of regular feedback in classroom and clinic interaction. Looking carefully at times of higher error encourages teams to take advantage of every opportunity to connect with team and patient to learn from feedback. It is this feedback that increases emotional intelligence (Hopkins, 2008). Emotional intelligence is the ability to manage one’s own emotions and to understand others’. Emotional intelligence is important to relationships, including clinical relationships. Researchers have noted the importance of emotional intelligence education to improving empathy and collaboration (Gribble et al., 2017; Stoler et al., 2013).
Field educators must encourage social work students to be leaders for social change within interprofessional teams. Helping social work students look at situations in which they are tempted to maintain the status quo has been considered an important start to recognizing areas of injustice on institutional and structural levels. The MSW students involved in exploring and reflecting on their experience in the IPE internship settled on themes that highlighted just such areas of passive concern. The students’ perspectives and analyses of their IPE internship experiences are invaluable to making changes to the field experience to include discussions of common errors, stereotypes, and fears, which get in the way of interprofessional connection, and likely get in the way of better understanding the patient. Teaching students how to lead feedback discussions and emphasizing the importance of emotional intelligence becomes crucial to creating cultures that decrease disparities and deaths due to medical error.
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