Learning to swallow together: Medical and speech and language therapy student interprofessional learning about dysphagia

2.1Participants

This study employed a pre-post, mixed-methods, quasi-experimental design to explore the learning of undergraduate SLTs (entering their penultimate year) and undergraduate/ graduate entry MEDs (entering their final year), following participation in one of two identical 3-hour dysphagia-focussed IPE workshops. These cohorts were selected as examination of both curricula indicated closely aligned dysphagia knowledge. Prior to the workshop, students had received uniprofessional introductory education related to the anatomy and physiology of the swallow and attended various clinical placements, though none focussed on dysphagia management. Students were randomly assigned to one workshop and then to small groups comprising 4–5 students, with at least two students from each discipline. Students were permitted to attend (compulsory for SLTs only) even if they chose not to participate in the research. Of the 58 students who were scheduled to attend the workshop, 50 students (25 SLT and 25 MED) attended.

2.2Ethical considerations

Ethical approval was sought and approved through the University’s Social Research Ethics Committee and Research & Postgraduate Affairs Committee.

2.3IPE workshops

The workshops were classroom-based, each facilitated by an SLT who was clinically experienced in dysphagia management and skilled in workshop facilitation. Workshop content development was led by author MC (SLT) alongside discussions with authors HK (SLT) and HH (MED), so workshops were tailored to both cohort’s educational needs. Influenced by the principles of Universal Design for Learning (Rose et al., 2006) and Entry Points to Learning (Gardner, 1991), student learning was maximised through active engagement, and teaching methods combined didactic, case-based discussions, and practical group activities. The workshop was organised into four parts. Learning was guided through discussion about causes, presentation, and management of dysphagia, interprofessional roles, ethical considerations, and discussion of real and simulated patient cases. Small group activities and discussions helped to illuminate, exchange, and consolidate knowledge which was shared with the main class. With the exception of patient-facing interaction, the content, learning methods (Appendix 1), and anticipated learning outcomes aligned with recommended IPE framework (Steven et al., 2017) and learning competencies (O’Keefe et al., 2017) (Table 1). Participating students signed a confidentiality document agreeing not to discuss or retain patient-related information beyond the workshop.

2.4Workshop evaluation

This study was evaluated through anonymised paper-based pre- and post-workshop number matched questionnaires. Students were given the questionnaire pairs and allocated time for completion during the workshop. With permission, Anderle et al.’s (2018) questionnaire was adapted and piloted in our previous study with medical students (Kelly et al., unpublished). We further adapted it for this IPE study (Appendix 2). The pre-workshop questionnaire comprised 15 multiple choice, Likert scale and free text questions, which explored the knowledge, previous education, clinical experience, and confidence concerning dysphagia. The post-workshop questionnaire comprised 16 questions to evaluate change in dysphagia knowledge, and gathered opinions on the benefits, advantages, and challenges of IPE as experienced by the students. Students placed completed or blank (if they did not wish to participate) questionnaires in a box when leaving the classroom.

2.5Data analysis

A guide was developed by authors MC and HK indicating acceptable responses to questionnaire questions 10 (signs of dysphagia) and 12 (role of professionals). Data entry and statistical analyses were carried out by authors SD and OT who were not involved in the study design or training. Analyses were independently checked for accuracy by author HK. Questionnaire responses were entered into IBM SPSS Statistics for Windows, Version 27 for analysis. Descriptive statistical analyses were carried out to summarise the data and facilitate data interpretation. Data were mainly nominal and ordinal scales with a relatively small sample size. Therefore, inferential statistical analysis of the data included non-parametric measures of Wilcoxon Signed-Rank test for Repeated Measures to compare the means across variables pre- and post-workshop. A p-value of 0.05 was considered significant in pre-post (one-tail) and between MED-SLT cohorts (two-tail). Any significant results found were further analysed using post-hoc tests (Mann-Whitney U-test) with Bonferroni adjustment to determine any differences between MEDs and SLTs. Spearman’s rank-order correlation was carried out to determine the relationship between correct and incorrect answers for dysphagia symptoms and medical conditions. Responses to the comments sections of the questionnaires were transcribed by SD and OT and entered into an Excel sheet. As the dataset primarily comprised one sentence responses, we took a qualitative descriptive approach which according to Sandelowski (2000, p.339) is the “method of choice when straight descriptions of phenomena are desired”. SD, OT and HK independently read the responses and undertook content analysis of the data by systematically applying codes, which were then further analysed. The codes were tagged by discipline to allow examination of any differences in experiences between the cohorts. Themes were identified based on the codes that occurred more commonly throughout the data and were agreed with the research team.

3.1Pre-workshop experience of dysphagia

Pre-workshop, 26/49 students (2/24 MED; 24/25 SLT) reported having previous dysphagia education; 21 students provided details about the nature of education received. SLTs detailed academic education, including lectures and Problem Based Learning (n = 15); 1st year workshops (n = 6) and videofluoroscopy swallow observations (n = 4), and some listed specific topics (n = 4). One third of participants (10 MED; 6 SLT) had encountered a patient with dysphagia during clinical placement.

3.2Knowledge about dysphagia

Both cohorts scored highly in identifying the correct sequence of swallowing, dysphagia definition and complications of dysphagia (Table 2). Wilcoxon Signed-Rank tests indicated statistically significant differences between pre- and post-workshop knowledge for the identification of all potential dysphagia symptoms (z = 4.624, p < 0.001) and all medical conditions that could cause dysphagia (z = 3.247, p < 0.001). Post-hoc analysis found no significant difference in knowledge between cohorts (p > 0.025). As students could potentially select every correct and incorrect response (Table 2) a Spearman’s rank-order correlation was run to determine the relationship between correct and incorrect answers for dysphagia symptoms and medical conditions. There was a weak positive correlation between correct and incorrect dysphagia symptoms pre-workshop only, which was statistically significant (r_s (47) = 0.340, p = 0.17). No other associations were found.

Students listed signs of dysphagia which we classified into oral preparatory/oral, pharyngeal, and oesophageal swallow phases, and other clinical signs independent of swallow phases, for example, eye tearing or recurrent chest infections. The most reported signs of dysphagia were at the pharyngeal phase for both cohorts pre- (n = 22 MED; 41 SLT) and post-workshop (n = 28 MED; 39 SLT). Other clinical signs reported pre- (n = 19 MED; 12 SLT) and post-workshop (n = 25 MED; 23 SLT) were statistically significant between workshops (z = 2.621, p = 0.009) but not between-groups. Fewer oral phase signs were reported pre- (n = 1 MED; 7 SLT) and post-workshop (n = 4 MED; 4 SLT). One MED noted an oesophageal phase sign post-workshop. Incorrect signs were indicated by pre- (n = 15 MED; 9 SLT) and post-workshop (n = 9 MED; 10 SLT), with ‘I don’t know/no response’ pre- (n = 11 MED; 3 SLT) reducing post-workshop (n = 7 MED; 1 SLT). A statistically significant difference was identified between pre- (n = 9 MED; 5 SLT) and post-workshop (19, MED; 20, SLT) knowledge about appropriate medication administration (z = 4.811, p < 0.001) but no difference between-groups.

Students rated their confidence in identifying dysphagia. The mean rating pre-workshop was x¯ = 5.08 (SD = 1.644). When asked what would further increase their confidence, both cohorts (n = 19 MED; 22 SLT) provided suggestions. The most highly identified need was for education (n = 15/19 MED; SLT 13/22), with SLTs in particular highlighting a desire for practical patient experience (n = 3 MED; 13 SLT). Two MEDs noted needing more interactions with SLTs. Wilcoxon Signed-Rank tests identified a statistically significant increase in confidence rating post-workshop ( x¯ = 7.65 (SD = 1.393)) (z = 6.014, p < 0.001). Post-hoc analysis revealed no significant difference between the cohorts. The main educational need highlighted by both cohorts (n = 13 MED; 19 SLT) post-workshop was for practical patient experience (n = 12 MED; 15 SLT). One SLT indicated the need for further education and two reported feeling more confident following the workshop. As with pre-workshop, 2 MED students noted that more interactions with SLTs would further increase their confidence.

3.3Knowledge about interprofessional roles in dysphagia management

Most students (n = 42/49) identified SLT as the main profession responsible for dysphagia management pre-workshop which slightly increased post-workshop (n = 47/49) (Table 3). There was no significant difference between workshops or the two cohorts (p > 0.05).

Students rated the relevance of dysphagia to their own clinical practice. Wilcoxon Signed-Rank tests revealed a statistically significant difference between pre- ( x¯ 8.82(SD = 1.481)), and post-workshop ( x¯ 9.12 (SD = 1.269)) (z = 1.977, p = 0.025). Post-hoc analysis found a significant difference between the cohorts pre- (U = 113.5, z = 4.008, p > 0.001) and post-workshop (U = 183, z = 2.686, p = 0.004) with SLTs recognising greater relevance than MEDs pre- and post-workshops. Students provided rationales for their ratings pre- (n = 19/24 MED; 20/25 SLT) and post-workshop (n = 10/24 MED; 16/25 SLT). The most prominent rationales related to (i) anticipated professional roles pre-workshop (n = 11 MED; 16 SLT) and post-workshop (n = 3 MED: 11 SLT), followed by (ii) medical conditions, complications and impact pre-workshop (n = 6 MED; 2 SLT) and post-workshop (n = 8 MED), (iii) part of curriculum pre-workshop (n = 3 SLT), (iv) effect on patient quality of life (n = 2 MED; 1 SLT) post-workshop and (v) one MED stated pre-workshop that it had ‘limited impact’ on their clinical role.

Students described the main roles of nine HCPs in dysphagia management (Table 3). Responses were classified into ‘dysphagia role’, ‘extended role’ (more general patient care), ‘incorrect roles’ and ‘no response’. Wilcoxon Signed-Rank tests revealed a statistically significant difference between pre- and post-workshops for dysphagia management roles of nursing (z = 2.111, p = 0.033), pharmacy (z = 2.041, p = 0.032), occupational therapy (z = 2.524, p = 0.01) and physiotherapy (z = 3.962, p < 0.001). Post-hoc analysis highlighted that pre-workshop MEDs were significantly more knowledgeable than SLTs about the pharmacy role (U = 173, z = 3.041, p = 0.002). There was no between-group differences post-workshop.

3.4Student IPE experiences

Students rated how beneficial they found the IPE experience ( x¯ = 7.86 (SD = 2.179)). Mann-Whitney U-test found no statistical difference between SLT and MED ratings (p = 0.305). Three common themes emerged from the qualitative descriptive analysis of student comments (16/24 MED: 18/25 SLT) (Table 4). The first theme ‘Learning’ provided insight into mixed feelings regarding the information covered in the workshops. Some students reported having prior knowledge of some material, with one SLT commenting that it was “a lot of revision for SLT students”. Others identified new areas of learning –“helped explain cause & diagnosis of dysphagia & treatment options, practical information”. Another theme highlighted the ‘Communicative Exchange’ between the students which was positive overall. Students reported beneficial learning from “getting other perspectives” in relation to patient care. The final theme ‘Interdisciplinary Role’ highlighted student learning about each other’s role in dysphagia management. Students commented that they “learned a lot about what SLTs do” and “realis[ed] the needs for information of other professionals”.

3.5Challenges and advantages of IPE

Students documented challenges and advantages of IPE. Five common themes highlighted challenges experienced during IPE (n = 18/24 MED; 17/25 SLT) (Table 5). The first theme ‘Prior Knowledge’ emphasised that “different knowledge levels” pre-workshop was considered challenging (6/18 MED; 8/17 SLT). Despite the inclusion of icebreakers and small group tasks, ‘Group Familiarity’ was noted to be a challenge of IPE by both cohorts (7/18 MED; 4/17 SLT) with several students stating that “meeting new people” and “getting to know others” was challenging. The theme of ‘Communicative Exchange’ was identified as students (11/18 MED; 8/17 SLT) reported struggling with conflicting opinions and perspectives. For instance, students reported “clashing points of view” and that “open discussion is difficult”. This negative perception extended to ‘Patient Care’ where some students (4/18 MED; 6/17 SLT) believed there were “differing priorities for the patient” between disciplines. A lack of understanding about ‘Interdisciplinary Roles’ was highlighted as challenging (3/18 MED; 8/17 SLT) with students commenting that “understanding a new discipline” was difficult. Several MEDs (6/18) commented that the timing of the workshop was burdensome “take[ing] up a lot of time in final year”.

Five themes were identified as advantages of IPE (24 MED; 22 SLT) (Table 6). The first theme ‘Knowledge’ (14/24 MED; 6/22 SLT) highlighted the benefits of “sharing knowledge” noting that the disciplines were “knowledgeable in different areas”. While the theme of ‘Communicative Exchange’ was previously noted to be a challenge, students (14/24 MED; 16/22 SLT) noted benefits of “exchang[ing] ideas” and “acknowledging different perspectives”. The advantage of IPE for ‘Patient Care’ was identified with both cohorts (7/24 MED; 8/22 SLT) remarking that IPE “aids holistic care” with “real world application”. ‘Team-Work’ was another identified theme where students highlighted that IPE fosters teamworking by “build[ing] rapport with other specialties” and “encourag[ing] cooperation”. The final theme ‘Interdisciplinary Roles’ identified by both cohorts (18/24 MED; 14/22 SLT) highlighted the importance of “learning about [the] role of another speciality” as being an advantage of IPE.

4.1Knowledge and confidence around dysphagia management

The education intervention had a significant positive effect on the learning of both student cohorts. Prior to the workshop, most students understood the correct swallow phases and definition of dysphagia. However, knowledge pertaining to the symptoms and medical causes of dysphagia, and medication administration showed statistically significant improvement following active shared learning, for both cohorts. Importantly, students reported having more confidence in identifying a patient with dysphagia following the workshop. While most students recognised the SLT as primarily responsible for dysphagia management, knowledge regarding the roles of other HCPs involved in dysphagia care increased significantly post-workshop, in particular nursing, occupational therapy, pharmacy, and physiotherapy. While SLTs rated the relevance of dysphagia more highly than MEDs, there was a significant positive shift in acknowledging its relevance to clinical practice post-workshop by both cohorts. This fostered important professional awareness given that a team approach to dysphagia management is considered optimal for positive patient outcomes (Aoki et al., 2016; Clavé & Shaker, 2015; Middleton et al., 2011).

4.2Student experience of IPE

Both cohorts rated their IPE experience overall as beneficial and highlighted advantages in relation to the acquisition and sharing of knowledge. Even so, student comments sometimes appeared contradictory. There was a sense of them wrestling with the challenges of IPE while simultaneously appreciating its benefits. While students welcomed the opportunity to hear the perspectives of the other discipline, they found it challenging to negotiate conflicting opinions and manage the communicative exchange, with one MED asking, “Who captains the ship”? Perhaps this is part of the essential growing process, shifting beyond what Eichorn et al. (2020) term as the ‘uniprofessional lens’ and broadening their understanding and appreciation of their future clinical selves within an interprofessional team. This shift can be challenging for students who, according to Vuurberg et al., (2019, p.158), may have previously engaged in a “socialisation process and mono-disciplinary learning experiences [that] enforce professional boundaries and silos”. This raises the complex question regarding the timing of IPE in healthcare curricula. On one hand, students must acquire specialist knowledge about their discipline and develop their own professional identity, whilst also learning how to work collaboratively with other disciplines. There is no clear-cut solution as various dynamics need consideration, such as age, mature students versus school leavers, prior knowledge, and previous teamwork experience (Anderson & Thorpe, 2008).

According to Reeves et al. (2016) for effective learning, IPE should ideally be carried out in a context that reflects the students’ future practice. Cox et al. (2016) also raise concerns that most IPE is classroom-based and recommends that to align IPE and healthcare services, IPE should relocate to clinical environments and include the patient, family, and caregiver experiences. However, our study and others (Anderson et al., 2011; Morison et al., 2003; Vuurberg et al., 2019) have demonstrated positive outcomes from classroom-based learning. Our classroom-based IPE workshop provided opportunities for teamwork activities and shared learning about a complex health condition. As our materials included real and simulated patient data with corresponding authentic ethical challenges, students were exposed to experiences requiring conflict resolution in interprofessional groups. Additionally, substantial clinically relevant knowledge acquisition is evidence of the value of IPE in an educational setting. However, our students emphasised the need for hands-on dysphagia-focussed clinical practice and considered it fundamental to improving their confidence in dysphagia management. Morison et al. (2003) report student preference for combining classroom and ward-based learning, considered particularly effective for supporting students to feel part of a clinical team. Anderson et al. (2011) found that IPE in clinical settings had a greater impact on student learning than classroom-based alone. Bringing IPE to the patients, or the patients to the classroom would further enhance clinical learning, where students can experience teamwork in action. This patient-facing interaction could also facilitate meeting relevant patient-related IPE learning competencies (O’Keefe et al., 2017).

4.3Limitations and future research

Questionnaire comments provided several insights into student IPE experiences. Some students reported a negative impact on discussions due to different prior knowledge around dysphagia. Future IPE could take a flipped-classroom approach where students would view cross-disciplinary learning materials to ensure an equitable knowledge base before IPE engagement. We erroneously assumed that student experience in working effectively in within-discipline groups would automatically transfer to cross-disciplinary learning. Machin et al. (2019) note student groups commonly feel anxious about revealing their potential lack of knowledge in IPE. Our findings concur, suggesting the need for preparatory support regarding expectations to reduce vulnerability when sharing knowledge with other disciplines. Reflective of the learning approach at our teaching hospital and university, students learn about dysphagia management from clinically experienced SLTs. However, Morison et al. (2003) found their students relied on faculty from their own discipline for encouragement in engaging with IPE. Therefore, students may benefit from having workshop facilitators from each discipline, modelling interprofessional collaboration in their teaching (Anderson et al., 2011). Finally, though potentially logistically challenging (Barrett et al., 2003), future IPE could expand the range of disciplines included, for example, dietetics, pharmacy, and other HCPs, thus providing learning opportunities more reflective of interprofessional discussions of complex dysphagia cases. This would provide a larger sample size but importantly better prepare healthcare students to become a ‘collaborative practice-ready’ workforce (WHO, 2010).