Interprofessional team training via telemedicine in medical and nursing education | BMC Medical Education

The analysis was based on how the participants described the work process and work outcomes. Three major themes were identified: challenging the dynamic of leadership, becoming familiar with a new setting, and finding new strategies to communicate. In each theme, two subthemes were found in the analysis (Table 1). The interactions between people, environments, tools, and tasks were also analysed and related to work processes and work outcomes according to a simplified version of SEIPS known as SEIPS 101 [11]. Excerpts are included in the presentation of the results in order to contextualize and illustrate the participants’ descriptions, labelled by team number (FG) and course of study (NS = nursing student, MS = medical student).

Challenging the dynamic of leadership

Collaboration via a screen was described by the interviewees as creating new challenges but also advantages. The medical students who participated via the screen talked of “taking a step back” as a leader to ensure they had an overview of the situation. In the excerpt below, a medical student compared the situation to cardiac and pulmonary resuscitation (CPR):

If you compare it to CPR, where you normally have one [person] with a good overview, another doing compressions, another giving medication, and one keeping an eye on the airways… And then one just standing there making sure everyone’s doing what they should. So it felt like I was in that situation. That I was like “Okay, have we done this? Good, then let’s do this now.” (FG1, MS1).

In this excerpt, the medical student described having an overview of the situation and time to plan for the next step of the patient’s care. The participants agreed that the leadership was not as clearly defined in these teams compared to their earlier experiences of teamwork in a co-located setting. Choosing the medical student as leader was not an active choice, but more an unspoken agreement. The medical student was perceived as medically responsible, and therefore also responsible for assigning tasks and carrying the teamwork forward. One of the nursing students concluded:

I found it a good structure. You have the overview and it’s… it gets kind of natural for you to be the leader, to provide structure, and so… And then we like, share among us who does what. (FG1, NS1)

As they were outside the emergency room (ER), the medical students felt less stressed than the nursing students who were situated with the patient in the ER. The medical students expressed that when the patients’ vital signs deteriorated in the first scenario, they could stay focused on their tasks; this was in contrast to the nursing students, who had to face the agitated patient and experienced more stress.

Yeah, but that stress didn’t affect me in the same way. Instead I could check my notes and be like, okay, we’re at A, then we do this first. So that was nice. If I was there I wouldn’t have had the same freedom to have all these things around me that way. (FG1, MS1)

Being present via the screen was perceived by the medical student as being by the patient’s side and still having access to the patient’s journal. This allowed the medical students to look up allergies and medical history without leaving the team.

Two groups pointed out that while the medical students were the overall leaders, the nursing students developed a dynamic of their own through swapping assignments between each other to better fit their strengths or current tasks. The nursing students found this aided workflow. One nursing student described it as follows:

I feel a bit like I said before, that maybe it was more you taking the lead as physician. But it wasn’t fully that either, that you delegated to us like “Do this, do that.”… It was more like “You need to do this,” and then we divided it among us, like what came naturally. (FG2, NS2)

The nursing students said that they had sometimes found the physician hard to reach during their previous experiences outside the study. Compared to this, the team training with telemedicine felt like an improvement because the medical student was available throughout the full scenario. This meant prescriptions and assignments could be changed on the go if, for instance, the patient needed more pain medication than was initially prescribed.

Well, I felt that it was really reassuring and good, that you could have more contact with the physician for a long time, and there was always support, and you could double-check. (FG3, NS1)

In terms of SEIPS, the team members (the people) described positive interactions via telemedicine (the tool), as the medical student was able to get an overview of the situation in the emergency room. This, in turn, could change the roles within the socio-organizational environment, affecting the workload differently. This had an impact on both the work process and the work outcome, as the medical students mentioned that participating via telemedicine could facilitate and contribute to a reduced workload. The nursing students described both barriers and facilitators; they experienced an enhanced workload due to having to step in as secondary leaders, while at the same time, they felt more secure with the medical student continuously present on the screen.

Becoming familiar with a new setting

When working in a team with a remote team member, the nursing students encountered situations they did not recognize from previous experience of interprofessional teamwork. Some of their tasks were related to the nursing profession, but they also became partly responsible for examinations usually conducted by physicians.

I think I could examine someone’s abdomen. We’ve practised that a little, I think I could do that. Some other things you’d need to practise… Like listening to the lungs maybe isn’t something you’ve really done a lot. But in that case it’s something you could practise. (FG1, NS1)

In the excerpt above, the nursing student said that performing tasks commonly done by a physician was challenging since they lacked the “reference bank” that comes with having a lot of practise. The interviewees agreed that in order to ensure that the tasks were completed correctly and in a safe and secure manner, it was important for them to be open about their own knowledge and experience, and to ask for guidance and advice when performing unfamiliar tasks. Nevertheless, the medical students expressed that even though the nursing students had performed the assigned tasks correctly, they would have preferred to do them on their own.

Well, it’s a bit like, when following ABCDE I would have preferred to listen to the lungs and heart on my own. Examined how the skin felt, pulse, and all that. I mean, it’s really not to do with not trusting what you say, but I think that, like, by doing, not just hearing, but instead seeing and feeling, you can get a better idea of the situation, so I think I would’ve done that. (FG2, MS1)

In the excerpt above, the medical student pointed out the difficulties of trusting the nursing student’s examination of the patient. On the other hand, the nursing students described how they had to prioritize their tasks and change how they worked, since they “had fewer hands”. They expressed that at times they felt crowded with tasks, and lost their overview of the situation when they had to do examinations usually done by the physician. However, both medical and nursing students expressed that knowing the patient’s symptoms and suspecting a diagnosis could help with executing tasks and workflow, rather than relying on the medical student’s responsibility:

… She arrives really anxious and nauseous and pressing her hands on her chest. I felt that ECG would definitely be needed here at some point, so I felt like I could be a step ahead in this and comfortable with that. (FG2, NS1)

In terms of SEIPS, when working via telemedicine the nursing students (the people) described a change in their responsibilities and the tasks they were expected to perform. Their duties extended beyond tasks typically performed by the nursing profession, to also include physicians’ examinations. In this way, telemedicine (the tool) could be interpreted as a barrier to executing tasks more accurately. These factors influenced the work process. For nursing students, working remotely, i.e., when the patient and provider are not in the exact physical location and digitally, i.e., these remote services are delivered via video conferencing, meant being open about their own knowledge and experience and asking for guidance and advice when performing unfamiliar tasks. On the other hand, for the medical students it meant the added difficulty of trusting the nursing student’s examination of the patient, potentially affecting the work outcome.

Finding new strategies to communicate

The interviewees concluded that the communication within the team needed to change when collaborating via telemedicine. One focus group described how they first tried to mimic a “normal” situation as much as possible and create opportunities for face-to-face communication. However, face-to-face communication with the medical student via the screen meant that the nursing students had to turn their backs on the patient, leaving them unattended. One of the nursing students narrated this as follows:

I remember standing there feeling nervous, now she [the patient] was unattended behind us, and both of us were doing other things. (FG1, NS1)

For the medical students, participating via telemedicine meant working with limited vision. They perceived this as a constraint, as it made it hard to have an overview and to know what the other team members were doing when they were out of sight. The interviewees mentioned that name badges were usually helpful, but recognized that in this situation, the medical student could only see the backs of the nursing students when they were interacting with the patient. This was deemed challenging, particularly within newly formed teams, when attempting direct communication and task assignment.

Another focus group expressed that it felt natural to work with direct communication using names and closed loops during the second scenario. One medical student said they were confident that vision and hearing were enough to communicate:

I mean, if you can hear me then it’s like, that’s enough for us to communicate and that I see what you see. (FG3, MS1)

Conversely, another medical student experienced that having the patient in sight provided an increased sense of control over the situation:

The thing is, during the first case, I could like only see her [the patient’s] legs and that they were shaking, and I heard some whimpering and things like that. And that didn’t feel very good… I got a good report, and to start with, we were like “Okay, we need to do these things.”… And then you ran off, and I was left behind far away like “Hello? Is everything alright?” I felt like I had no idea what was going on… None at all. But that all changed in case 2 [when the camera moved closer].” (FG2, MS1).

All participants agreed that it could be important for both parties for the patient to see their physician. For the medical student, this aided in clinically assessing the patient and conducting a proper anamnesis. For the patient, it was believed to help establish a connection to the physician and to let them receive their diagnosis and care plan in a more compassionate manner.

While the new setting presented new challenges, all teams experienced a positive development between the first and second team training exercise. Two of the three teams expressed that they would find it easy to learn with a bit more practise, as articulated by a nursing student in the following excerpt:

It feels like if you can do it [practise] a few times before doing it for real, you might be able to have a pretty good flow. (FG2, NS2)

Interacting via telemedicine required new ways of communicating. In the excerpt below, a nursing student described how she thought she had made eye contact with the medical student who was participating remotely via the screen. She then realized that she had gone out of the camera angle and was not visible to the medical student.

But it’s more difficult to make eye contact, or it was interesting to see what you were thinking, because we saw you out of the corner of our eyes, but then I realized that I was standing out of the sight for the camera. (FG3, NS1)

In terms of SEIPS, the interaction between team members (the people) changed when one team member was not present in the room (the environment). The screen was described as a barrier, due both to difficulties in performing tasks and to the necessity of communicating directly with the screen (the tool). The work process could negatively affect the work outcome, as the physical absence of a physician from the room could hinder patient interactions. However, telemedicine was also described as a facilitator when it allowed for directed and safer communication.