2. Method
Simulation-based training was provided for medical students and students of allied health professions (e.g., physiotherapists, speech–language therapists, and occupational therapists) from a variety of universities across the globe. The training was provided by the two authors. The professors of the students were present during the training. In an overt ethnographic research design, passive observations were made to ensure careful observations and accurate reporting. After providing the information and the assignment, both authors served as non-participant observers who took field notes. The framework of simulation-based training offered an excellent opportunity to directly experience the behaviors and interactions of a group of people within a specific context. By immersing ourselves in the social setting of interprofessional collaborative teams, we were able to access more authentic information by observing spontaneous interactions. The goal of ethnographic research is not necessarily to test a general theory or hypothesis. Instead, we attempted to gain insight into the group dynamics of an interprofessional team in the context of shared decision-making while we collected rich data.
2.1. Participants
In total, over the span of 5 years, 62 groups of 9 to 10 medical and health students from universities in Europe (the Netherlands, Belgium, Germany, Italy, Malta, Sweden, and Finland), the United States (New York and New Jersey), and Asia (the Philippines, China, Hong Kong, and Taiwan) participated in the training. Approximately 85% of the students were female, as often overrepresented in medical and allied health students. They had a variety of backgrounds, experiences working with children with DS, and experiences with interprofessional collaboration. None had previous experience within the context of shared decision-making, as was used in the training. Of the participants, roughly 60% were students of speech–language pathology. Other backgrounds were physiotherapy, podiatry, occupational therapy, psychology, pedagogy, nursing, and medicine. No further personal information about the students was gathered.
2.2. Procedure
Participants first received a lecture about interprofessional collaboration, shared decision-making, ICF-CY and the code set of Deckers et al. [
26], language development in Down syndrome, and AAC. Although we are well aware of the debate in using the ICF as a framework (i.e., [
30]), the fact that ICF-CY codes refer to a well-defined parameter provides a good opportunity to at least “talk about the same” and “use the same language”, which is highly important for interprofessional collaborative work.
Starting the assignment, participants were told to keep the following in mind: In interprofessional collaboration, several involved disciplines formulate shared intervention goals, use the same language, which is accessible and understandable for all involved, and perceive the qualities and perspectives of other disciplines as complementary and valuable. Only in close collaboration can the best health outcomes be accomplished for the individual client [
2].
Furthermore, all participants received the following case information with a first reference to ICF-CY codes: Jonas is a 4-year-old boy with Down syndrome who lives at home with his parents and brother for six days a week (e310). One day a week, he stays with a foster family (e340) to relieve his parents from the pressure of taking care of him. His parents and foster parents are involved and motivated to stimulate Jonas in his communicative development (e310). On weekdays, he visits a daycare center that specializes in care for children with multiple disabilities (e360). During daycare, he sees an SLP and a physiotherapist. Sometimes, he sees a doctor and an audiologist (e355). His parents have proposed the following need: “Help us improve the communication of and with Jonas”.
Then, three videos of Jonas, totalling 8 min, were watched together, if possible two times. The videos showed Jonas interacting with his parents at home during a play situation, with the teacher and class assistants during a teaching moment and during snack break, and with peers on the playground. Students were asked to write down detailed observations. After watching the videos, students were divided into groups of 9 or 10. Within each group, every student was assigned a specific role: (1) speech–language therapist, (2) parent, (3) foster parent where Jonas stays for the weekends, (4) audiologist, (5) teacher/day carer, (6) physiotherapist, (7) psychologist, (8) general practitioner, (9) secretary describing decisions and reasoning for these decisions, and (10) student observant describing observations about group dynamics, communication skills, and how and who made decisions. To obtain comparable learning outcomes and to let participants learn about other disciplines, we tried to ensure that every participant was assigned a role outside their professional training. However, it did occasionally occur that a student in speech therapy played the role of the speech–language therapist, given the relatively high amount of participating speech therapy students. When groups contained only 9 members, the roles of secretary and observant were combined. The group was given the task of deciding who would be the chair of the meeting. For a full description of the roles, see
Appendix A. Each participant received a description of the case according to his/her role. Some roles shared information, and some roles had unique information. After receiving their information, students had 30–45 min to carefully read and prepare for their role. For example, to look-up what certain codes meant in the ICF-CY when they were not familiar with certain terminology. Students were also allowed to ask questions to the trainers, but only to clarify terminology in their role information. Students were instructed not to share their information with other students before the official start of the interprofessional team meeting since sharing could directly influence the course and the start of the following team meeting. We are aware this does not necessarily reflect a ‘real-life situation’; however, it helped structure the assignments and make it possible to compare groups.
After preparation, students had approximately 60 min for an interprofessional team meeting. The following instruction was given: The goal of the setting is to prepare an interprofessional treatment priority plan to stimulate the communicative development of Jonas. The outcome should include the following: (a) three shared goals for collaborative practice, SMART (specific, measurable, achievable, relevant, and time-bound) formulated, for a period of at least the next 3–6 months, in order of priority; (b) within the interprofessional team, it should be indicated who is responsible for the monitoring and evaluation of goal attainment. How will you monitor and evaluate?; (c) reflection on the group discussion; (d) presentation of your goals and a short rationale (how and why these goals were chosen); (e) presentation of a brief evaluation of the group discussion. Both trainers walked around and observed each group and wrote down their notes. At the end of the sessions, all group secretaries and student observants presented the goals, rationale, and evaluations.
2.3. Analysis
All notes of the student groups and trainers were gathered. The first and second authors independently reported and open-coded their observations for meaning. After observing the first twelve groups, we generally refined our codes and constructed categories in themes. All categories and coded observations were compared and discussed until a consensus was reached. After the construction of the categories, we discussed them in relation to the prerequisites for achieving good, efficient, and effective interprofessional collaboration. Saturation for codes and categories was reached during analyses. The
Section 3 describes the identified themes and describes several observations per theme. Furthermore, since the goal of the present study was to gain more insight into the dynamics of shared decision-making in an ethnographic way, reflections of the trainers are described based on these observations.
3. Results
In this ethnographic research project, we wanted to answer the question of how group dynamics interfere with shared decision-making in interprofessional teams. We identified multiple constructs and themes by passively observing student groups in a simulation-based training exercise.
Table 1 describes the categories and themes. For each theme, several observations have been described.
3.1. Vision
For most groups, formulated goals were based on strengthening Jonas’ functioning as well as his immediate system. We feel that it is important to take into account the fact that people in Jonas’ environment also have an influence on his overall functioning and that the goals can, therefore, also be focused on the system around Jonas, which indirectly works on Jonas’ functioning. In the group discussions, a treatment or guidance goal was quickly determined, even if the participants did not yet have a holistic picture of the case. We saw that often, after discussing one area of functioning, it was decided to start working on that domain. Interprofessional values and related ethical aspects are an important part of the professional identity of every health or welfare and education professional who wants to work well, safely, effectively, and efficiently with all stakeholders. These values and ethical aspects are personal and stem from the common goal of promoting the health and well-being of a client or a client population. It is also a question of competences to see the clients themselves and their social network as valued team members and experts and to actively involve them in the whole process of treatment or counselling and support. In doing so, the professional realizes that the client population is characterized by diversity.
The fact that certain groups of people have difficulty finding, understanding, and applying information is not solely due to their lack of certain skills. A lot of information, both verbal and written, that professionals and professional organizations share with them is complex and packaged in language that is not easily accessible to them. Think of the jargon of professionals and specialists.
Being able to work together interprofessionally presupposes that you have insight into professionals and other stakeholders from their professional roles and responsibilities and that you can complement each other with the aim of providing person-centered care, support, and guidance. A diversity of roles and responsibilities between team members can be both a resource and a problem for collaboration. Effective teams need this diversity, but everyone in the team must be able to appreciate this diversity. Therefore, this refers to competences with regard to recognizing, acknowledging, and valuing one’s own limitations and strengths, but also those of others, and seeing the need for coordination and cooperation between different professionals, with the common goal of promoting the health and well-being of the client.
3.2. Structure
There was often (too) little coordination between those present. Technical jargon, for example, was used relatively often without checking whether it was accessible and understandable to parents or professionals from other disciplines. Paraphrasing or summarizing from time to time can ensure that everyone knows what the discussion is about and can, therefore, have input. Everyone must feel free to ask clarifying questions or ask for more explanation. Interprofessional collaboration means working with and learning from each other.
At the beginning of most roleplays, a chairman was appointed, but our observations indicate that they can and should play a stronger role and ensure that each participant can have their say. In general, the chairman would also be better able to respond to the different personalities present. We did not observe that one discipline was more inclined to take on the role of chairman than another. In some groups, it was decided to give the parent the role of chairman because they know the most about the client and everyone involved. In other groups, the psychologist or general practitioner was chosen as the most ‘natural’ leader of the meeting.
Being able to act interprofessionally also means that professionals have to be good team players. Teamwork competencies refer to any situation in which professionals communicate with each other about and align their actions with the shared goals for the care and support provided to a client. This is about being able to work together in person-centered care, coordinating shared care, solving problems together, and making decisions and choices together. Learning to work in teams means that the professional becomes part of a small, often complex system around a client.
3.3. Processes
A professional’s involvement as a team member will often be based on their added value, from their own professional expertise and background, and is complementary to that of other team members. As mentioned earlier, this diversity can also be a source of conflict between team members, for example, regarding who the leader of the team is. It is then important to stick to the client’s goals and how they can be achieved.
The outcome of the interprofessional meeting is strongly influenced by personalities and characters. A person with a strong, present personality may determine the extent to which information is judged and valued as important. For example, if the parent is played by someone with a strong personality, a lot of value is placed on his point of view. However, if the parent remains in the background, his opinions will soon be talked over. This process can occur in any role, but when working interprofessionally, it is important to be extra alert when it comes to the client and their representatives. The chairman of the interprofessional meeting or the care director has a clear task in this.
The order in which symptoms and characteristics are discussed within the interprofessional meeting corresponds strongly to the final prioritization of goals. In various groups, given the size of the group, it sometimes occurred that a certain role could not be taken up, for example, because the audiologist was absent from the conversation. This, of course, had immediate consequences for the way the interprofessional meeting went. Despite the fact that we always provided the same information to all groups, it appears that no group achieved exactly the same three goals or the same prioritization or rationale of goals.
In interprofessional collaboration in multidisciplinary teams, the starting point is the use of a common language and ICF terminology in the role descriptions. However, we did not see this reflected in the target formulation. There was not a single group that linked ICF codes to the formulated goals. What often happened was that technical jargon was used, but clarification questions about essential concepts or ICF codes were not discussed.
Goals were prioritized, but there was not always a clear reasoning as to why the goals were formulated in this order and not in another. It seemed that prioritization was related to the order in which the goals were dealt with in the interprofessional meeting rather than reasoning from the level of functioning of the client. The questions that should be addressed are as follows: Why is this goal so important, and how does it help Jonas to function and participate better? Are there any conditions that we need to take into account in order to achieve this goal?
Problems surrounding Jonas’ hearing were raised by several attendees, but little or no follow-up steps were taken. In a number of these groups, we saw that due to a lack of information, the theme of ‘hearing’ was quickly drowned out by other requests for help, for which the expertise was ‘at the table’. In these cases, it is important that the chairperson, note-taker and/or care director know that there is a need for information and that this must be addressed immediately after the interprofessional meeting. The absence of a role meant that the urgency and importance of the input from this role were insufficiently recognized. This, of course, argues for the presence of all those involved in the interprofessional meeting.
3.4. Results
Despite the fact that we always provided the same information to all groups, it appears that no group defined the same three goals or the same prioritization or rationale of goals. Overall, 39 different goals were defined by the groups in different orders of prioritizing and with different time frames or intervention ideas to reach those goals. Although working on interprofessional collaboration and shared decision-making, many goals were connected to one single role, making many goals monodisciplinary instead of interprofessionally. Interestingly, the goal “to improve Jonas’ hearing” was mentioned by 70% of the groups. This was surprising because (a) the parents clearly indicated he experienced no problem with his hearing and did not want Jonas to be tested again, and (b) the role of the audiologist and their total knowledge about Jonas was fairly small when compared to the other role descriptions. Shared decision-making was lacking completely on this point, and all groups chose to convince the parents that Jonas should be tested again. Due to the group dynamics, almost all parents ended up agreeing with the professionals in wording, although their non-verbal communication was not in congruence with that.
Another observation was that in many groups, goals were determined by many different AAC strategies and tools. Some groups advised using manual signs, with or without the combined use of speech (i.e., sign-supported speech), for the communication partners of Jonas. Other groups advised starting to use speech-generating devices or paper-based communication books. AAC advise was strongly steered by the information that was put most strongly to the table by a student playing a specific role. For example, when the psychologist had a more leading role, the cognitive abilities of Jonas were used in decision-making, whereas in other groups, motor development, language development, or vision or hearing status were, to a more or lesser account, used as a rationale for choices of AAC strategies.
In interprofessional collaboration, the starting point should be the use of a common language and ICF-CY terminology in the role descriptions. However, we did not see this reflected in the target formulation. There was not a single group that linked ICF-CY codes to the formulated goals. What often happened was that technical, discipline-specific jargon was used, but clarification questions about essential concepts or ICF codes were not discussed or even raised.
Goals were prioritized, but there was not always a clear reasoning as to why the goals were formulated in this order and not in another. It seemed that prioritization was related to the order in which the goals were dealt with in the interprofessional meeting rather than reasoning from the level of functioning of the client. Questions that should be addressed are as follows: Why is this goal so important, and how does it help Jonas to function and participate better? Are there any conditions that we need to take into account in order to achieve this goal?
In five groups, only eight students participated, and the choice was made to leave the audiologist out of the assigned roles. In these sessions, problems surrounding Jonas’ hearing were raised by several attendees, but little or no follow-up steps were taken. In these groups, we saw that due to a lack of information, the theme of ‘hearing’ was quickly drowned out by other requests for help, for which the expertise was ‘at the table’. In these cases, it is important that the chairperson or note-taker writes down that there is a need for information and that this must be addressed immediately after the interprofessional meeting. The absence of a role meant that the urgency and importance of the input from this role were insufficiently recognized. This, of course, argues for the presence of all those involved in the interprofessional meeting.
Of course, we also observed many positive behaviors in all constructed categories and themes. Positive behaviors reflect the opposite of the examples described in
Table 1. For example, we observed some groups where, from the start, the perspective of the parents was set as leading the discussion. Parents in these groups were often asked if they still understood and if what was discussed was in the best interest of Jonas according to their perspective. Additionally, there were groups with a strong or stronger chairman, making sure that all roles could share their information and, most importantly, that conflicting information was discussed. Some groups agreed to try not to use any jargon.
4. Discussion
The motto of shared decision-making is ‘Without me, there is no decision about me’. However, communication with a client, especially in the healthcare sector, is still often approached from the perspective of the professional and is sometimes characterized by a paternalistic communication style, in which decisions are mostly based on the information and opinions of the professional [
31]. As a result, clients usually feel unheard and excluded from the decision-making process, especially when decisions are made in a team. An important condition for shared decision-making is the willingness of the professionals involved to take the client’s vision and choices into account. In many groups, we saw this paternalistic communication style of students playing a professional role in that they mostly tried to argue with and convince parents that a goal should be set based on their role-specific information. Explaining to the parents what professionals have determined is very exclusionary and condescending. In many groups, students playing the role of parents did not feel included in the decision-making process.
An important aspect of shared decision-making is that the client really understands what it is about and what a decision will mean for him and his personal situation. We did not observe this in many groups, leaving parents and many of the professionals at the table as well, confused about what decisions would mean for their daily life. Professionals often use technical terms and complex concepts and do not actively check whether their client has actually understood the information [
32]. This may result in parents or other professionals who are not familiar with discipline-specific jargon taking a passive role in the process of shared decision-making, which might be misinterpreted as disinterest: the client apparently does not want to ‘decide together’ or leaves it up to the professional [
33]. The passive role of parents may be well understood by their experience, which is repeated time and again only for them to be outnumbered or overruled in these discussions. With the reclamation method, sometimes also called the retelling method, the professional can check whether the information has come across correctly [
2]. Does the client know all the pros and cons of the different options? The professional can do this by asking the client to describe in their own words what has just been discussed. The professional can then make adjustments or supplement if necessary. It is important that the client does not get the feeling that they are being monitored, so the professional should relate the question to them as much as possible: ‘I would like to know if I have explained it correctly. What are you going to tell (or do) at home?’.
Developing basic communication skills is a competency that is covered in all health, welfare, and teacher education and training programs, but most students and professionals often have less knowledge and experience with interprofessional communication [
2]. Interprofessional communicative competencies are important for collaboration with professionals from other disciplines and with clients and their social networks. This involves, for example, learning to speak each other’s discipline-specific language and tuning into your conversation partners, diminishing the amount of technical jargon used. Diversity, in the broadest sense of the word, also plays a role in this coordination. The use of jargon is often seen as a barrier to effective collaboration. Providing information that is accessible and understandable to everyone, including the client and the social network, contributes to safe and effective interprofessional care.
As we can clearly see from our experiences with simulation-based training, shared decision-making is thus an ongoing challenge, especially in an interprofessional context. Sharing knowledge and experiences during a decision-making meeting does not guarantee that team members will continue to work together afterwards [
10]. Each team member will make their own personal interpretation of the situation based on the information provided by the others and then make their own prioritization regarding the steps in the care and support process [
2]. This means that professionals must be able to deal with the perspectives of the client himself, his social network, and other professionals and that they have to adjust their own perspective accordingly. Only when a common perspective has been reached through communication with agreement on the prioritization of advice can we really speak of shared decision-making in the interprofessional context. As can be expected, most of the groups in our training did not reach this stage after following an extensive lecture and the current assignment, which strongly suggests the need for continued education in health and social care interprofessional collaboration skills. However, using the current assignment and reflecting with the students afterwards can be seen as a valuable starting point in raising awareness and gaining more insight into the required competencies for interprofessional collaboration. Therefore, we advise integrating the developed assignment into a broader interprofessional education program, which should focus on the core competencies of interprofessional collaboration as proposed by the Interprofessional Education Collaborative [
34].
Each team member, including the client and the people from his social network who are important to him, has his or her own specialist knowledge and experiences that are relevant to the specific situation and that can contribute to making informed decisions [
10]. Motivating and challenging a team to discuss conflicting ideas and perspectives (including those of the client and their social network) and to transform them into a single perspective will benefit the client’s care, education, and support. But, how do you arrive at a well-founded decision in which all this knowledge and perspectives have been weighed and in which everything is integrated? Makoul and Clayman [
35] formulated nine essential steps for shared decision-making. Some of these elements of Makoul and Clayman still veer too much towards a paternalistic style, such as making a recommendation, because this should really only be conducted at the explicit request of the client. Therefore, we prefer the four steps for shared decision-making of Stiggelbout et al. [
36]. We supplemented the steps proposed by [
2] from an interprofessional perspective:
The professional informs the client and/or his colleagues that a decision has to be made and that everyone’s opinion is important and will be discussed. The professional emphasizes that the goal of the conversation is to make a choice (creating choice awareness).
The professional explains the different options and possibilities and discusses the advantages and disadvantages of each option. In doing so, he leaves room for any additions from others present. The pros and cons are substantiated with possible scientific evidence.
The professional and the client discuss the client’s preferences, which are linked to norms and values, and the professional supports the client in weighing up options. In this way, everyone can indicate what is important to them. It is also important to relate the pros and cons to the client’s individual situation, e.g., social, home, and work situation. Keep in mind that different norms and values may play a role for clients or professionals with different cultural backgrounds. The professional must provide room to discuss this.
The professional and the client discuss the client’s desire and possibilities to make an informed decision. They then make the decision together or postpone it so that, for example, the client can think about it or discuss it with family and friends. There is also talk of a follow-up to the appointment and the decision. For some clients, such as the elderly or people with a different cultural background, they may feel uneasy participating in decision-making. They may assume that the professional is the one who knows what they are doing and that the choice will come from them. Therefore, it is important to explain that the professional does indeed know what he or she is doing but that it is also necessary to know what is important to the client. It may be that after discussing preferences, the client chooses to leave the decision to the professional. This is also a shared decision if the client actively indicates this.
The chair of the interprofessional meeting is responsible for leading the meeting well, regulating the conversation, introducing new topics, and, above all, completing the assignment items of the meeting in a good way. The chair makes sure that the meeting starts on time, maintains order, and makes sure that everyone who wants to say something has their say and that there is not too much talking. Additionally, of course, they pay close attention to the time, so that the goal of the discussion is reached within the given timeframe. The discussion has a specific process-based objective. The most important task of the chairman is to achieve this objective. Particular attention should be paid to the proper completion of the discussion. In order to show this necessary leadership in interprofessional communication Nieuwboer et al. [
37] suggested to (1) ensure that all team members are connected and motivated; (2) help develop a shared vision; (3) foster a culture in which the team members empower each other as much as possible; (4) work from connection and not from hierarchy, but with a certain degree of authority and expertise; (5) train team members to deal well with conflicts; (6) ensure team members to articulate their expectations and needs. Based on the results of this study, more interprofessional education is necessary for students to play this role in their professional lives.
Limitations
A limitation of simulation-based training and the assumption of roles we do not typically perform is that there is no chance for social relationships to develop over time, which can enhance or interfere with interprofessional collaborative practice. Where clients tend to have a taken-for-granted trust relationship with healthcare professionals to provide a competent service that meets their needs, trust is challenged after the introduction of changes in the organization and performance assessment of health professionals and in public attitudes to health care science [
38]. In this simulation-based role play, building trusting relationships with the other professionals or the clients was extremely limited by the lack of time for the simulation. Students were put together in groups, who often did not know each other. This may have interfered with how students played their roles and might have affected the group dynamics and outcomes of the assignment.
Simulation-based training has been conducted throughout the world. In the present study, we combined all our observations. It might be that cultural background played a role in group dynamics. We did not check for the cultural sensitivity of the training per se. We discussed the assignment beforehand with university staff and did not encounter any comments about culturally insensitive information. Many groups of participants were indeed composed of different cultural backgrounds. Cultural background might influence the role somebody takes in a group discussion, so the cultural background of participants might have influenced the way how they played their roles. We did not study this in further detail. Thus, our results might be influenced by cultural backgrounds; however, we did not observe substantial differences between group discussions and outcomes for different participants across the world. In a follow-up study, we advise taking the cultural background and communication styles of students into account.
Any simulation-based training is a simplification of a real-life situation. Information in the current assignment was scripted, and conflicting information was added to the roles to elicit the required discussion. This may not directly mirror a real-life case. Collaborating with different professionals and with parents is complex and is something that students need to learn by experience. Of course, they have to gain these experiences in real-life as well, for example, during internships. However, this kind of simulation-based training does give universities the opportunity to let students experience interprofessional collaboration in a relatively controlled and ‘safe’ environment. They have to learn how to form group meetings, how to bring information to the table, and how to take on their roles and responsibilities, all for the greater purpose of good care. Given the experiences with the current assignment, simulation-based training seems like a wonderful teaching moment. The themes and examples, as described in
Table 1, were also discussed afterwards with students to help their learning experiences further.