Lochner et al.

BMC Medical Education (2018) 18:48

https://doi.org/10.1186/s12909-018-1164-8

RESEARCH ARTICLE Open Access

Applying interprofessional Team-Based

Learning in patient safety: a pilot
evaluation study
Lukas Lochner1* , Sandra Girardi2, Alessandra Pavcovich2, Horand Meier3, Franco Mantovan1
and Dietmar Ausserhofer1,4

Abstract
Background: Interprofessional education (IPE) interventions are not always successful in achieving learning
outcomes. Team-Based Learning (TBL) would appear to be a suitable pedagogical method for IPE, as it focuses on
team performance; however, little is known about interprofessional TBL as an instructional framework for patient
safety. In this pilot-study, we aimed to (1) describe participants’ reactions to TBL, (2) observe their achievement with
respect to interprofessional education learning objectives, and (3) document their attitudinal shifts with regard to
patient safety behaviours.
Methods: We developed and implemented a three-day course for pre-qualifying, non-medical healthcare
students to give instruction on non-technical skills related to ‘learning from errors’. The course consisted
of three sequential modules: ‘Recognizing Errors’, ‘Analysing Errors’, and ‘Reporting Errors’. The evaluation
took place within a quasi-experimental pre-test-post-test study design. Participants completed self-
assessments
through valid and reliable instruments such as the Mennenga’s TBL Student Assessment Instrument and
the University of the West of England’s Interprofessional Questionnaire. The mean scores of the individual
readiness assurance tests were compared with the scores of the group readiness assurance test in order to
explore if students learned from each other during group discussions. Data was analysed using descriptive
(i.e. mean, standard deviation), parametric (i.e. paired t-test), and non-parametric (i.e. Wilcoxon signed-rank
test) methods.
Results: Thirty-nine students from five different bachelor’s programs attended the course. The participants
positively rated TBL as an instructional approach. All teams outperformed the mean score of their individual members
during the readiness assurance process. We observed significant improvements in ‘communication and
teamwork’ and ‘interprofessional learning’ but not in ‘interprofessional interaction’ and ‘interprofessional
relationships.’ Findings on safety attitudes and behaviours were mixed.
Conclusion: TBL was well received by the students. Our first findings indicate that interprofessional TBL seems to be
a promising pedagogical method to achieve patient safety learning objectives. It is crucial to develop relevant clinical
cases that involve all professions. Further research with larger sample sizes (e.g. including medical students) and
more rigorous study designs (e.g. pre-test post-test with a control group) is needed to confirm our preliminary
findings.
Keywords: Team-based learning, Interprofessional education, Patient safety, Learning from errors, Pre-qualifying
non-medical healthcare students

* Correspondence: lukas.lochner@claudiana.bz.it
1
Claudiana – College of Healthcare Professions, Via Lorenz Böhler 13, 39100
Bolzano, Bozen, Italy
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Lochner et al. BMC Medical Education (2018) Page 2 of 9
18:48

Background and integration of information and that allows for

International studies in acute hospitals reveal that, on
assessments of both individual and team performance
average, around 10% of patients experience one or more
[22, 23]. TBL combines multiple small groups into a
adverse events (e.g. healthcare-associated infections,
single classroom, where students master content
patient falls), and half of these events are preventable
through three steps: (1) individual out-of-class prepar-
[1]. Healthcare professionals work in a complex and high-
ation (e.g. textbooks, lecture videos); (2) in-class mul-
risk system and are confronted with making and observing
tiple choice test first administered to individual
errors: unsafe acts in the process of care that can lead to
learners (Individual Readiness Assurance Test, IRAT) and
critical incidents, i.e. near misses or adverse events [2]. In
then to assigned teams (Group Readiness Assur- ance
order to prevent errors and consequent negative health
Test, GRAT). These tests hold learners account- able for
outcomes, both technical and non- technical skills are
Step 1 and foster peer-to-peer teaching in areas of
fundamental for healthcare profes- sionals. Technical
deficiency; (3) in-class application of content through
skills refer to professional knowledge and abilities (e.g.
team problem-solving activities in which course content
basic life support and cardiopulmonary resuscitation).
is presented in real-world scenarios. Steps 2 and 3 are
Non-technical skills refer to communi- cation, teamwork,
facilitated by a content expert and typically involve intra-
and leadership [3–6]. Recent stud- ies have emphasized
and inter-group discussions of the course material. All
that non-technical skills are important core competencies
teams in the class work on the same problem at the
for healthcare profes- sionals to help them prevent errors
same time and share their solutions simultaneously. This
and encourage learning from errors [7, 8].
provides an excellent vehicle for student teams to work
Interprofessional education (IPE) is gaining increasing
collaboratively. Responsibility is divided, which helps
worldwide recognition as a way to enhance healthcare
with group learning during in-class discussions. Since
professionals’ non-technical skills [9]. In IPE two or
TBL also draws the attention of participants to the process
more health professionals learn with, from, and about
of learning, it has been correlated with encouraging bet-
each other to improve collaboration and the quality of
ter communication and teamwork skills [24, 25].
care [10]. There is growing evidence that IPE can have
Understanding IPE in the context of patient safety has
a positive impact on working collaboratively in clinic,
been the focus of recent research [14, 26–28], and there
thus improving patient care and reducing error rates
is a contemporary body of literature on educational in-
[11–16]. However, IPE is also criticized as sometimes
terventions that relates to training in non-technical skills
failing to generate positive changes in attitude with
respect to in- terprofessional communication and [6, 29]. Recent studies provide evidence that under-
teamwork [17, 18]. If the educational design of graduate IPE experiences can enhance readiness for
interventions is poor, then mandating students from interprofessional learning, attitudes to teamwork and en-
different programs to spend time together can be gagement in patient safety issues [30, 31]. However, to
counter-productive [19]. In order to avoid counter- our knowledge, no previous study has applied inter-
productive changes, students need to be engaged in professional TBL as an instructional framework for
meaningful learning activities. patient safety.
Experts recommend introducing IPE into under-
Aims
graduate programs as a way to reduce students’ prej-
In this pilot-study we aimed to investigate the effects of
udices towards other healthcare professions and prepare
interprofessional TBL for pre-qualifying, non-medical
them for the complexity of professional socialization
healthcare students with regard to (1) the students’ reac-
and teamwork, rather than simply as- suming that these
tion to the didactic approach (i.e. TBL methodology); (2)
skills will be acquired later on in their clinical positions
induced changes in student perception of interprofes-
[13, 20, 21]. In order to enable them to understand the
sional education (i.e. communication and teamwork,
contribution that effective interprofessional
interprofessional learning, interprofessional interactions,
collaboration makes to the delivery of safe and high-
and interprofessional relationships); and (3) changes in
quality care, their attention needs to be drawn not only
students’ attitudes to patient safety. The following
to the content but also to the process of learning.
research questions guided our study:
Students should interact with each other in a way that
fosters shared decision-making and listening to other
(1) How do students react to interprofessional TBL?
team mem- bers [13, 15].
(2) Do students’ perceptions of interprofessional
A pedagogical method that seems suitable for IPE in
education change?
the field of patient safety is Team-Based Learning (TBL),
(3) Do students’ attitudes towards patient safety issues
an instructional approach that focuses on the application
change?
Methods by one or two content experts and facilitated by a med-
Design ical educator; the role of the latter was to ensure that
We developed an “inter Professional Education in Patient the content experts could focus on the subject matter,
Safety (iPEPS)” course on ‘learning from errors’, an edu- rather than on the formal TBL process. Each session
cational pilot project for pre-qualifying, non-medical began with an IRAT, which consisted of five to 14
healthcare students, in which we adapted and applied the multiple-choice items. After the answer sheets were col-
TBL methodology. To evaluate the effect of the course on lected, students completed the GRAT by taking the same
students, we applied a quasi-experimental study designed test as a team. Following the GRAT, teams revealed their
as a pre-test-post-test without a control group. solutions simultaneously, step-by-step, holding up cards
to expose their answers. Then the medical educator
Educational setting moderated a debriefing, allowing for immediate feedback
The Claudiana – College of Healthcare Professions in and discussion between the teams and the expert. Before
Bolzano/Bozen, northern Italy, offers three-year bache- distributing the application exercises, the expert pro-
lor’s programs in 12 non-medical health professions vided a 10- to 15-min summary of the core messages to
(nursing, obstetrics, physiotherapy, dietetics and nutri- ensure a thorough understanding of the modules’ con-
tion, occupational therapy, speech therapy, radiology cepts. We considered this an appropriate measure to
techniques, laboratory techniques, environmental tech- guarantee adequate preparedness for the exercises, as
nology, orthoptics, dental hygiene and podiatry). Cur- students and teachers had no prior practical experience
rently, no medical students are being trained at our with TBL. A sample case is provided in Additional file 1.
institution. The programs are affiliated with four Italian In the application for Module 1 (‘Recognizing errors’),
universities (University of Verona, University of Ferrara, teams were asked to label the events as an error, near
Catholic University of Rome, Sapienza University of miss, critical incident or sentinel event, and/or select the
Rome). The predominant teaching method is didactic most appropriate safety behaviour from a given list. The
lecturing to groups of 20 to 120 students. Approximately team solutions were reported simultaneously to the
650 students are enrolled in the various programs. The whole class, followed by immediate feedback. Each team
curricula of the programs are strictly segregated, and worked on the same problems to make specific choices.
neither IPE nor TBL have been implemented so far. However, during the application phase for Module 2
(‘Analysing errors’) and 3 (‘Reporting errors’), the group
Development and implementation of the course assignments were adapted to simulate targeted real
The development of the iPEPS course followed Kern’s world experiences. Teams received the clinical scenarios
approach for curriculum development [32]. The TBL on paper, which they had to analyse by filling out a pre-
sessions are described based on the guidelines for defined scheme (fishbone diagram). In Module 3, they
reporting TBL activities [33]. had to complete the form sheet of the local critical inci-
First of all, we assessed Claudiana’s bachelor’s health- dent reporting system and results were not reported
care curricula with course directors and found that, al- simultaneously, but presented sequentially in plenum
though elements of patient safety and risk management and discussed together with the experts. As this was a
are taught, there was a lack of teaching related to ‘learn- pilot project that has not yet been implemented into the
ing from errors’. Following the WHO’s Multi- curriculum, no grading was performed and no peer
professional Patient Safety Curriculum Guide [34], we review was integrated. However, the IRATs and GRATs
developed a course to foster learning from errors. The results were analysed.
course teaches students to (1) apply systems thinking We invited second and third (final) year students to
principles to recognize care delivery problems and fac- participate in the course. The course was limited to a
tors contributing to critical incidents; (2) report critical maximum of 42 participants due to the size of the avail-
incidents via appropriate systems in a timely manner; able classroom suitable for TBL activities. Participation
and (iii) propose improvement strategies to avoid the was awarded on a ‘first-come, first-serve’ basis. Students
reoccurrence of incidents. The specific learning objec- were stratified according to their professional group and
tives and content of the iPEPS course are described in randomly allocated to one of the six teams, each con-
more detail in Table 1. taining six or seven members. The preparatory assign-
The course was organized into three sequential mod- ments (e.g. textbooks, videos) were available through a
ules (‘Recognizing errors’, ‘Analysing errors’, and ‘Report- web-based learning system.
ing errors’). The overall student workload was 12 h. For
each module, 1 h was allocated to pre-class preparation, Evaluation of the course
followed by 3 h of TBL sessions. The sessions were led Students filled out structured questionnaires on paper
2 to 3 weeks before the course and 1 week after it.
 Lo
ch
ne
r
et
Table 1 Outline of the iPEPS-course al.
B
Module 1 (4 h) Module 2 (4 h) Module 3 (4 h) M
1. Learning C
(1) Define the most relevant key terms, concepts (1) Describe the associations between error- (1) Decide which critical incidents need M
objectives and models in the field of ‘patient safety.’ contributing (system) factors and critical to be reported and justify the ed
(What will students be able to do?) (2) Explain the reasons and most important incidents, as well as strategies to avoid decision within an interprofessional ic
contributing factors for the occurrence of their reoccurrence. team.
al
critical incidents in healthcare organizations. (2) Compute an error and risk analysis of a (2) Correctly fill out a critical incident
E
(3) Reflect on their personal attitude towards critical incident based on the Accident report form of the South Tyrolean
Causation Model (“Swiss Cheese” du
critical incidents and how these are managed Health Care Trust with an
within an interprofessional team. Model) and according to the London ca
interprofessional team.
(4) Recognize the importance of developing a protocol. (3) Reflect on which factors can foster tio
positive and open safety and error-free culture (3) Recognize the perspectives and or hinder the reporting of critical n
for their professional work. roles within an interprofessional incidents in healthcare (2
team. organizations.
2. Content - Key terms, concepts and models (e.g. types of - The reporting and learning system of
(What will students learn?) errors, critical incident, near miss, adverse event, the South Tyrolean Health Care Trust
safety/error culture, Accident Causation Model - Accident Causation Model (CIRS) to improve patient safety.
(“Swiss Cheese” Model). (“Swiss Cheese” Model).
- The difference between errors, critical incidents and - Error and risk analysis according to the
near miss, adverse and sentinel events. London-Protocol.
- Human factors: reasons for and contributing factors
on the individual and organizational level to the
occurrence of critical incidents and patient harm.
- Methods and tools for recognizing and intervening in
potential critical situations (speaking up).
3. Didactic methods TBL Phase 1: Pre-class study - Critical Incident Report Form
(TBL) (How will students learn?) - iPEPS pre-test - Literature (articles)
- Literature (book chapters) - Watch WHO video on Vincrestine - IRAT/GRAT (multiple choice test)
TBL Phase 2: Readiness Assurance - Literature (London Protocol) - Appeals/Feedback
- IRAT/GRAT (multiple choice test) - IRAT/GRAT (multiple choice test) - Reporting errors (key messages)
- Appeals/Feedback - Appeals/Feedback Group work (Case scenarios / decision
Slide and lecture (15 min) - Analysing errors (key messages) making on which critical incident needs
- ‘Recognizing errors’ (key messages) Group work (error and risk analyses of an to be reported / filling out the critical
TBL Phase 3: Application adverse event using fishbone diagram / incident report form), followed by
- Group assignments based on case studies proposing quality improvement interventions), sequential presentation in plenum.
(speaking up/observing care delivery problems) followed by sequential presentation in plenum.
- Groups make specific choices, followed by
simultaneous reporting.
4. Assessment - Individual Performance (IRAT) - Individual Performance (IRAT)
(How will learning outcomes be evaluated?) - Team Performance (GRAT) - Team Performance (GRAT)
- Individual Performance (IRAT)
- Team Performance (GRAT) Pa
ge
4
of
9
Lochner et al. BMC Medical Education (2018) Page 5 of 9
18:48

Filling out the questionnaires was part of the course- Results

work and a prerequisite for the successful completion Participant demographics and response rate
of the course. The students’ socio-demographic char- A total of 39 students completed the entire course, with
acteristics (gender, age, course, education year) were representation from five different programs (nursing,
assessed in the pre-test questionnaire. The students’ dietetics and nutrition, occupational therapy, radiology
preference for lecture or Team-Based Learning was techniques, laboratory techniques). Table 2 shows the
assessed in the post-test questionnaire, using six items participant demographics. As completing the pre-
of the corresponding 16-item subscale of the Team- questionnaire was a prerequisite for participation, and
Based Learning Student Assessment Instrument (TBL- completion of the post-questionnaire was required to ob-
SAI) developed by Mennenga [35]. tain the participation certificate, we reached a response
The following variables and measures were included rate of 100%.
in the pre-test and post-test questionnaire: ‘Students’
attitudes towards interprofessional education’ was How did students react to the introduction of TBL in an
measured with the German version of the University interprofessional setting?
of the West of England’s Interprofessional Question- In the post-test questionnaire students were asked to
naire (UWE-IP-D), developed by Pollard et al. [20]. what extent they preferred the newly introduced TBL
This instrument consists of four subscales: communi- approach over the didactic lectures to which they
cation and teamwork (nine items), interprofessional were accustomed. Table 3 shows that for the items
learning (nine items), interprofessional interactions relating to ‘retention’ and ‘self-study’ students reported
(nine items), and interprofessional relationships (eight higher scores (84.6 and 64.1% gained scores of 4 and 5)
items). Each subscale achieved acceptable levels of in- for TBL, with the difference being significant (p < 0.05).
ternal consistency (α = 0.92–0.52). ‘Students’ patient Findings for the item ‘distraction’ indicate that fewer
safety attitudes’ were measured with 18 items selected students reported to be distracted during TBL sessions
from the students evaluation questionnaires of the compared to didactic lectures. However, there was no sta-
WHO’s Patient Safety Curriculum Guide for Medical tistically significant difference.
School [7]. All instruments and items used a five- To explore if students learned from each other during
point Likert scale ranging from “strongly disagree” to group discussions, the mean scores of the IRAT (adminis-
“strongly agree.” All instruments and items (except tered to all group members individually) were compared
the German version of the UWE-IP-D) were trans- lated with the scores of the GRAT (administered during group
from English to German by one member of the project discussion; answers were chosen based on consensus deci-
group and checked by another. The face valid- ity of the sion). All teams outperformed the mean score of their in-
questionnaire was assessed within the pro- ject team. dividual team members, with the average mean difference
being 1.41 points (10.1%). In one group, however, the best
Data collection and analysis team member did better than the group. Table 4 displays
Students generated a unique code (the first three let- Module 1’s IRAT mean score and GRAT score. With 14
ters of their mother’s surname, the first two letters of multiple-choice items, Module 1 featured the most exten-
their mother’s first name, the last two numbers of sive Readiness Assurance Process of the three modules.
their mother’s birth year) that allowed us to connect
their pre-test and post-test questionnaires. Data col- Did students’ perceptions of interprofessional education
lected from the questionnaires was entered into IBM change?
SPSS Statistics 21.0 (IBM Corp., Armonk, NY). First, The UWE-IP-D Interprofessional Questionnaire focuses
all reverse-coded items were recoded and then ana-
on attitudinal shifts on four subscales: (1) communication
lysed using appropriate descriptive analyses, including
absolute and relative frequencies of positive responses Table 2 Participant demographics (N = 39)
(scores 4 and 5), as well as means and standard devi- Age in years: Mean (SD) 22.65 (2.8)
ations. Differences between the students’ perceptions of
Gender: F:M 37:2
TBL and didactic lecturing, as well as pre-test and post-
Professional program: n Nursing: 15
test scores concerning interprofessional educa- tion and Occupational therapy: 9
patient safety attitudes, were analysed using parametric Laboratory techniques: 7
(i.e. paired t-test) or non-parametric (i.e. Wilcoxon signed Dietetics and nutrition: 6
Physiotherapy: 1
rank test) analyses. The statistical significance was set at a Radiology techniques: 1
p-value of less than or equal to 0.05.
Year of program: n First year: -
Second year: 15
Third (final) year: 24
 Table 3 Evaluation of preference for lecture or Team-Based Learning approach (N = 39)
1: Traditional lecture 2: Team-Based learning 1 vs 2
Questions %4+5 Significance,
Mean Questions %4+5 Mean
(Agree + Strongly agree) Wilcoxon
(SD) (Agree + Strongly (SD) test
agree)
Distraction
During traditional lectures, I 20.5% 2.67 I talked about non-related 38.5% 2.95 P = 0.076
often things
find myself thinking of non- (0,98) during Team-Based Learning (0.92) Z= −1.77
related things.a activities.a
Retention
I remember material better when 20.5% 2.67 I remember material better 84.6% 4.03 P < 0.001
when
the instructor lectures about it. (0.87) I used it during Team-Based (0.67) Z= −4.62
Learning activities.
Self-study
It is easier to study for an exam 7.9% 2.47 I would do better on exams if 64.1% 3.67 P < 0.001
we

a
item reversed for analysis (a higher score means lower students’ distraction)

and teamwork, (2) interprofessional learning, (3) fostering learning about ‘learning from errors’. All teams
interpro- fessional interaction, and (4) interprofessional outperformed the mean score of their individual mem-
relation- ships. Table 5 indicates that significant positive bers. The course yielded significant improvements in
changes occurred for the first two subscales (p < 0.05). students’ perceptions toward ‘communication and team-
Shifts in attitude towards interprofessional interaction and work’ and ‘interprofessional learning’.
relation- ships were not significant. Students rated TBL significantly higher than didactic
lecturing for ‘retention’ and ‘self-study.’ However, their
Did students’ attitudes towards patient safety issues attention span during group work presentations may not
change? have been entirely satisfactory, as we did not observe
Table 6 shows mixed results for the pre-test post-test significant differences for ‘distraction’. This constitutes a
comparison of seven safety attitudes and behaviours. matter that needs improvement ([23], p.53). During
While the scores of some items (e.g. ‘filling in reporting Modules 2 and 3, teams worked on different case scenar-
forms will help to improve patient safety’) increased as ios and reporting took place sequentially, not simultan-
expected from pre- to post-test, the scores of other eously. We experienced that building realistic case
items (e.g. ‘telling others about an error I made would scenarios that engage all the participating healthcare
be easy’) surprisingly declined. However, none of these professions is crucial for interprofessional TBL. This res-
changes were statistically significant. onates with statements of other authors who found that,
when planning IPE initiatives, particular focus is needed
Discussion to make sure that disciplinary knowledge is necessary in
This pilot-study aimed to evaluate the course “inter Pro- a way that all students are highly motivated to contrib-
fessional Education in Patient Safety (iPEPS)”. Our find- ute to the learning activity [30, 36]. Yet this is challen-
ings indicate that interprofessional TBL was well ging in the field of patient safety as there are few critical
received by the students as an instructional approach to incidents or adverse events that equally engage a high
number of different healthcare professionals. Both as-
Table 4 Score changes from IRAT to GRAT (N = 39)
pects could explain students’ distraction during the
Team no IRAT GRAT IRAT to GRAT
reporting of group work. However, all teams outper-
(max. 14 points) (max. 14 points) Mean difference
Mean (SD) formed the mean score of their individual team mem-
1 (n = 6) 10.33 (1.21) 12 + 1.67 bers during the Readiness Assurance Process, which
indicates that group discussion was beneficial for at least
2 (n = 6) 10.67 (1.03) 12 + 1.33
the weaker group members.
3 (n = 7) 10.71 (1.11) 12 + 1.29
We observed significant improvements in students’
4 (n = 7) 10.92 (1.98) 11 + 0.08 perception towards ‘communication and teamwork’ and
5 (n = 7) 11.43 (1.72) 13 + 1.57 ‘interprofessional learning’, providing first evidence that
6 (n = 6) 9.50 (1.22) 12 + 2.50 the course increased students’ positive attitude towards
TOTAL 10.59 (0.65) 12 + 1.41 communicating with other professions and working in
teams. IPE initiatives are not always successful in
Table 5 Pre- and post-results of the UWE-IP-D Interprofessional Questionnaire (N = 39)
Subscales (scale range) Pre Post Pre vs post
Mean (SD) Mean (SD) Significance, paired t-test
Communication and Teamwork (9–36) 21,46 (5,58) 23,59 (5,62) P = 0.038
T = −2.16
Interprofessional Learning (9–45) 33,97 (6,16) 36,36 (5,68) P = 0.036
T = − 2.17
Interprofessional Interaction (9–45) 25,82 (3,69) 25,77 (3,98) P = 0.952
T = 0.06
Interprofessional Relationships (8–40) 29,26 (3,63) 30,87 (3,78) P = 0.062
T = −1.92

producing attitudinal changes, since mandating positive outcomes, but it is only when students work to-
students to spend time together can prove counter-
gether over an extended period of time that their groups
productive [17, 18]. Judge et al. [30] investigated
can develop into teams in which communication be-
students’ readiness for interprofessional learning after
comes more open and conducive to learning ([23], p.11).
the exposure of 308 students from different health care
Although we were able to foster learning with and from
programs to inter- professional learning activities (i.e.,
each other, we were less successful at fostering learning
PowerPoint presenta- tions and case-based exercises).
about each other, e.g. about the different health profes-
This study revealed that interprofessional education
sions’ roles and clinical tasks. Here again, it becomes
activities require a student- centred teaching strategy
evident that the design of the clinical cases must ensure
rather that a presentation based intervention [30]. Our
that disciplinary knowledge of all participating profes-
findings suggest that TBL constitutes such a
sions is necessary in a way that learning about each
methodology as it supported the achievement of
other is fostered by the requirements of the activity
important IPE objectives. TBL was not compared to
another educational approach in this study, but free-text [19, 36].
Findings regarding students’ attitudes towards patient
comments in the post-course questionnaire confirmed
safety behaviours were mixed. For example, from pre- to
that participants greatly valued the contact and
post-test, fewer students reported that telling others about
interaction with students from different professional
an error was easy. It seems that students became more
backgrounds that were stimulated by the team assign-
aware of how challenging it is to deal with patient safety
ments. However, we did not find any improvements in
during daily professional routines. This new find- ing has
‘interprofessional interaction’ and ‘interprofessional rela-
not yet been reported in the literature. We need to be
tionships’. This might indicate that the course was too
aware that educating students on ‘learning from errors’
short. The interaction between the participants was lim-
might lead to expectations and attitudes towards critical
ited to 3 days and most likely ended at the end of the
incident reporting that might reduce their
course. Well-designed group assignments can produce

Table 6 Selected pre- and post-results of the students evaluation questionnaires of the WHO’s Patient Safety Curriculum Guide (N
= 39)
Questions Pre Post Pre vs post
%4+5 %4+5 Significance, Wilcoxon test
Mean (SD) Mean (SD)
If I keep learning from my mistakes, I can prevent incidents. 89.7% 82.1% P = 0.16
4.41 (0.85) 4.21 (0.80) Z= − 1.40
Acknowledging and dealing with errors will be an important part of my job. 89.7% 87.2% P = 0.21
4.33 (0.84) 4.13 (0.61) Z= − 1.26
Telling others about an error I made would be easy. 43.6% 28.2% P = 0.16
3.31 (0.98) 3.10 (0.79) Z= − 1.41
It is easier to find someone to blame rather than focus on the causes of error. 33.3% 17.9% P = 0.36
2.85 (1.11) 2.64 (1.04) Z= − 0.91
I am always able to ensure that patient safety is not compromised. 35.9% 23.7% P = 0.09
3.18 2.84 (0.92) Z= − 1.67
(0.89)
84.6% P = 0.30
I believe that filling in reporting forms will help to improve patient safety. 66.7%
3.95 (0.60) Z= − 1.05
3.72 (0.97)
100% P = 0.31
I plan to inform my colleagues about the errors they make. 64.1%
3.77 (0.43) Z= − 1.02
3.62
(0.75)

willingness to report errors. This would be undesirable as critical incident reporting systems are often under- used
 in clinical practice [37]. Students’ willingness to identify,
Acknowledgements
report, and analyse errors in their future clinical posts
We thank the Department of General Practice and Health Services Research,
needs to be investigated in follow-up studies. University Hospital Heidelberg, Heidelberg, Germany for providing us with
permission to use the UWE-IP-D questionnaire.

Limitations Funding
The findings need to be interpreted in light of several limi- No funding was provided.
tations. Applying a traditional pre-test post-test compari-
Availability of data and materials
son without a control group and the small sample size The datasets used during the current study are available from the
affects the internal validity of the study. As we did not corresponding author on reasonable request.
compare TBL to other forms of educational interventions,
causal interpretation of the effects of TBL is not justified. Authors’ contributions
LL, SG, AP, HM, FM and DA contributed equally to the development and
Since students compared the iPEPS course to their normal implementation of the course and to the study design. LL and DA analysed
coursework, their positive reaction to the introduction of and synthesised the findings and drafted the article. All authors critically
reviewed the manuscript and approved the final article for publication.
TBL might have been affected by the topic, the teachers
and/or the type of course material. Furthermore, there is a Ethics approval and consent to participate
selection bias. As participation in the course was volun- The study protocol was presented to the Institutional Scientific Review Board
tary, only highly-motivated students interested in IPE and of Claudiana – College of Healthcare Professions, Bolzano/Bozen, Italy
(Protocol 11/3/2015). The study was granted ethical approval. Students gave
the topic of patient safety participated in the course, lead- their consent to participate in the study by filling out and sending back the
ing to high pre-test values. questionnaires. To guarantee anonymity no personal information was
collected. Students generated a unique code on the questionnaire that
allowed us to connect their pre-test and post-test questionnaires.
Conclusion
This pilot study investigated interprofessional TBL about Consent for publication
Not applicable.
patient safety. It revealed significant improvements in stu-
dents’ perceptions towards ‘communication and teamwork’ Competing interests
and ‘interprofessional learning’. Interprofessional TBL The authors declare that they have no competing interests.
appears to be a promising pedagogical method to achieve
patient safety learning objectives. Design of clinical cases to Publisher’s Note
include all participating professions seems to be crucial to Springer Nature remains neutral with regard to jurisdictional claims in
support the achievement of learning outcomes. Qualitative published maps and institutional affiliations.

research with focus groups should further explore how Author details
1
interprofessional TBL fosters students’ learning and team- Claudiana – College of Healthcare Professions, Via Lorenz Böhler 13, 39100
work. To confirm our preliminary findings, further quanti- Bolzano, Bozen, Italy. 2South Tyrolean Health Trust, Bolzano, Bozen, Italy.
3
Ministry of Health (Department 23 – Healthcare), Clinical Governance,
tative research is required with larger and more diverse Bolzano, Bozen, Italy. 4Department of Public Health, Institute of Nursing
sample sizes (including medical students) from across vari- Science, University of Basel, Basel, Switzerland.
ous institutional settings and which applies more rigorous
Received: 22 December 2016 Accepted: 19 March 2018
study designs (i.e. pre-test post-test with a control group;
second post-test after students have begun their clinical
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