Interprofessional communication (IPC) for medical students: a scoping review

Background Effective Interprofessional Communication (IPC) between healthcare professionals enhances teamwork and improves patient care. Yet IPC training remains poorly structured in medical schools. To address this gap, a scoping review is proposed to study current IPC training approaches in medical schools. Methods Krishna’s Systematic Evidence Based Approach (SEBA) was used to guide a scoping review of IPC training for medical students published between 1 January 2000 to 31 December 2018 in PubMed, ScienceDirect, JSTOR, Google Scholar, ERIC, Embase, Scopus and PsycINFO. The data accrued was independently analysed using thematic and content analysis to enhance the reproducibility and transparency of this SEBA guided review. Results 17,809 titles and abstracts were found, 250 full-text articles were reviewed and 73 full text articles were included. Directed Content analysis revealed 4 categories corresponding to the levels of the Miller’s Pyramid whilst thematic analysis revealed 5 themes including the indications, stages of trainings and evaluations, content, challenges and outcomes of IPC training. Many longitudinal programs were designed around the levels of Miller’s Pyramid. Conclusion IPC training is a stage-wise, competency-based learning process that pivots on a learner-centric spiralled curriculum. Progress from one stage to the next requires attainment of the particular competencies within each stage of the training process. Whilst further studies into the dynamics of IPC interactions, assessment methods and structuring of these programs are required, we forward an evidenced based framework to guide design of future IPC programs.


Stage 2. Independent searches
Under the guidance of the expert team, search strategies (Supplementary File 1) were formulated with the following keywords: 'medical students', 'nursing students', 'allied health students', 'interprofessional', 'communication' and 'education'. In keeping with Pham, Rajić (47)'s approach to ensuring a viable and sustainable research process, the research team con ned the searches to articles published between 1 January 2000 and 31 December 2018 Seven trained researchers carried out independent searches of PubMed, Embase, CINAHL, Scopus, PsycINFO, ERIC, JSTOR, and Google Scholar databases and created independent lists of titles and abstracts to be scrutinized further based on the screening criteria as detailed in Table 1. The researchers discussed their ndings at online meetings and determined the nal list of full text articles to be reviewed using Sandelowski M (48)'s 'negotiated consensual validation' approach.

Selection of studies for review
The nal list full text articles was independently scrutinised by members of the research team and discussed their ndings at online meetings. The research team determined the nal list of full text articles to be analysed using Sandelowski M (48)'s 'negotiated consensual validation' approach. Figure 1 shows a summary of the PRISMA process. Stage 3. Data characterization and Split Approach (41,42,50) Inspired by the notion that communication skills training is a longitudinal process that develops in competency based stages, Hsieh and Shannon's directed content analysis was adopted (51). The codes and categories for this content analysis was drawn from various stages of the Miller's Pyramid (13)(14)(15)). Miller's Pyramid serves as an in uential conceptual framework for the development and assessment of clinical competence, one which sees learners move from cognitive acquisition of knowledge to applied behaviour in clinical settings where bene ciaries reside. Critically an initial review of prevailing programs suggest that many IPC programs appear to fashion their programs around the 4 levels of Miller's Pyramid (13)(14)(15) which are 'Knows' -which requires the learner to be aware of knowledge and skills, 'Knows How' -which sees the learner apply these knowledge and skills in theory, 'Shows How' -where knowledge and skills are applied in practice, and 'Does' -where the learner is shown to be able to function independently in the clinical setting (52).
The decision to adopt content analysis was not unanimous precipitating the employ of the 'split approach'. The decision to adopt Braun and Clarke's approach to thematic analysis (46) gained traction following the ndings of the deductive category application. Part of the directed content analysis, the deductive category application suggested the presence of a number of other categories not related to the 4 levels of Miller's Pyramid. These include the indications, structure, content, assessments and obstacles to IPC programs (34). Omission of these critical categories and the belief that the adoption of predetermined categories based on Miller's Pyramid required further evidencing, underpinned the decision to adopt Krishna's 'Split Approach' (43)(44)(45)(46).
The 'Split Approach' (54) sees two independent teams carry out concurrent reviews of the data using Hsieh and Shannon's directed content analysis (51) and Braun and Clarke's approach to thematic analysis (46). This saw two members of the research team carry out concurrent and independent analyses of the data using Hsieh and Shannon's directed content analysis (51) and three other members of the research team carry out simultaneous and independent analysis of the data using Braun and Clarke's approach to thematic analysis (46). The ndings were discussed within each sub-team at online and face-to-face meetings where "negotiated consensual validation" was employed to determine the nal list of themes and categories (57)(58)(59). The themes from Braun and Clarke's approach to thematic analysis (46) and the categories from Hsieh and Shannon's directed content analysis (51) were compared (54). Stage 4. Review of results and comparing them with current data Using PRISMA guidelines (Figure 1), an initial search in eight databases revealed 17,809 titles and abstracts after removal of duplicates. Two hundred and fty full-text articles were reviewed and a total of 73 articles were included for analysis. The narratives were written according to the Best Evidence Medical Education (BEME) Collaboration guide (61) and the STORIES (STructured apprOach to the Reporting In healthcare education of Evidence Synthesis) statement (62).
Scrutiny of the themes identi ed from the employ of Braun and Clarke's approach to thematic analysis (46) and the categories identi ed from Hsieh and Shannon's directed content analysis (51) were found to be overlap in some areas (54). In addition the 5 themes identi ed using Braun and Clarke's approach to thematic analysis (46) which were the indications, stages of trainings and evaluations, content, challenges and outcomes of IPC training were similar to the categories identi ed using Hsieh and Shannon's directed content analysis (51). This allowed the themes and categories to be presented together.

a. Indications for IPC programs
The indications for the development of IPC programs are outlined in Table 2. Most accounts sought to assess perspectives towards Interprofessional work and communication, to introduce the use of IPC amongst medical students, to assess the nature of these interactions, determine roles and responsibilities of tutors and students in IPC, to better understand the process of problem solving and teamwork, to scrutinize the decision making processes that occurred in collaborations and evaluate the impact of debriefs and feedback sessions following IPC sessions. Many of these interactions took place in case discussions, simulations and or clinical practice and involved medical students in pre-clinical and clinical postings. Other accounts focused upon training faculty on teaching, facilitating IPC, setting and evaluating clinical competencies and debriefs and reports of IPC programs.

b. Stages of IPC Training
Whilst there were accounts that assessed a speci c aspect of the IPC process or involved 'snap shots' of the IPC process and interactions, accounts of IPC that took a longitudinal perspective of IPC did consider the development of IPC along the 4 levels of Miller's Pyramid (Figure 2) (13, 15, 63, 64). As a result, we present the themes/categories related to each level of Miller's Pyramid.

Evaluation
Students were asked to re ect on their IPC experiences (70,77,93,96,127). In Robertson

Suitability of Teaching and Evaluation Methods
It is of note that across the 73 included studies, only 14 studies (1,71,74,80,84,87,88,93,96,102,104,109,113,123,124,126) offered evaluation methods that appropriately evaluated learning outcomes in a stepwise approach as delineated by the stage(s) of Miller's pyramid.
c. Content of IPC programs Table 3 describes the list of topics covered in IPC programs. Most interventions were centred around clinical scenarios in various settings, deliberation of ethical issues and care determinations.

d. Challenges to IPC training
Challenges to IPC training include scheduling con icts, di culties in preparing effective and appropriate programs, obstacles in recruiting (123) and training (96) teachers (77,104) and students (17,71,100,102). A further issue is failure to vertically integrate IPC training which has been found to reduce teamwork and collaboration and stunt professional identity (27).

Stage 5. Consultations with key stakeholders and synthesis of discussion
Consultations with the expert team and local educators, clinicians and researchers well-versed in IPC training revealed was particularly insightful. To begin these discussions following the review of the omitted data identi ed through deductive category application (34) and the belief that adopting categories based on Miller's Pyramid required evidencing, underpinned the decision to adopt Krishna's 'Split Approach' (43)(44)(45)(46). This led to the shift from use of Levac et al. (2015) (44)'s methodology to scoping reviews to adoption rst of the split approach and then the integration of a more structured methodology in the form of a SEBA guided approach to SRs following comments by the journal's anonymous reviewers.
Discussions with the expert teams and local educators, clinicians and researchers also revealed general consensus that the results of this review aligned with prevailing understandings of IPC programs. It was also agreed upon that there is an urgent need for further research on the impact of IPC training on interprofessional collaborations and in the design of comprehensive and longitudinal training and evaluation programs for medical students.

Discussion
In addressing its research questions, this scoping review revealed diverse approaches, learning objectives, and methods of assessing IPC in medical schools contribute to the poor alignment of training goals and the desire for a step-wise competency framework (13,15,64). Forty ve of the included accounts focused on just one level of the Miller's pyramid, 23 studies focused on two levels whilst 5 studies considered three levels of Miller's Pyramid. Critically 59 studies employed inappropriate assessments methods to assess the level of the Miller's Pyramid employed in their program (53).
Whilst we acknowledge that Miller's Pyramid is by no means the de nitive framework to be used in IPC training, it provides a sound, foundational, learner-centric, progressive scaffolding for the effective acquisition and assimilation of IPC knowledge and skills. There is su cient data to suggest that IPC programs is best 'spiralled' -bearing both vertical and horizontal integration within the curriculum. Whilst each stage builds upon prior core topics, knowledge and skills in a vertical manner, they must also work in tandem horizontally with the wider medical school curricula to ensure that students are equipped with other imperative skills which would adequately prepare them for simulations and clinical placements within their IPC training (129,130). This would enable the students to see the interwoven nature of speci c cognitive and procedural knowledge and skills across settings, allowing for more judicious decision-making and cohesive interprofessional collaborations.
Likewise, training and evaluation methods must be strategically curated and complementary with this stage-wise curriculum. Evaluations must be longitudinal, holistic, multi-sourced and allow for faculty members to quickly identify areas for remediation. Thus competencies must have both xed elements and personalised components to contend with the individual needs, abilities and contextual considerations. To this end, portfolios are recommended as a suitable learning and evaluation tool to accompany students as they hone their IPC skills (131)(132)(133). Extensive follow-ups assessing attitudinal and behaviour change (134,135) should also be conducted following graduation to determine the overall impact of the curriculum on IPC skills into the clinical setting (119).

Limitations
While it is reassuring that Millers' Pyramid may be used to address present gaps in IPC training, there are a number of limitations to be broached.
First, drawing from a small pool of papers which were limited to articles published or translated to the English language can be problematic particularly when most are North American and European-centric. This may limit the applicability of the ndings in wider healthcare settings.
Two, there is much to be clari ed about the IPC training and assessment processes. This endeavor is set back, however, by a lack of holistic and longitudinal assessments and the continued reliance upon assessment tools still rooted in "Cartesian reductionism and Newtonian principles of linearity" (137) and fail to consider the evolving nature of the IPC training process and training environment (18,24,26) Three, despite our independent efforts to carry out our searches and independent efforts to verify our searches and consolidate our ndings there may still be important articles that have been omitted.

Conclusion
This scoping review nds that despite efforts to design IPC programs around competency-based stages, most programs lack a longitudinal perspective and effective means of appraising competency. Yet it is still possible to forward a basic framework for the design of IPC programs.
Acknowledging the need for a longitudinal perspective IPC training should be structured around a 'spiralled' curriculum. This facilitates both vertical and horizontal integrations within the formal medical training curriculum. Being part of the formal curriculum will also cement IPC as part of the core training processes in medical school and facilitates the recruitment and training of trainers, established purpose built training slots over the course of medical training program, nancial support and effective oversight of the program and the training environment. With more medical schools adopting a portfolio-based assessment process, IPC would be furnished with a clear means of longitudinal assessments of IPC competencies over the course of each competency-based stage. It also allows effective follow up of graduates and a link with postgraduate training processes and portfolios.
The program itself must involve all 4 levels of Miller's Pyramid (13,15,63,64). For Level 1 of Miller's Pyramid, a combination of interactive workshops and role modelling of effective IPC in the clinical setting will help medical students appreciate the role of IPC.
Level 2 should involve case based discussions on ethical and care issues in the interprofessional setting whilst Level 3 and 4 may be demonstrated in simulated clinics and ward rounds. Perhaps just as critical is that IPC practice should be regularly assessed in all clinical postings to ensure that remediation can be carried out early.
Being part of the formal curriculum will also ensure that there are quality appraisals of the IPC program and policing of codes of conduct and practice standards. It will also facilitate research into better assessment measures and tools, communication dynamics and the professional identity formation.
Finally, it will also evaluate the translatability of these ndings beyond medical schools and their links to postgraduate practice. Availability of data and materials All data generated or analysed during this study are included in this published article under Table 2 Indications for an IPC Programme.