Working in Professional Teams
Tierney Kinnison1,2, David Guile1 and Stephen A. May2
1Institute of Education, University College, London, UK
2Royal Veterinary College, UK
We begin this chapter with a brief consideration of semantics. In Part Two, Chapter 7, John Tegzes gave an excellent account of teaching interprofessionalism. The interprofessional education (IPE) that he described primarily involved looking outward to veterinary students learning with members of the human healthcare team, such as doctors, nurses, dentists, and pharmacists. This type of learning can have far-reaching benefits through the consideration of humans, animals, and the environment as an interconnected ecosystem. It is therefore a style of One Health IPE. This chapter, however, looks inward and takes a more focused look at the veterinary team. It considers the professions and occupations that work together within typical veterinary practices across the globe on a more day-to-day basis. Indeed, the title of this chapter could have been very similar to John Tegzes’s and included the term interprofessional; its subject is interprofessional working, but at a different level. In the United Kingdom, where our research has so far been based, veterinarians have been recognized as a profession since the Royal College of Veterinary Surgeons (RCVS) was set up in 1844. Far more recently, in February 2015, a new Royal Charter came into effect that acknowledges veterinary nurses as a profession in their own right, and ensures their coherent regulation alongside veterinarians. Therefore, we have called our previous research regarding the relationship between veterinarians and veterinary nurses interprofessional. This chapter is instead termed working in professional teams. The important point is that, in the modern day, members of the veterinary profession will work alongside members of the veterinary nursing profession (in countries including the United Kingdom) and veterinary technicians (for example in the United States), as well as those in other occupations such as practice managers, receptionists, and animal physiotherapists, and animal charities. They must work as a team, whether we call it an interprofessional, multiprofessional, uniprofessional, or simply a professional team.
Published research on the topic of the veterinary team, whether it is regarding working in practice or educational strategies, is sparse. This chapter will therefore, in addition, make use of research from the medical field, which currently is ahead of veterinary research. We hope, as the importance of veterinary teamwork is increasingly appreciated, to encourage those in our field to help us catch up.
The chapter will first consider the rationale for teaching students about working in veterinary professional teams. It will then outline in detail an example of designing, running, and evaluating two educational interventions designed for veterinary and veterinary nurse students, with reflection on where to go next. Finally, the issue of assessing teamwork will be discussed.
The veterinary profession has evolved enormously over the course of its existence. Initially, the first veterinary schools in the world focused almost exclusively on the horse as the type species (Mitsuda, 2007), with some attention paid to cows and sheep in terms of their use as food animals. The students were all male, would graduate within a few years, and would set up practice on their own. They would charge for their services, but would perhaps also accept payment in kind, as in the portrayal of British veterinary surgeon James Herriot, who inspired a generation of veterinarians. Today this scene is an increasing rarity. Veterinary practices are becoming larger businesses, which these days are more likely to see a multitude of pet cats and dogs rather than any other species. They frequently employ a large group of veterinarians (including specialists) who carry out disease diagnosis and create treatment plans, along with veterinary nurses/veterinary technicians and assistants who cover all aspects of patient care. Practice managers, human resources managers, and finance managers have the expertise to deal with running the business side. Receptionists provide a front-of-house role and are the first point of contact for clients. Outside of the practice itself, veterinarians may work alongside other animal-related groups such as charities, farriers, farmers, equine dentists, and drug company representatives, as well as other nonmedical groups, for example accountants, web designers, and law enforcement officers, to name but a few (Root Kustritz, Molgaard, and Tegzes, 2013).
All of these groups, especially the in-practice groups, have developed their working roles alongside veterinarians, whose roles also continue to change. Creating a team with complementary knowledge, skills, and attributes is desirable for service efficiency and effectiveness. The availability of different ideas and perspectives can enable a team to solve problems in a way that one individual, or one profession on their own, could not achieve (Patterson et al., 2001). It is just not feasible for most veterinarians to work in isolation any more. The evolution of roles can, however, potentially lead to disagreement over which group performs which tasks, known as a “jostle for jurisdiction” (Adler, Kwon, and Heckscher, 2008). Using the right person for the task and making use of their professional skills is a strategy that is likely to have benefits for the practice (cost effective), the team (working environment), the client, and the patient, as explored in our paper that more fully details the rise of teamwork within the veterinary field (Kinnison, May, and Guile, 2014).
In order to achieve the beneficial outcomes that teamwork can offer, the team must perform efficiently and effectively. Several factors have been identified in medicine that affect teamwork. They include team structure factors (premises, size/composition, and organizational support) and team processes (meetings – with a culture of trust and respect – clear goals, nonblurred roles, and audit/reward) (Xyrichis and Lowton, 2008). Issues of power and status, common to interprofessional research, are still relevant when focusing on the veterinary team. Veterinarians continue to hold a position of power within the traditional hierarchical structure, which has developed as veterinarians have appointed other groups to join their veterinary practices. However, the relationships may be in flux while occupations gain more status and become professions, as veterinary nurses have done in the United Kingdom (Kinnison, May, and Guile, 2014). Communication underlies all teamwork and has frequently been identified as a source of medical error (for example, Alvarez and Coiera, 2006), which can lead to inefficiency, tension, inconvenience to patients, and procedural error (Lingard et al., 2004). Communication with colleagues has been identified by veterinary students and recent graduates as the second most important attribute of a veterinarian, only beaten by communication with clients and the public (Rhind et al., 2011). To foster trust, respect, and understanding of roles within the team, and to improve communication in order hopefully to minimize error, we suggest that the concept of working in professional teams should be included within the curriculum of veterinary students. It is important that veterinary education reflects real-life working so that it avoids issues such as dissonance and produces well-functioning teams.
Designing Face-to-Face Veterinary Team Interventions
A project conducted at the Royal Veterinary College (RVC), University of London, has produced the only peer-reviewed papers to date relating to the creation and evaluation of educational interventions specifically for the clinical veterinary team (veterinarians and veterinary nurses). The project itself was interprofessional, with staff coming from the veterinary nursing school and the Lifelong Independent Veterinary Education (LIVE) Centre and consisting of educationalists, veterinarians, and veterinary nurses. A summary of the project is outlined here, but more information on the analysis (Kinnison et al., 2011) and how to run the interventions (Kinnison et al., 2012) is available for those with a particular interest in the area. Resources relating to the interventions are available on the LIVE Centre’s website (LIVE, n.d.). The resources are free to download and we encourage their use and evaluation in other colleges and universities.
The RVC is fortunate in having both veterinary students and veterinary nursing students studying on the same site over periods of their curricula. This project therefore aimed to create face-to-face learning opportunities. It is acknowledged that not all veterinary schools are in this situation. Another potential mode of teaching students about teamwork is online and this is considered later in the chapter.
The project started with stakeholder consultation. The stakeholders were student and qualified veterinarians and veterinary nurses. Focus groups were used to identify potential teamwork issues and to begin to consider educational initiatives. Thematic analysis of the transcripts identified three main issues of teamwork that may occur between veterinarians and veterinary nurses. These were a misconception of each other’s roles, worries about working with other professions, and concerns about differing approaches to patient care. From this, two main objectives were recognized as targets for resources: to increase understanding of professional roles and to enhance communication skills. These objectives were supported by a review of the medical literature, as identified earlier. A resource was subsequently developed to address each objective. The resources had to be cheap to run and easy to facilitate. In creating the educational initiatives, the project team had to consider when and how to run the sessions.
Implementing educational initiatives that involve more than one student group can be challenging. Some professions, such as human physicians, have been identified as more reluctant to join in or appreciate shared learning opportunities (Reid et al., 2006; Horsburgh, Lamdin, and Williamson, 2001). The evaluation of the current veterinary resources also demonstrated a difference between the professions prior to their learning experience, with veterinary nurses being more supportive of the potential benefits than veterinary students. It is important that all educators involved in the promotion of teamwork (which should be everybody) are shown to be in favor of its benefits. Faculty may require training to facilitate IPE in a way that is context dependent, experiential, and allows peer feedback (Hall and Zierler, 2015). There are frequently logistical challenges in the design of novel teamwork activities. The student groups may never learn on the same site as each other and, even if they do, it is likely to be for a limited time. The numbers of students are often disproportionate; in our case there were many more veterinary students than veterinary nursing students. These factors inevitably direct some decisions on implementing the resources. We chose to run our evaluation with third- to fifth-year veterinary students (those toward the end of their degree) and first/second-year veterinary nursing students, as these cohorts were on the same campus. Since this evaluation, we have implemented the interventions in the BSc year (fourth) of the Veterinary Nursing degree and we recruit veterinary students from the third to the fourth years to join them. We considered it beneficial for the ages of students to be similar and for the nurses to have more experience, in order to foster their confidence in interacting with the veterinary students.
The Interventions: Talking Walls and Emergency-Case Role Play
The first intervention aimed to address the objective of increasing understanding of roles. It was adapted from an existing intervention in medicine, Talking Walls, and allows groups to identify their own and each other’s professional roles (Parsell, Gibbs, and Bligh, 1998). All that is needed for this session is a room (as large as possible), flipchart paper, and colored marker pens. It works best for groups of 15–25 with an equal split of members of each profession (this example is for two veterinary professions, but it could be used for One Health IPE and a greater number of professions could be involved). The session requires a facilitator to carry out the following stages over a course of approximately an hour to an hour and a half:
- Introduction to team-based learning.
- Divide the class into subgroups of about 6–8 people with an equal split of members of each profession.
- Allow the subgroups time to get to know each other.
- Split the subgroups up into uniprofessional groups and give each of them a sheet of flipchart paper.
- Ask them to write the roles and duties of the other profession on the sheet in a green pen. Roles can be general or specific and do not have to apply only to that group.
- Swap the flipchart sheets over so that the groups can see what the other profession has written about them. Give them a red pen to make amendments, additions, and deletions.
- Bring each subgroup back together to discuss the charts. Ensure that there is an atmosphere of sharing and encourage explanation of thoughts to overcome stereotypes and misconceptions.
- Bring the whole group together to explore the results and to extend the session to consider other groups with which they will both work.
Emergency-Case Role Play
The second intervention aimed to enhance the appreciation of communication skills between members of the veterinary team while allowing practical teamwork skills to be practiced. Communication is now an integral part of veterinary curricula (Mossop et al., 2015), but, as with physicians in healthcare (Stone 2010), it focuses on veterinarians communicating with clients and often neglects communication within the team, or between the team and clients. This intervention is a basic simulation using a model of a dog requiring cardiopulmonary cerebral resuscitation (CPCR). CPCR is an emergency situation that could happen at any time and requires effective teamwork from any and all available staff. During the evaluation of the intervention, pairs of students (one veterinary student and one veterinary nurse student) undertook the scenario separately. Since the evaluation it has become apparent that this is unfeasible given logistical issues such as time and group size. Therefore, the session is now run as a group session in which pairs of students conduct the role play in front of their peers. The role play is run several times with suggested improvements incorporated.
At the beginning of the role play, a facilitator describes the patient’s clinical situation. The patient has “crashed” (no spontaneous ventilation or circulation) and the students are told to resuscitate the patient as if in a real-life situation. The facilitator observes clinical as well as interpersonal aspects of the task, such as how long it took for any action to occur, leadership, and the effectiveness of communication. During the intervention evaluation, the students were provided with feedback as a pair. In the new format, peers also volunteer feedback to the pair, both during and after the role play.
Evaluating Teamwork Interventions
Freeth et al. (2005) developed a typology of interprofessional education outcomes based on Kirkpatrick’s original four-level evaluation pyramid. The levels are:
- 1) Reaction
- 2a) Modification of attitudes/perceptions
- 2b) Acquisition of knowledge/skills
- 3) Behavioral change
- 4a) Change in organizational practice
- 4b) Benefits to patients/clients, families, and communities.
Freeth et al. (2005) claim that their levels, like Kirkpatrick’s, are not hierarchical. As the levels are not hierarchical and each has its own value, it is desirable to conduct evaluations that cover all levels. However, the majority of publications that focus on evaluation concentrate on the first levels in terms of asking students about the value and feasibility of the initiative, while longitudinal demonstrations of behavior change are rare (Olson and Bialocerkowski, 2014).
Our initial evaluation was part of this trend and was aimed at Levels 1 (reaction) and 2a (modification of attitudes and perceptions). This was achieved through a questionnaire regarding the individual interventions alongside an adapted version of the Readiness for Interprofessional Learning Scale (RIPLS), developed by Parsell and Bligh (1999). Suggesting that there are attitudinal, organizational, and structural challenges to implementing IPE, but that attitudes are the hardest to change, we wanted to create a questionnaire that could assess readiness for interprofessional learning.
Thannhauser, Russell-Mayhew, and Scott (2010) conducted a review of instruments designed to measure aspects of interprofessional collaboration and education, and included instruments that could involve a range of roles and situations, rather than being specific to one interaction or team. The inclusion criteria reduced the hundreds of abstracts found to eight formal measures. The majority of these questionnaires, however, were only ever used once or twice and had limited assessments of validity. Only two instruments were considered to be accessible and psychometrically validated. These were RIPLS and the Interdisciplinary Education Perception Scale (IEPS), originally developed by Luecht et al. (1990). While the IEPS was designed specifically to be a pre- and post-intervention assessment of changing attitudes, the RIPLS is an assessment of readiness for interprofessional learning that can be used once or repeatedly, and according to the literature has been validated across disciplines, stages of education, and countries (e.g., Reid et al., 2006; McFadyen et al., 2005; Lauffs et al., 2008). However, there is a continuing debate over the precise makeup of the scale items, and indeed the validity of the scale as a whole, due to low internal consistency of subscales, which has promoted the recent suggestion of utilizing individual scales for different competencies (Mahler et al., 2015). Back in 2010 when we undertook this pilot to gauge the veterinary professions’ changing opinions of team interventions, the RIPLS was chosen as the instrument to adapt and use. The adaptation primarily consisted of the term “healthcare students” being replaced by “veterinary and veterinary nursing students” or “students from the other veterinary professions” where appropriate. The “healthcare team” became the “veterinary team.” The scale is split into three subscales – Teamwork and Collaboration, Professional Identity, and Client and Patient Centeredness – with a total of 23 items rated on a five-point Likert scale from strongly disagree to strongly agree. Demographic questions relating to gender, age, area, time of qualification, route to qualification, and current employment were also included. The scale was then sent to two veterinary nurses and two veterinarians involved in education at the RVC who are knowledgeable regarding the design of questionnaires. Comments were sought regarding clarity of instructions, accuracy of items, and layout. All appropriate edits were included.