Keeping it going: the importance of delivering interprofessional education during the COVID-19 pandemic

Keywords: Educator; interprofessional education; IPE; online teaching; pandemic.

Globally, the ongoing fight against the coronavirus disease 2019 (COVID-19) pandemic has shown both the benefits of health professional interprofessional collaboration and teamwork and the threats to health and health professionals when teamwork does not occur.^1–5

New Zealand’s COVID-19 elimination strategy has three pillars: (1) prevent entry into the country through border restrictions and managed isolation for new arrivals; (2) respond to COVID-19 incursions with community-wide lockdowns that limit physical interaction; and (3) mass vaccination. Each pillar requires interprofessional teamwork. Interprofessional teams are also treating people with acute COVID-19 symptoms in managed isolation facilities and hospitals and supporting the rehabilitation of patients with long-COVID-19.⁶

Yet, teamwork skills do not just happen. Like any other essential skill-set, teamwork needs to be learned and practised, starting during pre-registration training. Before the pandemic, preregistration interprofessional education (IPE) initiatives were increasingly offered in university and other training organisations. Recognised learning outcomes from IPE include interprofessional communication, role clarification, reflective practice interprofessional coordination, collaborative leadership, and teamwork.^7,8 Collaborative practice skills are learned and practised through IPE so that students are teamwork-ready when they graduate.⁹

The INVOLVE initiative (INterprofessional Visits to Learn Interprofessional Values through Patient Experience) has been run for more than a decade. Multifaceted evaluation has demonstrated achievement of learning outcomes.¹⁰ Students enjoy taking part in INVOLVE,^11,12 particularly interacting with students of disciplines other than their own.¹³ Students completing INVOLVE have improved attitudes towards health-care teams and obtained greater knowledge of other disciplines.¹⁴ Students also value home visits to a person with multimorbidity, the clinical topic on which the initiative is based, learning who is involved in the person’s social network and hearing the person’s perspective of what interprofessional interaction occurs.^15,16 A description of the INVOLVE initiative is presented in Figure 1.

Figure 1.  The INVOLVE IPE Interprofessional Visits to Learn Interprofessional Values through Patient Experience interprofessional education) initiative.

In 2020, with the changing pandemic alert levels impacting on face-to-face teaching, many changes were made to the delivery of INVOLVE to enable students to continue to participate in IPE and develop collaborative skills. In this article, we describe the quality improvement process^17,18 used to assess the effectiveness of the change strategies through use of the following structure: assessment of the problem, mechanisms for change; assessment of the change; strategies for quality improvement and lessons for others.

Throughout the pandemic, the University of Otago (and likely others) has focused on continuing the delivery of uni-professional training programmes. Despite its importance, and similar to other countries,^19,20 some IPE initiatives have been cancelled or postponed in favour of uni-professional classes, with little emphasis on developing alternative forms of IPE delivery.²¹ Educators may not recognise the importance of health science students learning inter-professionally, in real-time, about the impact of a pandemic on people with multimorbidity^22,23 and the likely increased disparities for this group,^24,25, particularly for Māori and Pacific peoples and people living with higher deprivation.^25–29 These people are the most physiologically and psychologically at-risk from COVID-19^{22,23,30–37} and their existing health conditions, coupled with COVID-19 mitigation strategies (eg stay-at-home lockdowns), have meant isolation from family and friends and challenges in accessing both health care^38–40 and COVID-19 vaccination.^41,42

When the first nationwide Alert Level 4 stay-at-home lockdown was imposed in March 2020,⁴³ the Wellington Interprofessional Teaching Initiative, a partnership of several teaching organisations,¹³ made it their priority to continue delivery of INVOLVE IPE, knowing that teamwork is an essential skill in global health crises.²⁰ Two key strategies were used to continue IPE training when alert levels changed (see Table 1 for a summary of changes).

Table 1.  Summary of changes to INVOLVE in 2020–21 as a result of COVID-19 alert level changes

INVOLVE was redeveloped to be delivered entirely online by Zoom videoconferencing and with hybrid mixes of online, Zoom and physically distanced and ‘standard’ classroom teaching. Students now know INVOLVE will continue, despite some other teaching being cancelled.

Gaining the perspectives of people with multimorbidity, formerly undertaken only through home visits, can now be undertaken by Zoom or phone, face-to-face, or by use of case vignettes developed from real people.

Before the pandemic, students routinely completed anonymous online evaluations at the end of each INVOLVE cycle. Likert scale questions asked about learning outcomes and open-ended questions about experiences. Evaluation ratings from students in INVOLVE sessions where alert levels changed did not differ notably from typical pre-pandemic INVOLVE 2019 ratings (see Appendix 1 for a comparison of medians and interquartile ranges).

Since the pandemic started, we have added and thematically analysed free-text questions about the impact of alert levels changes to monitor effects on students. Considered responses from students reflected positive and negative views. Table 2 presents a summary of comments.

Table 2.  Student views of INVOLVE sessions impacted by changed alert levels

Home visits to a person with multimorbidity has always been a highlight of INVOLVE. At the start of the pandemic, when we rapidly switched to delivering INVOLVE online, we were unable to arrange recruitment of people with multimorbidity. Instead, we provided a patient case vignette to each interprofessional group. Evaluation ratings of INVOLVE programmes where groups of students worked inter-professionally on vignettes were similar to programmes involving home visits, indicating that students were able to engage with these to achieve learning outcomes.

In a pandemic situation, stay-at-home orders and ‘bubble’ recommendations,^44,45 particularly for more at-risk populations, mean students cannot always physically visit people. Abrupt alert-level changes resulted in overnight cancellation of home visits and switching to phone or Zoom visits challenged students. Students found it difficult to undertake conversations with people using phone or Zoom communication tools (not unlike health professionals using telehealth⁴⁶). To support skills development, we developed resources for guidance and provided debriefing opportunities in the second workshop, when students present in their interprofessional groups.

Internationally, IPE educators are sharing examples of IPE initiatives that have been successfully used in the COVID-19 pandemic.^47–48 This pandemic will likely continue for several years and future pandemics are likely.⁴⁹ The way we live and practice health care will likely be very different from pre-pandemic times, and new teamwork skills will be required to adapt, including different ways to provide collaborative care.^50,51 We used two strategies to adapt INVOLVE. We moved immediately to use online, Zoom and hybrid forms of teaching according to alert levels and broadened the options for students to interact with people with multimorbidity. The quality improvement process used to assess the impact of these strategies led us to identify key lessons that may support other IPE educators.

Foresee the challenges and commit to continuing IPE throughout a pandemic. As soon as changes to alert levels or rules about physical distancing that affect face-to-face IPE teaching are announced or imminent, immediately make plans for alternative delivery methods.²¹

Be aware that making prompt and creative changes relies considerably on trust among the IPE educator team members. Sometimes a small group will need to lead the changes and the others must swing in behind. The Wellington Interprofessional Teaching team has worked together for many years and was proactive and flexible in considering options for teaching delivery.

Meet interprofessional collaborative practice objectives by using real-time opportunities to learn about teamwork in a pandemic and the impact of a pandemic on the health and wellbeing for people with multimorbidity.^31–35,52

Ensure students are supported. The wellbeing of the students is the key focus. Take account of the impact of stay-at-home lockdowns on students and the potential for more inequity in learning. Students may live in suboptimal or unsupportive physical or emotional environments, some with poor internet connectivity. During long lockdowns, students may need to take on additional caregiving responsibilities for family members or take-up employment in essential services. Solutions our university offered were access to a hardship fund and urgent provision of internet resources and electronic devices.⁵³ Remember, some students will not ask for help.

The COVID-19 pandemic has considerably impacted young people’s mental health.^54–56 The move to online learning associated with physical isolation from other students and educators will not suit some students’ preferences for face-to-face, in-class learning.^57–59 Some issues can be mitigated in an on-line learning environment by using a more informal conversational style, ensuring the tone, warmth and clarity of the email communications and in the design of the Zoom workshops. Zoom breakout rooms seem to help to build group social and interprofessional connection and encourage students to keep on their video feeds to assist making personal connection. Having an IPE administrator also attend the Zoom workshops is helpful as students will have already had contact with this staff member through email. Administrators can welcome students as they arrive, provide support if they encounter difficulty and monitor on-line messages.

Throughout the pandemic, alert level changes have substantially affected the New Zealand health services, and it may not be appropriate to ask general practices to recruit people with multimorbidity for IPE. Patient–case vignettes can be substituted.

Continue to reach out for help. General practices were very conscious of the need to continue the teaching initiatives and were often able to recruit people with multimorbidity during alert level changes.

Decisions need to be made quickly when alert levels change, often with limited and unfolding information. It is particularly challenging to deal with overnight changes in alert levels, the first time it happens, and easier to see in retrospect how responses could be improved. Act promptly and communicate clearly.

Nominate one key person to communicate email messages or electronic announcements to students and staff. Messages need to be clear, with unambiguous subject lines and copied to all relevant people.

Do not send too many messages; we found that students and educators struggled with the volume of electronic information.

Using stable electronic technologies in effective ways is critical during the pandemic. Using Zoom (or another equivalent platform) and an e-learning platform (eg Blackboard, Moodle) made it possible for educators to facilitate IPE during changing alert levels.²¹ But beware: not all educators are comfortable with these technologies. Help them to achieve a minimum, no-frills skill level.

Supply brief step-by-step instructions for educators. These are best crafted by someone who can see technology processes from an educator view rather than an IT guru view.

Remember students do not demand perfection in times of uncertainty.⁵⁹

Anticipate and be patient with the pauses and freezes that occur on Zoom.

Shorter-length workshops mean less fatigue for educators and students.

Provide more student Zoom breakout room exercises to enable regular changes in focus.

Not all educators have perfect internet connections at home, so try to have two educators in a Zoom room plus an administrator. If one connection fails, hopefully the others will be secure.

Teaching administrators have a key role. Administrators are likely already known and trusted by students and educators. Administrators often have stronger IT and multi-tasking skills than educators and can focus on IT and logistics, leaving educators free to focus on teaching. Administrators can use the Zoom chat function to personally message educators or students during class and provide troubleshooting suggestions or alerts.

Have resources available and provide these ‘just-in-time’ when students need the resource on how to conduct Zoom and multi-user phone conversations. Even though students had not received prior teaching about the value and application of these (telehealth) communication tools, they immediately grasped the idea.

Similarly, develop resources to support students to undertake effective Zoom and phone conversations. Students need information on how to build an empathetic connection, assure confidentiality in a virtual setting, have a conversation with someone who has more complex communication needs (eg being deaf), account for a lack of or reduced visual cues, have a conversation that involves multiple people, and how to manage hard-to-gauge pauses.

Collect information from students about IPE initiatives affected by changing alert levels and compare this with previously collected information.

Use an appreciative inquiry approach as well as a quality improvement process to understand what has worked well and what is challenging.⁶⁰

Take account of the context of a pandemic when considering the results (eg if a variant is affecting particular age groups or ethnicities, or countries and causing heightened anxiety).

Use technology to ask for and receive help.

Reach out to other educators with brief and reasonable requests. Paradoxically, during the stay-at-home lockdown, some staff had more time and headspace to think of solutions and to help.

Facilitate access to technology specialists, IPE administrators and other staff specialists.

Remember staff with young children are under increased pressure with parenting and home schooling.

There were several unexpected silver linings for INVOLVE as a result of the changes necessitated by the pandemic.

Understanding the role of the home-visit: We found that the physical home visit was not an essential component of the INVOLVE initiative and communicating with people at home using Zoom and phone proved very successful. Home visits, however, have advantages, when possible, as they change the balance of power between patients and students. Students can assess a person’s context and environment and gain insight into their life and interests.

Comprehensively and consistently detailed case vignettes, based on real people, could achieve the same learning outcomes. Paradoxically, using vignettes democratised students’ access to the equivalent of physical home visits. It resolved the usual pre-pandemic difficulties students with conflicting timetables had when trying to find a suitable time to undertake the home visit. Vignettes also alleviated the challenges of contacting a person at home, travel costs and travel time.

Using Zoom during the changing alert levels widened the pool of disciplines and students able to take part in INVOLVE. We were able to include speech language therapy students from another city, as well as accommodate increased numbers of students from other disciplines (as their clinical placements had been cancelled). This was a bonus for the INVOLVE class as a whole, as well as for these particular students. Similarly, we invited more guest educators as observers to join the Zoom INVOLVE workshops.

Welcome relief: Delivering INVOLVE via Zoom during stay-at-home lockdowns created warm connections, welcome relief, distraction or a meeting opportunity for the students who were feeling particularly isolated (eg international students worried about families in faraway countries, or New Zealand students who were in lockdown by themselves). Similarly, offering opportunities for students to talk to people with health issues (multimorbidity) via Zoom or phone meant a different social interaction for these potentially isolated people and an opportunity to brighten their day.⁶¹

Learning telehealth skills: Students switching to using Zoom or phone communication tools has alerted us to telehealth being a suitable IPE topic and a necessary skill to develop for the future where telehealth applications bring benefits to patients, professionals and students.^62,63

Keeping IPE going during the COVID-19 pandemic requires a united educator team committed to the outcome of interprofessional collaboration and improving health service delivery. The team themselves have needed to demonstrate IPE competencies of communication, mutual respect and collaboration.

We have recognised the importance of collaborative health care in this particular time of health system strain. We quickly anticipated the threat to IPE delivery and implemented strategies and evaluated these using a quality improvement process and then responded by making improvements. The lessons highlight the needs of the students, being quick witted, creative, adaptable to uncertainty and change and drawing on the help of supporters.

The authors taught the INVOLVE interprofessional education initiative during the COVID-19 lockdowns or alert level changes in 2020 and 2021.

Dr Ben Gray is an Associate Editor of The Journal of Primary Health Care and was blinded from the peer review process for this paper.

This research did not receive any specific funding.

The data used to generate the results are not available.

The authors are members of the Wellington Interprofessional Teaching Initiative. In March 2020, the educator team converted the face-to-face INVOLVE IPE initiative to online delivery by Zoom and have facilitated it online by Zoom or hybrid methods throughout the pandemic. This article was conceptualised at a meeting of the Wellington Interprofessional Teaching Initiative. The authors have contributed to all aspects of the paper.