2011; 33: e22–e26

WEB PAPER

Effects of interprofessional education onpatient perceived quality of care

KARIN HALLIN, PETER HENRIKSSON, NILS DALEN & ANNA KIESSLING

Karolinska Institutet, Sweden

Abstract

Background: Active patient-based learning by working together at an interprofessional clinical education ward (CEW) increases

collaborative and professional competence among students.

Aim: To assess the patients’ perceptions of collaborative and communicative aspects of care when treated by interprofessional

student teams as compared to usual care.

Method: Patients treated by student teams (medical, nurse, physiotherapy and occupational therapy students) at a CEW

comprised the intervention group. Patients treated at a regular ward were taken as controls. The patients answered a questionnaire

representing collaborative and communicative aspects of care. Questionnaires from CEW (n¼ 84) and control (n¼ 62) patients

were obtained (82% vs 73% response rates).

Results: CEW patients rated a significantly higher grade of own participation in decisions regarding treatment as compared to

controls (p¼ 0.006). They did further rate a higher grade of satisfaction with information regarding need of help at home

(p¼ 0.003) and perceived that the CEW staff had taken their home situation into account at a higher grade in the preparation of

discharge (p¼ 0.0002). Finally, CEW patients felt better informed (p¼ 0.02).

Conclusion: Patients perceived a higher grade of quality of care as compared to controls with no signs of disadvantages when

treated and informed by supervised interprofessional student teams.

Introduction

The main aim of clinical education is to develop a competence

to perform high-quality health care. However, it has been

difficult to assess to what extent this mission is fulfilled.

In traditional disciplinary clinical education, the different

professions learn very little from and about one another.

However, in shared learning, students are enabled to acquire

knowledge, skills and attitudes that they would not be able to

acquire effectively in uniprofessional education (Funnell

1995). Interprofessional education (IPE) occurs when two or

more professions learn with, from and about each other in

order to improve collaboration and the quality of practice

(CAIPE 2002). IPE increases the students’ ability to look at the

task from the perspective of other professions as well as from

the perspective of their own profession (Barr 1996). Clinical

interprofessional education wards (CEWs) were established in

1998 in Sweden and in 1999 in the United Kingdom. These

clinical practice wards are platforms of clinical IPE. They

provide an opportunity to pre-qualified health care students to,

under supervision, systematically develop, e.g. collaborative

skills (Mogensen et al. 2002; Reeves & Freeth 2002; Reeves

et al. 2002; Ponzer et al. 2004; Hallin et al. 2008).

We have previously shown that active patient-based

learning by working together at a CEW was an effective

means for the students to increase their collaborative and

professional competence. All four student categories at our

CEW improved their knowledge of other professions’ work,

their own professional role and the educational period

profoundly contributed to the students’ understanding of the

importance of communication and teamwork to the quality of

patient care (Hallin et al. 2008). However, there is a paucity of

studies assessing effects at patient level when patients are

treated by supervised students (O’Malley et al. 1997). This is

true in particular as regards studies assessing the patients’

perceptions and experiences of the quality of care when

treated by interprofessional student teams.

The aim of this was to assess the patients’ perceptions of

collaborative and communicative aspects of care when treated

at a CEW as compared to usual care.

Practice points

. To evaluate outcome of medical education at patient

level is important, complicated, but possible.

. We have shown that from a patient perspective the CEW

provides increased quality of communication and col-

laboration as compared to usual care.

. We found no signs of disadvantages when patients were

treated and informed by supervised interprofessional

student teams.

. A more structured interprofessional team-based care

may be beneficial even in usual care.

Correspondence: K. Hallin, Capio Artro Clinic AB, Box 5605, SE 11486 Stockholm, Sweden. Tel: 46 701684849 or 46 709605827; fax: 46 84062691;

email: karin.hallin@capio.se

e22 ISSN 0142–159X print/ISSN 1466–187X online/11/010022–5 � 2011 Informa UK Ltd.

DOI: 10.3109/0142159X.2011.530314

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Methods

Patients and study design

The CEW at Danderyd University Hospital, Stockholm,

Sweden, was incorporated as a part of a regular orthopaedic

ward during the period of this study (2004–2005), where CEW

consisted of eight patient beds and the rest of the ward had 12

patient beds. The patients treated at the ward represented a

wide variety of orthopaedic diagnoses. They were admitted

both from the emergency room and for elective surgery. A

majority of the patients were elderly and presented – besides

the orthopaedic diagnosis – a wide range of other diagnoses

such as cardiovascular diseases, diabetes and malnutrition.

Patients were randomly allocated to the CEW or to the regular

part of the ward depending on patient beds available at the

moment. Only patients in need of a single room or with

dementia were excluded from care at the CEW. A staff nurse –

at the arrival to the CEW – informed all patients about the CEW

concept. They had an option to be treated by regular staff.

Very few patients used this option. The occupational therapy

supervisor was placed at CEW solely and the regular ward had

another occupational therapist at their service. The rest of the

staff had rotating schedules at the entire ward, including both

CEW and the regular ward. Due to pedagogic skills and

interest, some of the staff had their main placement at CEW.

The staff were not instructed to alter their clinical practice

when they changed between the regular part of the ward and

the CEW. During weekends and other periods, with no

students at the ward, regular staff treated all patients.

Accordingly, the ward context with facilities, personnel and

medical profile was equivalent in the two parts of the ward and

the main difference was the participation of students at the

CEW. Supervised IP pre-qualification student teams consisting

of 1–2 medical students, 3 nurse students, 1 physiotherapy

student and 1 occupational therapy student per team treated

patients at the CEW. The 2-week CEW course was mandatory

to the medical students during their eight term (out of 11) and

to the other three student categories during their last (sixth)

term. The main objectives of the students were to provide the

patients independently, but under supervision, with good

medical care, nursing care and rehabilitation activities; to

develop their own professional role; to enhance their under-

standing of the other professions and to highlight the

importance of good communication to teamwork and to

patient care. The supervisors, representing all four professions,

supported the students but kept to the background to give the

students’ all opportunities to get involved. The cooperation

and communication with patients as well as direct patient care

were thus mainly performed by the students. Further details

regarding intended learning outcomes, teaching and learning

activities of the students, etc., have been presented earlier

(Ponzer et al. 2004).

Patients at the regular part of the ward were also treated by

interprofessional teams but with qualified professional staff.

However, these teams were less structured and did not include

IP student attendance.

We assessed all patients who were treated and prepared for

discharge to their homes at the ward during the study period.

Patients discharged to another clinic or to inpatient aftercare

were excluded. Furthermore, patients in need of a single room,

usually due to serious illness or at high risk to acquire an

infection and patients suffering from dementia were excluded.

The reason was that care of such patients could not be

performed at the CEW. We excluded patients discharged from

the ward during weekends and on holidays when no students

were present. In addition, patients readmitted to the hospital

within 4 weeks after discharge were excluded.

Thus the CEW group consisted of patients treated and

prepared for discharge by supervised IPE student teams at the

CEW. The control group consisted of equivalent patients

treated by ordinary staff without participation of students.

Outcome measures

All patients included in the study were asked to fill out a

questionnaire after they had been prepared for discharge, i.e.

after all information had been given to the patients by the

students at the CEW or by the ordinary staff at the regular

ward. In order to diminish any bias, only two persons handed

out or mailed the questionnaires to the patients. Seven

questions were chosen from a valid patient satisfaction

questionnaire (Jenkinson et al. 2002) regularly used by the

hospital for quality assurance purposes. The questions con-

cerned the collaborative and communicative aspects of care –

areas were student involvement could have a positive or

negative impact. The patients had the option to fill out the

questionnaire and put it in a sealed envelope at the ward or

they could fill it out at home and use regular mail service.

Patients who did not get a questionnaire at the ward had one

sent to their homes within a week after discharge. In case of a

missing answer, one reminder was mailed within 4 weeks after

discharge. All patients had given written informed consent to

participate and were informed that the answers were to be

analysed at group level with no possibility to identify the

answers of a particular individual.

Statistical analysis

The aim of the analysis was to assess the effects of the IPE

initiative on patient perceived quality of care. The assessments

by patients at the CEW were compared to those of the control

patients treated by qualified professional staff teams (usual

care). Nonparametric and Chi-square analyses were per-

formed. The patient characteristics are given as n (%) or

n� SD. The results were considered significant at p5 0.05. All

analyses were performed with the STATISTICA Stat Soft, Inc

8.0 package.

Results

The study population consisted of 102 patients in the CEW

group, treated by the student teams and 85 patients in the

control group (usual care), treated by regular staff. A total of 35

reminders were mailed to patients in the CEW group and 26 to

the controls. A total of 84 patients filled out the questionnaire

in the CEW group and 62 patients in the control group. The

response rates were 82% and 73%, respectively. There were no

Quality of care by interprofessional learning

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significant differences between the groups of responding

patients regarding gender, age, length of the hospital stay or

whether the patients were planned or acutely admitted to the

ward. There were 62% women in the CEW group versus 60%

women in the controls. The mean age was 64 years in the CEW

group versus 62 years in the control group. The length of

hospital stay was 5� 2 days in the CEW group and 5� 3 days

in the controls. In the CEW group 43% of the patients were

acutely admitted to hospital versus 58% in the controls.

Furthermore, there was no significant difference between the

groups as regards the distribution of the patients’ diagnoses.

Forty per cent of the patients in both groups were attended

due to fractures, where hip fractures dominated. Nine per cent

of the patients were admitted due to other acute orthopaedic

lesions than fractures. Thirty-four per cent of the patients were

admitted to receive elective joint replacements, with hip

replacement as the dominant procedure. Six per cent of the

patients were admitted due to other elective orthopaedic

procedures and a further 11% of the patients were tended due

to lumbar spine disorders.

Perceived quality of care

As shown in Table 1, the patients treated and prepared for

discharge by student teams rated a higher grade of participa-

tion in the decisions regarding their care as compared to

controls (p¼ 0.006). They also rated a higher grade of

satisfaction with information regarding possible home assis-

tance as compared to controls (p¼ 0.003). Furthermore, they

stated in a higher grade that the CEW staff had taken their

family and home situation into account when preparing for

discharge as compared to usual care (p¼ 0.0002). In addition,

CEW patients felt more well-informed as regards the results of

their treatment than the controls (p¼ 0.02). No unfavourable

effects or trends were noted in the CEW patients.

Reliability and validity analysis of the patientquestionnaire

The reliability of the questionnaire was good with a high

internal consistency. The Cronbach alpha-coefficient of total

satisfaction with the collaborative and communicative aspects

of care (items 1–7) was 0.73.

Discussion

We assessed the effects of this IPE intervention through the

patients’ perceptions of the collaborative and communicative

aspects of the quality of care. We found that patients with

orthopaedic disorders treated by IPE students at a CEW

perceived a higher quality of care compared to patients at a

regular orthopaedic ward. Our results are in line with O’Malley

et al. (1997). However, our study was, in contrast to theirs,

performed in a setting with acute in-patient care and with an

IPE team-based care with four professions in each team.

Interprofessional collaboration (IPC) in teams is assumed to

be beneficial because it allows a more holistic approach to

patient care than what is possible in uniprofessional care

(Funnell 1995). IPC has been defined as an activity that

involves members of more than one health- and or social-care

profession interacting together with the explicit purpose to

improve IPC (Zwarenstein et al. 2009).

IPE has, according to Barr et al. (2006), three foci: to

prepare individuals, to cultivate collaboration and to improve

services. These three foci could be seen as three cogs where

the first drives the second, which in turn drives the third.

Translated into effects of IPE, the hypothesis is that preparation

of individuals should lead to effective collaborative teamwork

resulting in beneficial changes of service and care. This

understanding has led to more and more patient centred IPE

initiatives in pre-qualification health-care education. However,

some worries regarding patient safety and quality of care have

been posed if inexperienced students are allowed to inde-

pendently take care of patients. The contention that IPE

student care at a CEW should result in unfavourable effects,

such as a reduced well-being of the patients, insufficient

information to patients or a decreased patient involvement,

could not be supported in this study. One plausible explana-

tion to our positive results could be the competent and always

present supervisors. In the CEW concept, this is a prerequisite

for IPE learning.

Patient outcome and quality of practice is important but

intricate fields of IPE research (Barr et al. 2006). According to

Kirkpatrick (1967), the outcome of educational interventions

could in principle be evaluated at four levels: reaction,

knowledge, behaviour/performance and result levels

(Hutchinson 1999). The relevance to patients and also the

complexity of the evaluation increases by each level. Barr et al.

(2000) have revised Kirkpatrick’s levels as regards to classifi-

cation of IPE outcomes and have added two levels (Hammick

et al. 2007). Figure 1 shows an illustration including these two

new outcome levels. The illustration is inspired from

Kirkpatrick (1967) and Hammick et al. (2007).

We assessed and found positive effects at two levels;

both concerning service delivery and patient perceived

quality of care. To our knowledge, this has not previously

been shown in prequalification IPE. A weakness of our

study is, of course, that only patient perceived quality of

care was assessed. However, patients’ perceptions concern-

ing disease and illness have been shown to be a sensitive

marker that in many instances contains prognostic informa-

tion that could not be assessed by conventional objective

markers. An indication that the CEW patients had at least the

same prognosis as the control patients was that there was

no difference in readmission rate between the two groups.

Another weakness was that it was not possible to make a

strict randomisation because patients were allocated where

there were empty beds.

One could of course speculate that patients should be

bothered by an anticipated less distinct and coherent infor-

mation by the student teams but our results did not support

such a contention. An explanation of the present results could

be that one of the intended learning outcomes of students at

CEW was to acquire skills on how to professionally inform

patients. Each working session started with a team conference

where all the students of the team and the supervisors of each

profession gathered. The students discussed each patient’s

relevant goals of the day and also the patient’s appointed goals

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of the hospital stay. The students’ objectives were to specify

their own professional goals and needs. Subsequently,

together with the other members of the student team they

agreed upon the interprofessional tailored strategy that best

suited the patients’ needs. Our strategy was to emphasize

group culture as opposed to a culture of hierarchy (Singer et al.

2009). The supervisors helped the students, when needed, in

the planning. Accordingly, the students were well prepared

both professionally and interprofessionally, when they started

the work of the day. Continuous follow-up of the goals were

performed by the student team during the day. The day ended

with a reflective session where the student team together with

one supervisor discussed the work of the day. Were the goals

fulfilled? What went wrong? Why? How to improve? Any

misunderstandings? Good examples of communication and

cooperation during the day?

We believe that this structured cooperation was a main

reason of the beneficial results. The supervisors’ role was, of

course, also vital in the support of the student teams. Our

findings strengthen the assertion that IPC improves the quality

of care (Reeves et al. 2008). We have shown that it was

beneficial to include students in the close care of patients.

Furthermore, this was shown to be true even when students

from different professions worked together.

Reactions

Acquisition ofknowledge and skills

Behavioural change

Relevance for patients

Difficulty and complexityof evaluation

Modification ofperceptions andattitudes

*Change inorganisationalpractice

*Benefits topatients and clients Improvements in health or well

being of patients and clients

Wider changes in the organization and delivery of care

Individuals’ transfer of interprofessional learning to their practice setting and their changed professional practice

Knowledge and skills linked to interprofessional collaboration

Changes in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude towards the value and or use of team approaches to caring for a specific client group

Learners’ views on the learning experience and its interprofessional nature

Figure 1. Assessment of IPE outcome at six levels. The relevance to patients and the complexity of the evaluation increases by

each level of the ladder. Adopted from Kirkpatrick (1967) and Hammick et al. (2007).

Note: *Denotes the levels of evaluation used in this study.

Table 1. Perceived quality of care among patients at the Clinical Education Ward compared to in Usual care. The answers were considered tobe significant at p5 0.05 are shown as bold values in the table.

CEW Usual care

Question Yes Partly No N A Yes Partly No N A p-value

1. Did you understand the information given to you regarding

the results of your treatment?

61(73) 19(23) 3(4) 1 36(60) 14(23) 10(17) 1 0.02

2. Where you involved in the decisions regarding your care? 63(76) 17(20) 3(4) 39(65) 9(15) 12(20) 0.006

3. Did you get enough information regarding as to how your

disease will influence your daily living?

34(44) 28(36) 15(20) 6 22(37) 23(38) 15(25) 2 0.6

4. Did you receive information regarding possible home

assistance?

49(72) 17(25) 2(3) 15 20(49) 12(29) 9(22) 19 0.003

5. At discharge – were you informed on whom to contact if

you had questions?

58(77) 17(23) 7 44(76) 14(24) 3 0.8

6. Were you bothered, at discharge, on how to cope at

home?

45(54) 33(39) 6(7) 38(64) 14(24) 7(12) 0.12

7. Did the staff take your family and home situation into

account when preparing for discharge?

62(75) 19(23) 2(2) 34(59) 10(17) 14(24) 0.0002

Notes: All values are given as count and percentage; n (%). p-values are calculated according to Chi-square statistics. Answers could be given as Yes; Partly; No or

Not applicable (N A).

Quality of care by interprofessional learning

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The patient care at the regular part of the ward was also

performed by interprofessional teams but not as structured as

at the CEW. The rounds included a nurse and an orthopaedic

surgeon and at times also a physiotherapist, an occupational

therapist and a nurse’s aid. At most times, the patient

information was shared by only two professions – usually a

nurse and one of the other professions. The regular part of the

ward had more patients to tend to and some of the patients

had more severe conditions, not appropriate to the CEW. It can

thus be argued that shortage of time made it difficult to

implement structured teamwork and communication.

However, we would suggest that the present result implies

that a more structured IPC should have been beneficial also at

a regular ward. There are several studies evaluating an

association between organizational culture, collaboration,

quality of care and patient safety (Singer et al. 2009). It is

reported that beneficial strategies in this respect are reduced

hierarchy and increased group orientation, well in accord with

our results.

Conclusion

From a patient’s point of view we found no signs of

disadvantages in terms of collaborative and communicative

aspects of care when care was performed by supervised IPE

student teams at a CEW. By contrast, we found several

indications that the patients perceived a higher grade of quality

of care when cared by the supervised IPE student teams. A

more structured interprofessional team-based care may be

beneficial even in usual care. Our findings should be

reassuring and be a further support in the future development

of CEWs.

Ethical aspects

The investigation conforms to the principles outlined in the

‘Declaration of Helsinki; 1964’. The Regional Ethical Review

Board in Stockholm, Sweden, approved the study.

Acknowledgements

We would like to thank all patients for their willingness to

share their experiences and attitudes with us. We would also

like to thank all professional staff at the CEW and at the regular

ward for their support during this study.

Funding was provided through the regional agreement on

medical education and clinical research (ALF) between

Stockholm County Council and Karolinska Institutet.

Declaration of interest: The authors report no conflicts of

interest. The authors alone are responsible for the content and

writing of this paper.

Notes on contributors

KARIN HALLIN, MD, was during the study Consultant at the Orthopaedic

clinic and Director, Clinical Education Ward at Danderyd Hospital and is at

present Orthopaedic Consultant, Capio Artro Clinic at Sophiahemmet,

Stockholm, Sweden.

PETER HENRIKSSON, MD, PhD, is a Professor and Director of studies at

Karolinska Institutet and an experienced medical educator.

NILS DALEN, MD, PhD, is a Professor and Orthopaedic surgeon and an

experienced Senior lecturer.

ANNA KIESSLING, MD. PhD, is an experienced medical educator and

Director, Centre for Clinical Education of North East Stockholm at

Karolinska Institutet.

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