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Keywords:

  • Interprofessional;
  • student;
  • clinical education;
  • clinical learning unit;
  • team care

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B

Purpose

The development and implementation of interprofessional (IP) clinical learning units as a method to enhance IP clinical education and improve patient care in a rehabilitation setting are described.

Methods

Using a community-based participatory research approach, academia and healthcare delivery agencies formed a partnership to create an IP clinical learning unit in a rehabilitation setting. Preimplementation data from surveys and focus group data identified areas for improvement to enhance IP understanding and collaboration. A working group developed and implemented initiatives to enhance IP practice.

Findings

Preimplementation, eight themes emerged from which the working group identified goals and implemented strategies to strengthen IP learning. Goals included Creation of an IP Learning Environment, Increased Awareness of IP Practice, Role Clarification, Enhanced IP Communication, and Reflection and Evaluation. Postimplementation data revealed six themes: Communication, Informal IP Learning, Role Awareness, Positive Learning Environment, Logistics, and Challenges.

Conclusions

The development of the IP clinical learning unit was successful and rewarding, but not without its challenges. Formal IP education was necessary to enhance collaborative practice, even in a multidisciplinary environment. Commitment and support from all participants, particularly managers and administrators from the healthcare agency, were critical to success.

Clinical Relevance

The focus of this unit was on a stroke rehabilitation unit; however, the development and implementation principles identified may be applicable to any team-based clinical setting.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B

Team work in health care is not a new concept; practitioners have been working in multidisciplinary environments for many years. However, working in a multidisciplinary environment on a multidisciplinary team is not the same as working interprofessionally. To be truly interprofessional (IP), team members must value mutual respect, trust, shared decision making, equal voices, and acknowledge and be familiar with each other's roles (Canadian Interprofessional Health Collaborative, 2010; Legare et al., 2011; Sommerfeldt, Barton, Stayko, Patterson & Pimlott, 2011).

Clinical education, or preceptorship, is an essential component of health science student education. In most instances, students are supervised by members of their own discipline and learn discipline-specific knowledge, skills and behaviors. In some cases, learning from, or being supervised by, one's own discipline might be mandated by regulatory colleges and associations. However, the global move toward IP practice is stimulating change from historically uniprofessional practice to more multidisciplinary and eventually IP practice (Frenk et al., 2010; WHO, 2010). Interprofessional education occurs when professionals or students from two or more professions learn about, from, and with, each other to enable effective collaboration to improve health outcomes (WHO, 2010). In a recent “call to action,” the WHO stated that:

After almost 50 years of inquiry there is now sufficient evidence to indicate that interprofessional education enables effective collaborative practice which in turn optimizes health services, strengthens health systems and improves health outcomes. In both acute and primary care settings, patients report higher levels of satisfaction, better acceptance of care, and improved health outcomes following treatment by a collaborative team. (WHO, 2010, p.18)

One innovative model for IP collaboration is an Interprofessional Clinical Learning Unit (IPCLU). The establishment of IP clinical units on orthopedic wards has been reported from both Sweden (Hallin, Kiessling, Waldner & Henriksson, 2009; Ponzer et al., 2004) and the United Kingdom (Reeves, Freeth, McCrorie & Perry, 2002). Interprofessional “training wards” have been found to provide students with realistic IP, team-based learning in a clinical environment. Results from those studies were encouraging. An environment was created which allowed students to develop skills and knowledge regarding IP patient care and teamwork (Hallin et al., 2009; Ponzer et al., 2004; Reeves et al., 2002), as well as to improve IP competence relating to professional roles (Hallin et al., 2009). Clark (2011) noted that sharing responsibility and making decisions as a group provides team members with a sense of security and validation when all team members agreed to a course of action for a specific patient. Also, learning about how other professions approached a patient problem led to more integrated care delivery (Clark, 2011).

In response to the need for enhanced IP clinical learning, and as part of a larger project (IPCLU Research Team, 2011) academics and healthcare providers collaborated to develop an IPCLU in a rehabilitation hospital in Edmonton, Canada. The IPCLU project engaged stakeholders during all levels of development and implementation. Academic representatives and healthcare delivery personnel were incorporated into the IPCLU steering committee, research team and working groups.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B

This project received funding from the Health Workforce Action Plan of the Alberta government's Health and Wellness ministry. Approvals were received from the Health Research Ethics Board of the University of Alberta and the healthcare agencies’ operational entities.

The researchers adopted a community-based participatory research approach to create an equitable and collaborative partnership between academia and healthcare delivery agencies. Community-based participatory research has been used in a variety of different fields of study; participants are treated as partners in the research process where being fully engaged and informed has led to better project outcomes (Shalowitz et al., 2009). This collaborative partnership was operationalized in the IPCLU project through the formation of a Working Group (WG) which held its first meeting in June 2009. Comprising academic and clinical partners, the WG provided a regular venue for members of the patient care team (PCT), unit management and the Research Team (RT) to brainstorm IP initiatives, discuss the progress of implemented initiatives and further develop new ones. The WG was a key element in operationalizing IP concepts with the clinical unit team members and was essential in the implementation of the initiatives created from within the group itself. It comprised the Patient Care Team, Clinical Manager, Physical Therapist, Nurse, Occupational Therapist, Recreation Therapist, Speech-Language Pathologist, Nutritionist, Pharmacist, and a Social Worker. Faculty representatives were from Dental Hygiene, Physical Therapy, and Speech-Language Pathology. A student involved in an IP placement experience on the unit at the time also joined the WG. Substantial support was provided to the WG by a Project Manager and a Research Assistant, who attended all meetings. The WG met 12 times over a 10-month period.

Preimplementation data were collected from PCT members, students, and associated faculty via surveys and interviews during a 6-week period in April and May 2009. Qualitative methods were used to analyze the interview data and open-ended survey responses. Data were analyzed by four RT members individually, coded thematically, and overarching themes identified by each reviewer. The RT met to discuss each analyst's overarching themes and achieve consensus on theme identification and content.

As in the preimplementation phase, postimplementation data were collected in the form of surveys and individual interviews from PCT members, students, and faculty who were working on, or associated with, the clinical unit during a period of 6 weeks in April and May 2010. Qualitative data were analyzed as before by three RT members. The time period from preimplementation data collection to the postimplementation data collection was 13 months.

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B

Preimplementation

Data were generated from 14 patient care team participants, five students, and five faculty participants in the preimplementation phase. The participants represented the disciplines of: Nursing (five), Medicine (one), Occupational Therapy (two), Physical Therapy (two), Speech-Language Pathology (two), Recreation Therapy (two), Social Work (two), Nutrition (one), Clinical Psychology (one), Audiology (one), and Dentistry (five).

Eight predominant themes emerged from the pre-implementation data collection: Communication, Work Environment, Interdisciplinary Environment, Learning Environment, Discipline Specific and Interdisciplinary Roles, Benefits and Challenges, Discipline Specific Focus, and Teamwork. The findings highlighted the existing positive aspects of IP work on the unit including positive interactions with students, an environment conducive to IP learning, and a general feeling that IP teamwork on the unit was “very good.” Results also indicated a lack of familiarity with IP student roles and competencies, limited opportunities for students to learn from other disciplines, inadequate opportunities for students to interact with students from other disciplines and limited feedback to students from professionals in other disciplines.

Based on the results of the initial surveys and interviews, and the themes and issues from the preimplementation data, the WG used an inclusive and collaborative process to select goal areas and implement initiatives to strengthen IP learning for both PCT members and students on the clinical unit. Five key areas were identified:

Creation of an Interprofessional Learning Environment

The team recognized that the current environment did not fully meet the goals of the IPCLU learning environment, and therefore made several critical changes. First, a dedicated IPCLU space was created. Desks, chairs, textbooks, bookcases, computers, and bulletin boards were placed in the area (see Figure 1). This allowed the team to meet formally and informally to discuss IP approaches and issues. The team created a Resource Binder which highlighted resources pertaining to IP practice, communication/collaboration and team work, as well as clinically relevant resources for each discipline who were providing patient care in that clinical area.

Then, a team mission statement was created, based on IP concepts:

The Stroke Team strives to create an interprofessional learning environment where knowledge and skills of team members and students are recognized and respected to provide exemplary rehabilitation care for patients and families. The IPCLU focuses on evidence-based practice and participation in research.

image

Figure 1. IPCLU Resource Center

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Increased Awareness of Interprofessional Practice

With information from the interviews and surveys, the WG realized that the clinical disciplines worked in a multidisciplinary manner yet they had little understanding of the how IP education and service delivery might differ from their normal practice. To increase awareness of IP practice and education, the WG gathered IP information and then developed an IPCLU website for all students and clinicians. The website includes an overview of the IPCLU program on the unit, an introduction to IP learning, IP learning pathways, IP student competencies and specific information about the IP student experience on the unit (IPCLU Research Team, 2011). The website provided students and clinicians with information about the resource center, specific resources, IP education opportunities, and areas where students may wish to focus during their IPCLU experience. The IPCLU website is utilized for all student and staff orientation (www.ipclu.ca).

Role Clarification

As the team began to integrate IP concepts, they realized that they may have a good understanding of their own role as part of the team, but insufficient knowledge of the disciplines and roles of those with whom they worked. The team developed role descriptions for each discipline which culminated in the creation of an IP Team Board (see Figure 2). The Team Board outlined the various disciplines and their roles, allowing each student and/or team member to identify team members and seek out their expertise. Photographs of each team member were included and the board was placed in the unit corridor for easy access. Information about physician roles and patient rounding schedules were included so students could identify physicians and attend patient rounds. Students also had access to information related to disciplines and roles on the IPCLU Orientation Website.

image

Figure 2. Interprofessional Roles

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Enhanced Interprofessional Communication

Once the team had an understanding of the various disciplines and roles involved in their patients’ care, they expressed the desire for an efficient way to follow their patient throughout the day. The team developed a Patient Scheduling Board (see Figure 3) located near the main desk area. The Patient Scheduling Board outlines the treatment and therapy programs for each patient, including time, type of therapy and identity of therapist. This allowed students and staff to quickly refer information and follow a patient through particular types of therapy and rehabilitation sessions, whether it was driver training or occupational therapy. This communication tool was found to be particularly helpful for families as a guide to their family member's daily schedule.

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Figure 3. Patient Scheduling Board

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A further step in providing IP information for the team, patients, and families was the development of the Patient Bedside Board (see Figure 4). Although these were utilized before the IPCLU, the previous board did not include or identify the specific disciplines involved in the patient's care. The Patient Bedside Board was revised to include the identification of all disciplines (including students) involved with the patient, as well as information about diet, grooming/hygiene, transferring and mobility, upper and lower dressing capabilities, and braces and splints.

image

Figure 4. Patient Bedside Board

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To ensure that all disciplines and team members had access to consistent information about formal IP communication, additional information was added to the website. This included specific integration of IP concepts into unit communication practices. For example, changes were made to patient conference formats, and the unit communication book to address and enhance IP collaboration.

Reflection and Evaluation

The WG realized that traditional student practices such as formative and summative evaluations with a specific disciplinary focus would not meet the need for reflection and evaluation in the IPCLU environment. A student clinician reflection form was developed to guide students in their reflective practices while practicing in the IPCLU (Appendix A). Sharing student reflections with the larger IPCLU team became a valuable tool to assist team members in providing feedback to the student clinicians on IP skills on an ongoing basis. In addition, an IP appraisal for student clinicians was developed which focused on evaluation of IP competencies with feedback from a variety of disciplines (Appendix B). At the end of their IPCLU experience, students evaluated the IP learning environment and provided suggestions for improving the experience for students and team members. Students felt that the IP environment enhanced patient care as each student immediately felt part of the IP team, were clearly aware of the student-clinician expectations, and were able to be involved earlier in providing patient care.

Postimplementation

Eleven patient care team participants, two students, and five faculty participants provided postimplementation data. The participants represented the disciplines of Nursing (five), Medicine (one), Occupational Therapy (two), Physical Therapy (five), Speech-Language Pathology (one), Recreation Therapy (one), Pharmacy (one), and Clinical Psychology (one). One student completing an IP experience also provided data.

The predominant themes from postimplementation focus groups and surveys were as follows: Communication, Informal IP Learning, Role Awareness, Positive Learning Environment, Logistics, and Challenges. These results emphasized the value of informal and indirect methods communication and learning about IP practice. As in the preimplementation data, the positive environment on the unit was emphasized.

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B

The development and implementation of an IPCLU was a successful and rewarding experience; although not without challenges. Key findings from pre- and post- implementation qualitative data provided insight into the day-to-day processes and issues involved in the implementation of the IPCLU. A key factor in the success of the IPCLU was the support and involvement of all participants, but particularly that of leaders and managers. Within the setting, “leadership” roles and “management” roles were differentiated. Leadership in this project referred to the roles and functions of the research team, project coordinator, and research assistant, while the “manager” of the IPCLU was a collaborative participant in the IP working group and responsible for ongoing face-to-face support and facilitation of the IPCLU concept on the frontline. “Leadership” provided education, direction, and guidance to the project as a whole, with the aim of supporting and informing the entire IP team. Within the theme of Challenges, participants expressed that leadership roles and functions fell beyond the role of a busy frontline manager. The role of project manager in this research project was crucial to the overall success of the project. As part of a sustainability plan for this and future IPCLUs, participants felt strongly that an interprofessional coordinator should replace the project manager as the person to coordinate interprofessional learning and practice on site.

Within the theme of Logistics, resource room setup, creation of the IP team board, and patient bedside communication board required a coordinated effort to navigate the channels of a large healthcare agency and were not without delay. This, at times, hampered progress of the WG and PCT and dampened the mood on the unit.

However, the creation of the resource room, IP team board, and patient scheduling board has led to a greater understanding of roles, improved communication among team members, and an enhanced student experience as was evident in comments from the Communication theme. Students have become “higher profile” on the team even though they had been a part of the team for many years. As one of the patient care team noted:

This [IPCLU] is a great initiative – it is good to foster teamwork while students are still learning in their field of interest (to be aware that the goal of health care is a team approach). The improvements made on the unit in terms of communication have been an asset in my own work (i.e., whiteboard with staff pictures), and will help my future students.

Within the theme of Role Clarification, the creation of the IP team board provided a starting point for all team members and students to “figure out who was who” and “who did what.” “Even new staff and students are going to the board and saying, “OK that's who that is and that's who that is. It's great,” said one of the patient care team.

Although there have been significant improvements in recognition of roles and team communication from the student point of view, there are still areas of collaborative, IP practice that require work. As an example of Challenges, one student noted the confusion that often comes with multiple clinical placements on multiple sites:

There are still some areas where I'm not totally sure as to what they do or what goes on there, and things like that. But I think that it's coming and by kind of working with the team and being in an area like the [SITE] where everybody's more team focused, you get a greater opportunity to see what the other disciplines do.

The need for formal education about IP practice in the rehabilitation setting became evident. A common assumption was that a multidisciplinary team was naturally collaborative and IP. However, some team members still work in a discipline specific manner alongside team members of other professions. It was acknowledged that collaboration does not just happen, but it requires active participation and commitment from team members to work in such a manner:

It's always going to be a bit of a barrier that's going to be a bit of a challenge. We have a pretty good idea of what each other does within our interprofessional team, but we still don't do it on a day-to-day basis, nor have we had that extensive experience doing their work. There are some things that are easily met, like communication that we can continue to work on and help each other out on. But it would be very difficult to have a nurse trying to give direction to a physiotherapy student, for instance, about direct physiotherapy needs. (Patient Care Team member)

At the end of the project, the participants could fully appreciate that the tangible results such as data, scheduling boards, and role descriptions were the result of a process that in and of itself was a key finding. The process of involvement in the WG, where each discipline collaborated, communicated, reflected and evaluated their practice, encouraged a move beyond disciplinary silos toward full immersion in what it means to be interprofessional.

Each of the challenges encountered during this project required leadership, resources (time and staffing) and a continued commitment for success; commitment from members of the patient care team, commitment and leadership from both the executive level of the healthcare delivery agency, and from academic partners whose students are hosted by the unit.

Conclusion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B

The creation of an IPCLU on this particular rehabilitation unit has had a positive overall effect on patient care team members and student clinicians of all disciplines. Key outcomes include a change in unit culture toward IP collaboration, enhanced awareness of IP practice and IP competencies, an improved student learning experience, and enhanced patient care. With the development of a toolkit for IPCLU development, another clinical unit at this rehabilitation site is in the process of creating their own IPCLU.

Ultimately rewarding, IPCLU implementation is not without challenges, many of which can be mitigated by education, mentorship and committed leadership. The sustainability of the IPCLU is dependent upon strong leaders with the facilitation and mentorship skills necessary to gain support and commitment from the IP teams. A collaborative and visionary frontline manager can act as a role model for IP practice, and facilitate the IPCLU concept while still attending to myriad management responsibilities. The introduction of a dedicated site/facility IP coordinator would be beneficial, and is likely necessary, to develop and provide ongoing IP education, orientation and resources for both practitioners and students. In addition, the IP coordinator could act as a central contact for IP education and a liaison for academics and professionals regarding student placements, as well as support existing and future IPCLUs as the IP culture develops and spreads.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B

We acknowledge the nursing clinical learning unit research that informed the development of this project. Refer to: Marck, P. B., Barton, S., Day, R., Bulmer-Smith, K., Gushue, S., Kemp, L., Martin, K., Peterson, K., Worrell, J. Transforming Clinical Learning Environments for Undergraduate Nursing Students: A Collaborative Clinical Learning Unit. Final Research Report. 23 November 2010. Faculty of Nursing & Teaching and Learning Enhancement Fund, University of Alberta & Royal Alexandra Hospital, Alberta Health Services. Available at http://www.nur5s.ualberta.ca/clu/CLU STK2010/CLU Final%20Report 23Nov2010%20(2).pdf

Key Practice Points
  • Interprofessional education and collaboration is one strategy that may alleviate the global health workforce shortage.
  • Working in a multidisciplinary environment on a multidisciplinary team is not the same as working interprofessionally.
  • Interprofessional education occurs when professionals or students from two or more professionas learn about, from, and with, each other to enable effective collaboration to improve health outcomes.
  • Key outcomes following the development and implementation of a clinical learning unit in a rehabilitation setting include a change in unit culture toward interprofessional collaboration, enhanced awareness of IP practice and IP competencies, an improved student learning experience, and enhanced patient care.
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References

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B
  • Canadian Interprofessional Health Collaborative. (2010). A national interprofessional competency framework. Vancouver, BC: University of British Columbia.
  • Clark, P. G. (2011). Examining the interface between interprofessional practice and education: Lessons learned from Norway for promoting teamwork. Journal of Interprofessional Care, 25(1), 2632. doi:10.3109/13561820.2010.497751
  • Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., et al. (2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet, 376(9756), 19231958. doi:10.1016/S0140-6736(10)61854-5
  • Hallin, K., Kiessling, A., Waldner, A., & Henriksson, P. (2009). Active interprofessional education in a patient based setting increases perceived collaborative and professional competence. Medical Teacher, 31(2), 151157.
  • IPCLU Research Team. (2011). Building clinical education capacity with interprofessional clinical learning units across the continuum of care. Retrieved June 9, 2011, from http://www.ipclu.ca/
  • Legare, F., Stacey, D., Pouliot, S., Gauvin, F., Desroches, S., Kryworuchko, J. et al. (2011). Interprofessionalism and shared decision-making in primary care: A stepwise approach towards a new model. Journal of Interprofessional Care, 25(1), 1825. doi:10.3109/13561820.2010.490502
  • Ponzer, S., Hylin, U., Kusoffsky, A., Lauffs, M., Lonka, K., Mattiasson, A. C. et al. (2004). Interprofessional training in the context of clinical practice: Goals and students’ perceptions on clinical education wards. Medical Education, 38(7), 727736.
  • Reeves, S., Freeth, D., McCrorie, P., & Perry, D. (2002). It teaches you what to expect in future: Interprofessional learning on a training ward for medical, nursing, occupational therapy and physiotherapy students. Medical Education, 36(4), 337344.
  • Shalowitz, M., Isacco, A., Barquin, N., Clark-Kauffman, E., Delger, P., Nelson, D. et al. (2009). Community-based participatory research: A review of the literature with strategies for community engagement. Journal of Developmental and Behavioral Pediatrics, 30(4), 350361. doi:10.1097/DBP.0b013e3181b0ef14
  • Sommerfeldt, S. C., Barton, S. S., Stayko, P., Patterson, S. K., & Pimlott, J. (2011). Creating interprofessional learning units: Developing an acute-care model. Nurse Education in Practice, 11, 273277.
  • World Health Organization. (2010). Framework for action of interprofessional education and collaborative practice. Geneva: World Health Organization.

Appendix A

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B
IPCLU PROJECT
GLENROSE WORKING GROUP
Student Clinician Reflection
Name:
Please provide the information requested and submit to your clinical educator at mid-term and end of placement
Three most valuable interprofessional experiences in this placement.
Midterm: Final:
At least three reflections on knowledge, skills or attitudes acquired during those interprofessional experiences.
Midterm: Final:
Describe one interprofessional experience or interaction that you would do differently and explain why.
Midterm: Final:
Most important interprofessional objectives for the remainder of the placement (or next placement).
Midterm: Final:
Actions currently taking to improve interprofessional skills
Midterm: Final:
Barriers to achieving objectives
Midterm: Final:
Resources needed from agency and/or other team members
Midterm: Final:
Ratings of four Interprofessional Competencies

** This type of rating form is a focus of an interprofessional project at the University. I would suggest that we try to align our development with that committee. The competencies and basic structure are below:

Four Interprofessional Competencies:

  1. Interprofessional Communication: adapts communication strategies to suit context and optimize patient care
  2. Interprofessional Collaboration: engage team process skills to achieve common goals
  3. Role Clarification: adapts understanding of own role and the roles of others to suit context
  4. Reflection: critically approase evidence, professional practice and team experiences, within own context, values and beliefs in order to lead to a new understanding and appreciation of self, team, events and context

Level of Competence:

  1. Exposure: Knowledge/comprehension of concepts and values; exploration of skills
  2. Immersion: Application of knowledge and skill practice
  3. Competence: Integration and translation of knowledge. Acts to promote best practices: (Adapted from http://www.ccl.org/leadership/assessments/assessment360.aspx).

Appendix B

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
  10. Appendix A
  11. Appendix B
IPCLU PROJECT
GLENROSE WORKING GROUP
Team Member Feedback on Interprofessional Skills
Date:
Student Clinician:
Interprofessional Interaction: (please describe the type of interaction you had with this student)
Staff member:
Feedback:
Interprofessional strengths and positive qualities I have noticed (minimum of 1, maximum of 3)
Areas for improvement in interprofessional skills (minimum of 1, maximum of 3)