Development of an Interprofessional Education Event To Improve Dental and Pharmacy Students’ Attitudes Toward Interprofessional Collaboration

Alireza Hayatshahi, PharmD, BCPS, is the chair and associate professor of pharmacy practice at the Loma Linda University School of Pharmacy and an associate professor in dental education services in the Loma Linda University School of Dentistry. Conflict of Interest Disclosure: None reported.

Erin Richards, DDS, is an associate professor at the Loma Linda University School of Dentistry and an assistant professor of pharmacy practice at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported.

Paul Gavaza, PhD, MS, MSc, is as an associate professor of pharmaceutical and administrative sciences at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported.

Farnoosh Zough, PharmD, BCPS, is the director of introductory pharmacy practice experience and an associate professor of pharmacy practice at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported.

Jennifer Mathew, MA, is the director of alumni affairs and communications at the Loma Linda University School of Pharmacy. Conflict of Interest Disclosure: None reported.

ABSTRACT:

This study assessed 119 second-year pharmacy and dental students’ knowledge and attitudes toward interprofessional collaboration (IPC) before and after a two-hour curricular event held in May 2017. The event was associated with a significant improvement in the students’ attitudes toward IPC on six of the 21 items assessed (p < 0.05). Pharmacy students had significantly different mean attitude scores than dental students on 18 of the 21 IPC-related items assessed (p < 0.05). This interprofessional event (IPE) allowed for collaboration between dental and pharmacy students and faculty and improved students’ acceptance of and attitudes toward IPC.

Key words: Pharmacy, health professions education, interprofessional teamwork, interprofessional learning, interprofessional education

Improved patient safety, quality of patient care, improved health of populations and reduced per capita cost of health care [1–3] are important goals of health care. To achieve these goals requires that different health professionals work together in caring for their patients. [3] Pharmacy-dentistry collaborations have led to improved medication documentation and evaluation, less errors for taking medication history, reduced medication discrepancies, fewer opioid prescriptions and greater patient knowledge and intentions to use medications for tobacco cessation [1,4,5] among others. The collaboration between professionals may take many different forms in practice including the integration of pharmacists in dental clinics. [1,2,4–9]

Collaborative practice is best learned or introduced in professional training in the form of interprofessional education (IPE). IPE is “when students from two or more health care professions learn about, from and with each other to enable effective collaboration and improve health outcomes.” [3] IPE prepares health professions students to work collaboratively when they graduate. The Commission on Dental Accreditation (CODA) and the Accreditation Council for Pharmacy Education (ACPE) now require dental and pharmacy schools respectively to incorporate IPE within their curriculum. [10,11] It is crucial to introduce the concept of learning with other future colleagues early on in the curriculum to help shape their newly developing perspectives on clinical teamwork. [12]

However, little is known about efforts to incorporate IPE in pharmacy and dental education. IPE training in pharmacy and dental education primarily consists of clinical experiences, didactic training (e.g., in-class sessions and online lectures) or both. Clinical experience is mainly comprised of pharmacy or dental students collaborating within pharmacies or dental clinic settings. [1,4–8] Some schools and colleges such as the Midwestern University Colleges of Pharmacy and Dental Medicine have developed a comprehensive elective IPE course with a didactic portion designed to improve pharmacy and dental students’ knowledge of pharmacotherapy for dental conditions 6 and practice experience components (e.g., clinic sessions). [6]

IPE initiatives and events improve pharmacy and dental students’ knowledge about the scope of practice of other health care professions and improve their attitudes toward interprofessional collaboration (IPC). IPE initiatives help students understand different ways that pharmacists can contribute to dental practice including taking medication histories, providing medication management, providing patient counseling for medication adherence issues, addressing concerns regarding information about illness, identifying drug-related problems such as adverse drug reactions or drug interactions, understanding dental implications of medication and offering recommendations for prescribed medications. [1,5–8]

There are barriers to IPE and IPC including the dental and pharmacy faculty’s and students’ lack of knowledge and understanding of the roles of the other health care profession, schedule limitations for dental and pharmacy students and faculty, logistical difficulties such as the interference with routine workflow of the dental clinic, limited access to patients, limited administrative support, lack of collaborators and champions within the institution and students’ lack of openness toward IPE and lack of acceptance of an interprofessional role. [1,9,13] Another important barrier to these concepts is administrative, faculty and student attitudes in this regard because it is foundational to the initial yet necessary cultural shift in perception of health care education.

Since 2010, Loma Linda University has embraced the principles of IPE and taken measures to incorporate a shared learning approach in its teaching methods. The vision of the University’s Center for Interprofessional Education (CIPE) is, “To train students in a way to work and communicate with other health care professionals in an environment of mutual respect and values, using their knowledge and experience to provide a team-based approach and patient-centered care.” An example of an IPE activity held at Loma Linda University is the annual Critical Event/Disaster Response (CER) course that is taken by all graduating medical, pharmacy, allied health and nursing students. [14] This four-hour interdisciplinary course includes critical-event response and IPE competencies, features highfidelity medical simulations and provides students with hands-on decontamination modules and a mass-casualty triage. [14]

This study reports on an IPE event that was designed to improve second-year pharmacy and dental students’ knowledge, attitudes and acceptance of IPE and IPC.

Faculty from the Loma Linda University School of Pharmacy and School of Dentistry responsible for teaching two second-year dentistry and pharmacy didactic therapeutic courses collaborated to design a two-hour curricular session held in May 2017. This IPE satisfied the Accreditation Council for Pharmacy Education (ACPE) and CODA requirements. [10,11] Faculty from both schools created patient cases and summary questions that incorporated content from lecture material from both courses. The cases and questions asked of students were designed to encourage discussion on the management of adverse drug events and preventable drug-drug and drug-disease interactions.

All second-year dental and pharmacy students registered in the two required courses were required to participate in the IPE event. The content from the discussion of the patient cases was included on the final exams for both the pharmacy and dentistry courses. During the event, the students were assigned to 25 groups each comprising on average two pharmacy students and four dental students. Students were instructed to work collaboratively to assess each of their five assigned patient cases. Dental and pharmacy faculty observed and facilitated student interactions and deliberations. Following the group discussions, each group was asked to answer a question pertaining to the patient case when all of the other groups were listening. Group members chose one student to represent their group to respond to questions posed to their group during the open forum. The Q&A session helped the faculty to assess the depth of students’ understanding of the patient cases and provided faculty facilitators the opportunity to further clarify and explain the rationale of the therapeutics and treatment modifications.

The Readiness for Interprofessional Learning Scale (RIPLS) was used to assess students’ attitudes toward interprofessional education and collaboration a day before and two days after the event. The online pre- and postsurveys were administered to the students using Qualtrics and took approximately five minutes to complete. The survey instrument consisted of 21 items measured on a five-point Likert response scale ranging from strongly disagree (1) to strongly agree (5). These items generally measured students’ understanding of the importance and benefits of IPE, perceptions toward dentists and pharmacists and openness to collaborate in the future. All students were assigned a unique code that they were instructed to enter on both surveys. This code was used solely for matching the pre- and postsurveys. The study was determined to be exempt from institutional review board (IRB) approval by the Loma Linda University Health IRB. All data were analyzed using SPSS version 25 (IBM Corp, 2017). Descriptive statistics (e.g., frequencies, means and standard deviations) were computed for all items. A repeated measures t-test as well as repeated measures generalized linear model were conducted to compare the mean differences in pharmacy and dental students’ attitudes toward IPC and IPE before and after the event and by gender and profession. A p-value of less than or equal to 0.05 was considered to be statistically significant.

A total of 163 students comprising 91 second-year dental students and 72 second year pharmacy students participated in the session (TABLE 1). However, we were only able to match pre- and post-data for 119 students (73%) comprising 79 dental students (66.4%) and 60 pharmacy students (50.4%) (TABLE 1).

Both pharmacy and dental students had high mean attitude scores on all positively worded items and low means on all negatively worded attitude statements (TABLE 2).

The IPE event significantly improved dental and pharmacy students’ attitudes toward IPC on six of the 21 items assessed (p < 0.05). Following the event, students reported being more comfortable consulting with a dentist or pharmacist regarding a patient’s oral, pharmaceutical and general health outcomes (p < 0.001), realized the importance of interprofessional collaboration between pharmacists and dentists (p < 0.001) and recognized the importance of shared learning for future clinical practice (p < 0.001, TABLE 2)

Verbal feedback from dental and pharmacy students indicated that they also appreciated the opportunity to build rapport and gain an understanding of each other’s profession. Many students showed interest in having more IPE sessions with other professions such as medicine and nursing.

Pharmacy students had significantly more positive opinions about IPE than dental students on 18 of the 21 items investigated (p < 0.05). For example, pharmacy students were more likely than dental students to agree with the following statements:

■ “Learning with other students/ professions will help me become a more effective member of a health care team.”

■ “Learning with health care students from other disciplines before clinical practice would improve relationships during clinical practice.”

■ “Shared learning with other health care students will help me to understand my own limitations.”

Pharmacy students were also significantly more likely to disagree with the following statements than dental students:

■ “It is not necessary for health care students to learn together.”

■ “Clinical problem-solving skills should only be learned with students from my own discipline.” (TABLE 3).

There were statistically significant differences in the students’ attitudes toward IPE by gender on 17 of the 18 items investigated (p < 0.05). In general, female students were more likely to have more favorable opinions about IPE than male students (p < 0.05, TABLE 4).

The mean pre- and postsurvey attitude scores for most of the 21 positively worded items were high indicating that students in general had favorable opinions about IPC, teamwork and learning. Similarly, previous studies also found that students viewed IPE and IPC positively. [6,15] These findings suggest that students appreciate the importance of effective collaboration between providers from different disciplines. Given the emphasis on IPE in health professions accreditation standards, more IPE opportunities and experiences will be offered to students in the future. The IPE experiences educate health professions students about their future scope of practice and roles of other health care professionals.

Despite the short duration of the IPE session, students’ attitudes toward IPE on six of the 21 items showed a statistically significant improvement between the preand postsurvey (p< 0.05). The IPE event improved dental and pharmacy students’ attitudes toward IPE, IPC and acceptance of other health care professions consistent with other studies on IPE. [6,16,17] The IPE session gave dental and pharmacy students a rare but important opportunity to interact with other health professions students. Exposing professional students to IPE cultivates IPC and teamwork through clarifying expectations for students who might otherwise adopt a traditional silo approach to working in health care and equipping students with requisite skills and knowledge for effective collaboration with other health care professionals. [1,2] It is hoped that the opportunity to learn together given to those students will make it easier and more likely for them to work together when they graduate.

Hosting this IPE was beset with several logistical challenges including lack of time, scheduling complications and lack of adequate venues and other resources. Similar and more challenges have been reported in the literature including faculty’s comfort level with IPE and crowded curriculum. [18–20] Other studies have reported that lack of administrative and faculty support [13,18,19] was an impediment, but this was not a major issue in our case. Overcoming these barriers is possible with committed faculty and support from administrators and the availability of adequate classroom space.

It is unclear why pharmacy students had significantly more favorable opinions about IPE than dental students in general. However, oral health care professionals tend to care for their patients “with limited interaction with other health care professionals in a clinical setting” [7,21] and as leaders of the oral health care team. [22] Traditionally, dentists were trained in a “silo” approach and tended to work in isolation from other health care professionals. [23] On the other hand, pharmacists by nature of their practice tended to work with many other health care professionals including physicians, nurses and social workers among others. Other studies have found that pharmacy students had significantly more favorable attitudes toward IPC than dental students. [13,16,17,22] More studies are needed to explore this association.

This study found that female students had significantly more favorable attitudes than male students on most items. Previous studies found that having women in the group significantly improved collaboration. [24–26] Women have been found to exhibit “higher levels of social sensibility” than men [24] and to be better at reading nonverbal cues and interpreting what others are feeling. [27] These factors may explain why female students had more favorable attitudes on IPE than males. More research needs to be conducted to further explore the relationship between gender and the students’ attitude toward IPE.

This study has several limitations. First, there were more dental students than pharmacy students, and dental students tended to dominate during the discussion sessions and in responding to questions. Second, social desirability response bias may not be completely ruled out. However, there was no incentive for the students to be dishonest given that their responses were anonymous. Third, the one-time event was only two-hours long. More time is needed to expose students to IPE at different time periods throughout the curriculum. Such interventions are more likely to improve the students’ attitudes, skills and knowledge of IPE. Fourth, some students forgot to provide their unique codes on their survey making it difficult to match the pre- and postsurveys for these students. Fifth, this study did not assess the clinical critical-thinking skills of pharmacy and dental students individually versus interprofessionally. Sixth, this study only included students from one university in California and the results may not be representative of all dental and pharmacy students in California or in the United States.

Pharmacy and dental students had favorable attitudes toward IPE before and after the IPE event. The IPE event was associated with a significant improvement in students’ attitudes toward interprofessional education and collaboration. Pharmacy and female students had more favorable attitudes toward IPE than dental and male students, respectively.

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THE CORRESPONDING AUTHOR, Alireza Hayatshahi, PharmD, BCPS, can be reached at ahayatshahi@llu.edu.