The purpose of this study was to explore healthcare student threshold learning experiences within the context of interprofessional education. This chapter presents the findings with
delineation of individual experiences, parts, often in comparison to the collective experiences that make up the whole. I encourage readers to consider the research questions not as linear or concrete constructs, but pieces of information that weave throughout to describe the threshold concept of interprofessionality. The research questions are additionally summarized in Chapter 5.
This chapter delivers the healthcare student stories of interprofessional learning. In the first section, a short excerpt is provided for each student interviewed, describing the context for learning, and the threshold moment. The student perceptions of change are delineated by the five threshold concept criteria of being bounded, troublesome, integrative, irreversible and
transformative. These individual perceptions were aggregated into the experience of
interprofessionality. After a description of learning contexts that played a part in the threshold moments, the next section provides the first example of the collective foray into the liminality in healthcare education, described in a short story format. Then, to set the stage, student
descriptions of working in different interprofessional contexts within Saskatchewan are shared, specifically the perceptions of change in the context from before and after the threshold moment. Next, the threshold concept of interprofessionality is outlined by describing the four categories of description, or learning steps, which are the result of aggregated categories of learning from all the healthcare student contributions. Finally, the student reflections on changes to their
interprofessional learning and working are presented from the aggregated follow-up interviews. The structure of this chapter follows the students on a journey through individual professional experiences in diverse learning contexts, through the liminal chaos of being a student, over the threshold of working with patients and others and into aggregation as an interprofessional healthcare team member.
Participants were 13 students from three different educational institutions enrolled in healthcare programs. Nine students had been in undergraduate programs and shared stories of threshold moments. One student was a graduate student with a public health background. He was interviewed on his request because he had recently had a threshold moment and was the only male participant. Students were from a variety of communities across the province of
nursing and public health programs. They shared about experiences in student-run clinics, acute care clinical placements, community agencies and structured educational experiences with patient-actors. One student had already graduated but requested an interview to discussion her IPE experience from during her program which she was currently comparing to her practice settings. An additional three students provided reflective writings online but refused interviews.
Healthcare Student Threshold Moments
The following accounts are an overview of interprofessional experiences across the province from each individual interviewee. This section addressed the research questions, what were the experiences of students, in specific situations, in which there has been a threshold moment? and, what were the individual experiences of change associated with the threshold moment? Each student was given a pseudonym and each account of the individual threshold moment was titled based on the student appreciation of the transformative moment. Each story describes the learning context including the patient and healthcare team member contributing to the experience, the threshold moment, and each of the five threshold criteria of boundedness, troublesomeness, integration, irreversibility and transformation.
Sylvia: Shift
Sylvia was a third-year nursing student at the University of Saskatchewan in Saskatoon. Sylvia seemed very excited to talk about her goals for learning in nursing and her reflections on interprofessional experiences. The impetus behind her foray into an interprofessional
environment was her insight that she needed to learn to communicate with clientele with different backgrounds and life experiences than her own. Sylvia also felt that she had too few volunteer hours and while she was a full-time student doing a few hours of work on the side, volunteering at SWITCH, the student run clinic, would provide opportunities to help grow her communication skills. In particular, Sylvia seemed to focus on gaining experience with children. She talked warmly about her relationship with her nephew, but then when discussing young children and babies, described her learning challenges with words like, “not my forte,” “the kids had all the power,” or “negotiating” versus “engaging” with children. Despite communicating with others and children, “not coming naturally” to her, Sylvia was very observant and thoroughly described the learning context that led to her threshold.
Sylvia described SWITCH as student-focused, which to her meant accessible; orientation was structured, times were flexible and working with peers meant a chance to compare
experiences at school. Sylvia described the waiting room which was the entry to all services and programming, the clinic rooms and the childcare room. She relayed multiple stories comparing her learnings, but she specifically focused on the instance where her interprofessional learning began. Sylvia and a medical student were assigned to food services to prepare and deliver snacks to SWITCH clientele. Both were on their first shift and neither had worked together before or since. Besides the confusion of figuring out duties and responsibilities for the first time, was the added anxiety of how to communicate with the clientele. What are the rules around providing food especially to clients who are intensely affected by the social determinants of health? Sylvia described how confident the medical student seemed and surmised it must be from her previous degree and therefore extra life experience. They talked to each other quite a bit about their programs before heading to the waiting room with the cart. Sylvia described herself as nerve- wracked prior to entering the room because she was unsure what to do or say. However, on entering the room, Sylvia experienced what she described as a shift. Greeting the clientele and answering any questions became her responsibility despite her own perceived lack of confidence or skills. The other student did not talk as much as when they were preparing food.
This moment was troublesome because talking to diverse clientele in this setting was foreign to Sylvia. The concept of communication was clearly bounded in this moment. Both students had learning and experience communicating and understanding a therapeutic approach and rapport. This moment was transformative in a few ways. Sylvia was required to change her behaviour and communicate. Her description gives the sense that she was forced to answer because the other was not. Yet in describing the other student’s shift in behaviours, Sylvia took on the experience, changing her language from describing what she saw the other student doing to owning her own shift in learning communication skills. The remainder of her interview included multiple stories where Sylvia learned from other students about different aspects of communicating interprofessionally suggesting that her threshold had been an irreversible experience and one she integrated into future learning.
Helen: Bigger Brain
Helen was a second-year psychiatric nursing student at Saskatchewan Polytechnic originally from the Ukraine. Her previous education was in finance. In high school she never imagined working closely with people but with time and experience, she chose a helping profession because of her passion for mental health. Her first interview was at the beginning of
her last year and the follow up interview in her final practicum before graduation. She had a variety of mental health clinical experiences across the province. She spoke about her long-term care experience followed by mobile crisis.
The learning context for Helen was at Saskatchewan Hospital in North Battleford, which she described as a long-term care facility for patient with special needs. Most patients had their own rooms, and most were employed externally or in therapy during the day. Report was delivered between teams at shift change and this team included a nurse and care aides. While Helen was on this clinical rotation with her faculty member there were two nursing degree students and their faculty.
Helen described the situation as starting with a feeling of polite disrespect. A couple of degree nursing students chose not to introduce themselves, nor utilize Helen as a resource despite her having more time on the ward. Helen got the sense that the other students knew everything. She was surprised that the professional tension discussed in class was actually real. Helen’s focus became about not conveying the same tense attitude but using communication techniques to show trust.
Helen entitled her threshold a ‘bigger brain.’ While she did not want to force learning, sharing or teamwork on anyone, she also did not want to sit around and wait for things to happen. She sought out challenging experiences even though she was scared, as a way to increase her knowledge and experience and decrease her fear for the next time. Her experiences with the nursing students as compared to social workers closer to practice taught her what had been missing in her education (i.e., the initiative to learn together).
Helen’s transformative experience was realizing education is not better or worse because it is longer or shorter, just focused on different things. The best of decisions with patients come from learning from different perspectives. The troublesome aspect of Helen’s threshold was expressed as fear. Her descriptions of fear centered on taking initiative asking for advice, sharing perspectives and not being perfect or making any mistakes. In working through the fear, Helen realized because patients are unique, and professionals have unique perspectives there is no one way to approach a problem and one person cannot know everything.
Helen solidified her threshold by repetitive behaviour. She was wary of forgetting things and “freezing” in clinical, so she sought multiple experiences to reduce the chance of an unusual situation. In this way, fear became a part of her, integrated into her learning process to use for
adrenaline to take on new learning responsibilities. Interestingly, Helen’s interprofessionality, the ‘bigger brain’, was not bounded by mental health content, but was literally about finding the specifically trained person for the problem. While she was distressed that the nursing students would not use her expertise as a psychiatric nursing student, she pondered what expertise she could use of the nursing profession. She also admitted to seeking out an expert more familiar with medications. While no patient was specifically addressed in her narrative, Helene
mentioned that it was the patient, the one person working with all three students, who brought up the differences in interactions.
Elanna: Awareness of Bias
Elanna had been in Canada for 10 years and was a Filipino addictions counselor. She requested an interview after participating in an interprofessional problem-based learning experience as part of her program a few months before she graduated. Elanna described
addictions counseling as a profession focused on harm reduction. She often stated people are not their addiction and relayed stories of frustration when working with others who made
judgements, or created labels and stereotypes, rather than the unconditional positive regard she expected from not only addictions counselors but all healthcare professionals. She shared that her role was to help others understand how trauma affects life and help create safety for patients living with addiction if the behaviours cannot be changed immediately. I asked Elanna about healthcare professionals giving patients a clean slate. She disagreed. A clean slate suggested forgetting the experiences of the past, whereas unconditional positive regard acknowledged the past but created safe space for focusing on the present.
After her last clinical up north in Buffalo Narrows, to her first job at the treatment centre in Prince Albert, Elanna joined me to talk in Saskatoon where she was working as a personal support worker at a halfway house because the job market for addictions counselors was very competitive. Elanna stated the iPBL, despite being paper based, was significant learning for her which she compared to personal and professional experiences of working in interprofessional environments since graduating. Elanna reflected on the iPBL saying that it really worked to bring different professionals together and that more experiences, especially in relation to empathy and counseling would assist students in providing holistic team-based care.
The threshold moment for Elanna was titled, ‘awareness of bias.’ When discussing the paper case, the nursing students focused on the biomedical aspects, especially vital signs and
tasks related to medical diagnoses or interventions. In comparison, Elanna was impressed by the psychiatric nursing student who offered screening tools and started a discussion on how to approach and interact with the patient. Elanna felt that the psychiatric nursing students were well equipped to provide balanced care that acknowledged mental health and conveyed empathy. The experience and reflecting on the experience in the interview almost a year after it happened, made Elanna share her bird’s-eye view of learning about her bias toward other professionals and how that subsequently played out in different clinical and work experiences since that day. At one point in the interview she reacted to her own statements when she realized her bias was coming out again after relating a story of being in emergency with nurses who acted like robots. When re-interviewed about her categories of learning, Elanna reiterated the value of
interprofessional education during her program and said, “I just really care, I think. I really do want change.” While continually frustrated with the sense of numbness she witnessed from other professionals, Elanna’s now omnipresent awareness of bias made her acknowledge where being humane did exist. She shared changing thoughts and behaviours to assist herself and other professionals to understand how bias affects a sense of belonging for patients and
interprofessional teams.
The troublesome knowledge for Elanna was focused on emotional safety. Because Elanna was working intersectorally in custody environments, she questioned whether the setting or type of practitioner affected empathy as compared to traditional healthcare environments. While she acknowledged a bias toward nurses, she could also share where she trusted nursing skills but trusted their judgment more when nurses also provided for emotional safety. Acknowledging where her bias did not fit meant her learning was irreversible. She integrated her appreciation for the skills of others by conveying respect for professionals despite the level of education. She advocated for daycare workers in one setting because of the assessment and planning skills they shared with the interprofessional team. The ability to see similarities and differences in
professions occurred for Elanna at this iPBL; she had been bound by the mental health concepts in her own profession and now testing bias has expanded her patient care to an interprofessional scope. The resultant transformation was accepting that other professionals will challenge her bias.
Samantha: Not Left Out to Dry
Samantha was 25 years old and graduated as a dental hygienist from Saskatchewan Polytechnic one week from the primary interview. She had a previous degree in kinesiology though her first choice was dentistry. She made the tough choice to enter this program instead of nursing because of her health at the time. She attributed some of her success to her age, her previous university experience, having learned how to manage her time and not being homesick as she moved to attend this program. She felt the program and her cohort challenged her to be outgoing, respect their diverse experiences and become both the class clown and the leader.
The dental hygiene program was more than cleaning teeth. There was so much
coordinating of the patient’s care plan, where Samantha was exposed to the lab and bloodwork, pharmacy and medications, dentistry, medicine, and nursing. The program was based on points for each patient in a clinic chair and so many were required to graduate. Samantha described a major difference between the school clinic and private practice being time. Patients to the school paid a flat fee of $50 but appointments were two hours long and many patients required more than two appointments for a full assessment. Where patients at the school clinic were often the elderly or immigrants, patients in private practice often had insurance and required shorter appointments because they had education on, and access to, oral care.
Samantha was a perfect example of requiring more than one experience to solidify her interprofessional threshold crossing. She did not even remember her first until the very end of the interview and because of probing questions. All five criteria for her threshold therefore spanned the two moments in time; the first early in her first year and the second in her second year. Both experiences were structured IPE developed with patient actors and were with combinations of nursing and paramedic students. Her first experience she called an ‘a-ha!’ her second she called ‘the clicker.’ The threshold moment for Samantha was entitled ‘patient care is better when you’re not left out to dry.’ Samantha was considered a leader by her peers and was often pushed into being the representative for the class or going first in educational experiences. Because she was first, she was required to figure out how to negotiate new learning contexts and working with a patient actor with limited support, until the team stepped up to help. Samantha’s learning was surrounded with frustration and anxiety until the team came together for the patient actors.
To elaborate further, in the first experience, her team was required to transfer a patient actor with dementia from a car, using a walker and wheelchair to the dental clinic chair. In the
course of the experience, the team banged the head of the patient on the car door, lied to the patient about where her deceased husband was and failed to offer hand hygiene. The troublesome part of this experience was communication with the patient and team, especially figuring out the knowledge and skills of others. The integration in this experience was the frustration of learning. To overcome not knowing and not being prepared, Samantha learned to seek resources from others and ask questions.
Her second experience was a simulation where she had to call the paramedic students after assessing her patient for chest pain. Yet, the actor forgot to show abnormal symptoms and