Conditions for interprofessional education for students in primary healthcare: a qualitative study

Conditions for interprofessional education for students in primary healthcare: a qualitative study Background: Primary healthcare in Sweden and worldwide has a diverse structure with many kinds of healthcare units involved. This is a challenge for collaboration between different professions in primary healthcare, as the different healthcare professions often work in silos. Interprofessional education (IPE) in the context of primary healthcare is less studied than IPE at hospitals and most of the studies in primary healthcare have focused on collaboration between general practitioners and nurses. The aim of this study was to describe how healthcare students perceived conditions for IPE in primary healthcare. Methods: Qualitative group interviews were used and a total of 26 students, recruited on a voluntary basis participated in four group interviews with students mixed from study programmes in nursing, physiotherapy, occupational therapy and medicine. Students from the study programme in medicine were in their second to eleventh semesters of 11 semesters in total, whilst students from the occupational therapist, physiotherapist and nursing programmes were in their fourth to sixth of six semesters in total. Results: Our findings indicated one theme: Students perceived a need for support and awareness of IPE from both study programmes and clinical placements. Five categories were found to belong to the theme. Students’ tunnel- vision focus on their own profession may have affected their ability to collaborate with students from other professions. The nature of the patients’ healthcare problems decided if they were perceived as suitable for IPE. Clinical supervisors’ support for and attitude towards IPE were important. The hierarchy between different professions was perceived as a hindrance for seeking help from the other professions. The students asked for more collaboration between different study programmes, in order to gain knowledge about the roles and responsibilities of the other professions. Conclusions: In conclusion, students in this study considered it essential for different study programmes and clinical placements to be more aware of the opportunities for and importance of IPE. The study identified conditions that were required for IPE in primary healthcare that may be helpful for healthcare teachers and clinical supervisors to better understand how students perceive IPE in primary healthcare, thus facilitating the planning of IPE. Keywords: Interprofessional education, Primary healthcare, Healthcare students, Qualitative study, Content analysis * Correspondence: carrie.tran@ki.se Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Alfred Nobels Allé 23, 141 83 Huddinge, Sweden 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. Tran et al. BMC Medical Education (2018) 18:122 Page 2 of 8 Background students similar to the present study. Kent & Keating [8] Patient safety and quality of care would be improved if could only find two such studies in their systematic lit- there was increased collaboration between healthcare erature review from 2015. Moreover, according to San professions [1, 2]. Most healthcare educations involve a Martín-Rodríguez et al. [9], seven of ten studies have large number of students and take place in isolation been conducted in hospital contexts but only three in from each other, reducing possibilities for interaction be- primary healthcare settings. Collaboration in hospitals is tween the different student categories [1, 3]. This ten- usually easier since most of the staff work in the same dency for both healthcare professions and educations to building. Hammick, Freeth, Koppel, Reeves and Barr work in silos makes collaboration between different pro- [10] reviewed more than 21 scientific papers, most of fessions a challenge [3]. them in a hospital context. In Sweden, IPE had been In Swedish primary healthcare, some healthcare profes- studied in clinical education wards in hospitals [11–14]. sions rarely have direct contact via meetings in person It was difficult to find studies about IPE in primary about the individual patient’s care, since they do not work healthcare in a Swedish context. We have only found close enough to each other. Furthermore, most of the time one study in Sweden that investigated undergraduate students do not meet students from other professions students’ experiences of a full day practicing teamwork since they do not have their clinical placements at the with a fictitious home care patient [15]. Most of the pre- same time. IPE occurs by definition “when students from vious studies in primary healthcare have focused on cre- two or more professions learn about, from and with each ating interprofessional learning activities. Students have other to enable effective collaboration and improve health rarely taken part in creating IPE and their views of what outcome”. The World Health Organization stated that is required for IPE to take place having not been previ- once the students understand how to work interprofes- ously explored in the context of primary healthcare. This sionally, they will have increased readiness to work collab- indicates a gap in knowledge regarding how students oratively when entering a workplace [4]. perceive prerequisites for IPE in primary healthcare. According to the Declaration of Alma-Ata [5], primary This study used an interprofessional approach in meth- healthcare is the first level of healthcare contact for indi- odology and had students in mixed groups from four viduals who live in the community. It brings healthcare different study programmes. The purpose of the present as close as possible to where people live and work. The study was to describe how students from study pro- main health fields that primary healthcare deals with are grammes in nursing, occupational therapy, physiother- preventive, curative, supportive and rehabilitative ser- apy and medicine perceived the conditions for IPE in vices. There were about 200 primary healthcare centres primary healthcare. and a total of around 500 units (including rehabilitation, child and maternity care units) in primary healthcare in Methods Stockholm, Sweden, when the present study was con- Design ducted. Most of the nurses and medical doctors work at This was a qualitative study and data was collected primary healthcare centres, whilst occupational thera- through group interviews. The data was analysed using pists and physiotherapists generally work at rehabilita- qualitative content analysis since this method provided tion units. It is uncommon for primary healthcare knowledge and gave new insight into how the students centres and rehabilitation units to be co-located. Coun- perceived conditions for IPE in primary healthcare [16]. sellors, psychologists and dietitians also work at some of In order to obtain rich data from the interactions be- the primary healthcare centres. tween the students from the different study pro- There has been an increased focus on IPE because grammes, group interviews was chosen as a method. there exists a growing recognition and evidence of com- The analysis had an inductive approach and focused munication and collaboration improvements in interpro- mainly on the manifest content. fessional teams [6]. Social engagement is important for the students’ learning process and ability to make sense Context and participants of new information and ideas. Learning takes place in a The context of this study was primary healthcare in community of practice [7] and is a part of a social prac- Stockholm, Sweden. Nursing, physiotherapy, occupa- tice. Through social interaction with peers and clinicians tional therapy and medicine students from one medical in a clinical environment, the students construct new university (Karolinska Institutet) had clinical placements knowledge and are introduced to their future profession in primary healthcare. Some nursing students were from by doing and acting. two other universities in Stockholm that also had place- There are several previous studies about IPE in pri- ments in primary healthcare. The period for these place- mary healthcare [8] but there still exists a lack of re- ments in primary healthcare varied between 1 and search that relates to IPE involving several professions’ 6 weeks and took place at different periods of the Tran et al. BMC Medical Education (2018) 18:122 Page 3 of 8 semester. The students were recruited on a voluntary “meaning units”, were highlighted. The analysis was first basis via information given to all four programmes, and done by the first author (CT) identifying the meaning the students passed on information to other students via units from the text. CT then condensed the meaning their Facebook pages. units and gave names with codes and then sorted the Four group interviews with five to nine students in data into categories [17]. The codes were aimed to stay each group were carried out as follows: two group inter- as close as possible to the text and were then grouped views were conducted at the Centre of Family Medicine into categories and higher order categories. All authors and the remaining two groups at one Academic Health agreed that the main theme covered the categories. Centre. Medicine students were in the second to elev- Graneheim & Lundman [17] described category as a enth semesters of their 11 semester study programme, group of content that shares commonality and a theme whilst students from the occupational therapist, physio- can be found in several categories, describing the under- therapist and nursing programmes were in their fourth lying meanings. In order to increase trustworthiness, all to sixth of six semesters in total. The groups were mixed authors who were from different professions identified with the aim to get participants from different study main categories independently and then discussed simi- programmes in the same interview. As all the partici- larities and differences until consensus was reached. pants still had the same student status, we did not an- ticipate any problems with hierarchy among the Ethical considerations students. Three groups had students from all four study The Ethical Review Board in Stockholm had no objections programmes included and one group had students from to the study. All participants were informed about the aim three study programmes (with no nursing students). The and method of the study and gave signed informed consent. intention was only to include undergraduate students with prior experience of a clinical placement in primary Results healthcare but unintentionally three students who were A total of 26 students participated, 18 females and eight included in the study had not had their clinical place- males. The mean age of the participants was 26.8 years ments in primary healthcare. The majority had experi- (range, 25–44 years). Students represented medicine (n = ence of IPE from their clinical placements at hospitals in eight), nursing (n = four), occupational therapy (n = nine), interprofessional student wards. physiotherapy (n = five). See further Table 1.All students considered IPE in primary healthcare important. At the Data collection same time they found it difficult to collaborate in primary A semi-structured interview guide was used consisting healthcare because the different professions did not work of five open-ended questions (Additional file 1): What close to each other, and therefore it was difficult to get to does IPE mean to you? What possibilities do you see to know each other and begin collaboration. As an answer to learn with, from and about each other in primary health- our aim to describe how healthcare students perceived the care? What hindrances do you see to learn from each conditions for IPE in primary healthcare, our results showed other in primary healthcare? What can you learn from one theme that immersed all underlying categories: Students each other in primary healthcare? How can you learn perceived a need for support and awareness from both study with and from each other in primary healthcare? Two programmes and clinical placements. Five categories were people with different roles conducted all four interviews. found related to this main theme, representing the students’ KB acted as a moderator while the third author (HS) perceptions of conditions needed for IPE in primary health- acted as an observer. The interviews were recorded and care; students’ tunnel-vision focus on their own profession, transcribed verbatim. Each session lasted approximately patients’ healthcare problems, clinical supervisor’s support 90 min. After the fourth group interview, the recorded and attitude to IPE, hierarchy between different professions data showed little new information and the data had lit- and collaboration between different study programmes.The tle variation so saturation was considered to have been main theme could be found in every category. Support and achieved. The data was collected in autumn 2012. awareness from study programmes and clinical placements, could help students to change focus from their own Data analysis Table 1 Descriptive characteristics of the participating students Data was analysed using qualitative content analysis in- All participants (n = 26) N OT PT M spired by Krippendorff [16]. As there was not enough Male 8 1 1 3 3 knowledge about how students perceived prerequisites for IPE in primary healthcare, an inductive approach Female 18 3 8 2 5 was used. The analysis started by reading the text several Previous experiences in IPE 23 3 9 3 8 times in order to get a sense of a whole. Sentences and N nursing, OT occupational therapy, PT physiotherapy, M medicine, IPE phrases with content relevant to the aim known as interprofessional education Tran et al. BMC Medical Education (2018) 18:122 Page 4 of 8 profession to be more aware of other students’ professions. placements. The students did not feel comfortable, without This support could facilitate for the students to get in touch support from the programme or the clinical supervisors, to with patients suitable for interprofessional learning. It could initiate IPE activities themselves in clinical environment. also break down hierarchy and provide role models for the students. This increased awareness and collaboration could I think there ought to be more – we have a lot of facilitate for the students from different study programmes placements but I think there should be a bit more to meet and learn together more often. See further Fig. 1. cooperation with the other programmes, that you should have the placements at the same time Students perceived a need for support and awareness (occupational therapy student, group 1) from both study programmes and clinical placements This main theme that immersed the collected material, showed that study programmes and clinical placements It must be brought into the education in some way, I were perceived by students as in need of support and in- mean actively, if it is to have any effect because creased awareness of IPE, otherwise IPE would not take otherwise nothing happens (medical student, group 3) place. According to the students, it felt strange that they did not see or collaborate with each other during their edu- cation but that they were expected to collaborate later Students’ tunnel-vision focus on their own profession when they had graduated. IPE was perceived important by Students spent most of their time focused on learning all participants and they asked for more opportunities for their own profession and they had no time to spend on IPE. They suggested some interprofessional learning activ- learning from other professions. They found it difficult ities, for example, case seminars and interprofessional dis- to know what exactly their own professional role was at cussions around patient cases. They thought that primary the clinical placements; hence they were busy attempting healthcare centres either facilitated or hindered IPE de- to find out how to act in their own profession. The stu- pending on what attitude the staff had towards IPE. The dents were so pre-occupied with learning the responsi- students also argued that something had to be done about bilities of their own profession that this may have the logistical problems. Most of the students interviewed affected their ability to collaborate with students from did not meet any other students during their clinical other professions. The students believed that if they were Fig. 1 Students’ perceptions of IPE in primary healthcare: theme, categories and subcategories Tran et al. BMC Medical Education (2018) 18:122 Page 5 of 8 expected to collaborate with other professions’ students, it Perhaps not those who come on one visit, but for the would have made it easier for them to change focus from kind of people who come several times, to have more their own profession. During the interviews the students team conferences (medical student, group 4) seemed unaware of their own attitude of not having time to learn from other professions. Some students felt stressed Some of the patients’ healthcare problems in primary about having very short clinical placements of around a healthcare were more suitable for IPE and others were week, most often medical students, so they preferred to do not, according to the students. things that only concerned their own profession. Clinical supervisor’s support and attitudes to IPE I can imagine that it’s very much a matter of an Students did not often experience that the primary attitude you have, even my own attitude, you know, healthcare worked in teams or strove for collaboration that I come to the healthcare centre and I become because of several reasons. Different health professions rather narrow in my thinking because I say to myself, had their own localities and each profession worked in- you know, what should I do to start thinking like a dependently and collaborated mainly by referring the pa- doctor (medical student, group 4) tient to the others when needed. However, the students perceived a need for role models. If their supervisor interacted with other professions the students also You’re terribly locked, you know, you don’t think that wanted to do so. The students perceived that the whole you could do that too, or that you can follow primary healthcare had to be a good example for the someone else when you’re on a placement. You’re students by showing how to work in teams so that they really geared to learning your own thing (occupational were able to follow good examples of best practice. As a therapy student, group 1) student they found it hard to introduce something new at a workplace. Nurses collaborated mainly with doctors The students’ focus on their own profession was per- while physiotherapists collaborated with occupational ceived as an obstacle to IPE. therapists, but those two different constellations rarely collaborated. One occupational student said it could Patients’ healthcare problems happen that she never met a medical or a nursing stu- In primary healthcare, the students came across a wide dent during her clinical placement. range of patients and perceived that only a subset of the patients required collaboration with more than one pro- In a place where they don’twork inteams,across fession. Many of the patients that the students had en- professional boundaries, it can be hard as a student to counters with in primary healthcare had healthcare get into the work and as a student to start working problems of low severity that did not seem urgent ac- more in teams when you’re so fresh and you don’thave, cording to the students. Those patients who did not you know (occupational therapy student, group 2) need collaboration came perhaps for just a cold, wanting antibiotics from the doctor, or they just wished to have their blood pressure measured by a I agree with that, actually, you get very much influenced nurse or to have a blood test in the laboratory. How- by what your supervisor is like. If they focus only on ever, patients in primary healthcare with pain, elderly their tasks and aren’t interested in collaborating with people with several diseases and complex problems other professions, it ends up that you do the same who needed care in their homes, patients who were yourself there (nursing student, group 4) frequent visitors and patients with undiagnosed or not easily defined problems, were considered by the The students found it important that all the healthcare students as suitable for IPE. Those patients were per- staff in primary healthcare were good role models for IPE. ceived to need collaboration and it seemed to be more natural to involve other professions in the care of those patients. Hierarchy between different professions The students had experiences of hierarchy between differ- But it’s a bit like this, some groups, you hear ‘I need a ent professions in health care. In their opinion, hierarchy penicillin that works well’, and then maybe you don’t made people feel too proud of themselves and prevented need to get involved, but if there’s someone who takes them from seeking help from other professions. According a lot more time or something like that, then you to the students, prejudices existed among all professions. know there’s something to be found there The students perceived that increased knowledge of other (occupational therapy student, group 3) professions would help to prevent these prejudices and Tran et al. BMC Medical Education (2018) 18:122 Page 6 of 8 help to break down the hierarchy. In primary healthcare the start, where you study theory together the professions worked in isolation. Therefore, the stu- (physiotherapy student, group 1) dents suggested that students from different professions together with their supervisors would meet with the aim The students perceived a need to know more about to increase knowledge about each other. When the differ- each other from the beginning. They also wanted their ent professions had gained an increased knowledge about teachers to remind them about IPE before their clinical each other, obstacles relating to hierarchy could be over- placements. come. Further, students stated that hierarchy prevented the professions from communicating and reduced the op- Discussion portunities to learn from each other. The students be- The aim of this study was to investigate how students lieved that hierarchy hindered them from seeing the other perceived the conditions for IPE in primary healthcare, professions as resources. and the main finding was that students perceived a need for support and awareness of IPE from both study pro- Hierarchy creates so much status that’s unnecessary, grammes and clinical placements. This was essential you know, creates attitude in a way that makes since both study programmes and clinical environments cooperation difficult, I think (medical student, group 4) could either hinder or enhance possibilities of IPE for students in primary healthcare. Students did not always According to the students, hierarchy between profes- encounter exemplary teamwork at their clinical place- sions was an obstacle to collaboration and learning from ment. Our study showed, in accordance with a previous each other. study by Thistlewaite [18], that if IPE was going to take place, it needed support and awareness from both study Collaboration between different study programmes programmes and clinical placements. The students felt that there was lack of knowledge re- Our most interesting finding was students’ tunnel-vision garding the roles and responsibilities of other profes- focus on their own profession. Since they were preoccupied sions. The students would like to have had with their own profession and wanted to only learn and do interprofessional learning activities together with other things related to their profession, this created an obstacle to healthcare programmes. If they had the opportunity to learning with and from other professions. Fifty-five percent learn more about each other from different programmes, of medical students in the study by Morison, Boohan, Mou- it would have increased their willingness to ask for help tray and Jenkins [19] expressed that they did not want to from the other professions in future when they had wastetimelearning with other healthcare students but they graduated. They wanted to start early and carry on with did not explain the reason. Abu-Rish et al. [20]found that interprofessional learning activities during their whole the most frequently reported barrier to interprofessional education. They thought that, in order to make them col- education implementation was scheduling, followed by dif- laborate better with other professions, increased know- ficulty in matching students of compatible levels. Our find- ledge was required about each other. If they knew what ing of students’ tunnel-vision focus on their own profession knowledge and competence the other professions had, it adds to these previous studies, since this finding has not would be easier for them to ask for help, refer to the other been described previously. professions when needed and to collaborate. Otherwise, Another interesting finding in our study was how the they rather preferred to ask their supervisors. Students nature of the patients’ healthcare problems affected the perceived that their study programmes did not pay students’ interest in IPE. Our findings differ considerably enough attention to IPE. Therefore, students needed to be from studies made in hospital settings where patients reminded about IPE from their teachers in both verbal were sicker or perceived as having health problems of a and written instructions, before their clinical placements. higher urgency. Several studies have mentioned that chronically ill patients need collaboration, which stu- That it’s more integrated somewhere in the education, dents in our study also suggested [21]. All students in that you get to learn what the others do, because I our study agreed about interprofessional learning being don’t know (nursing student, group 3) crucial and important but complex and difficult for sev- eral reasons. The students in our study called for interprofessional The important thing is to bring it in more often and learning activities in concordance with the study by Tsa- both early and late, I feel, because now you say it’s kitzidis et al. [22]. According to the students in the study very late because we’re also in the last semester as above, interprofessional learning should be included in physiotherapists. If, for example, you were to start undergraduate courses. The best timing for IPE whether perhaps together with doctors and have a course from early in the students’ education or later when they have Tran et al. BMC Medical Education (2018) 18:122 Page 7 of 8 formed their professional identities – is a question where pre-understanding of all the authors, who represent pri- there exists no consensus [23]. IPE should not be an mary healthcare and teachers from the medical school “add-on” educational activity, it should be included in with experience of working in primary healthcare, may the curriculum because there could be problems regard- have influenced in interpreting the collected data. There- ing the time required for IPE [24]. Students from differ- fore, results and interpretations were continuously dis- ent study programmes usually have their clinical cussed between all authors until consensus was reached. placements at different periods and most of the time the students do not meet students from other study pro- Conclusions grammes in the clinical learning environment. This lo- Our results indicated that IPE was perceived as import- gistical problem seems to be a challenge all over the ant but it required support and awareness from both world and difficult to solve [1, 25]. Chen, Delnat and study programmes and clinical placements. The study Gardner [26] found that the lack of connection between identified conditions that were required for IPE in pri- education and clinical workplaces resulted in less oppor- mary healthcare. Our findings may be helpful for health- tunities for students to experience structured IPE in care teachers and clinical supervisors to better their clinical placement. Students in the present study understand how students perceive IPE in primary appreciated meeting and having discussions with stu- healthcare, thus facilitating the planning of IPE. dents from other professions, which rarely happened. According to the students in the present study, clinical Additional files supervisors’ support and attitude towards IPE were im- portant. The supervisors, through their support and atti- Additional file 1: Interview guide. (DOCX 12 kb) tude, could be either enablers or barriers to IPE since they acted as role models [27]. Abbreviations Students in our study experienced hierarchy among IPE: Interprofessional education healthcare professionals, and from their perspective this Acknowledgements hindered collaboration, communication, and shared The authors thank Karin Björklund (KB) who undertook the data collection. knowledge; findings that were in concordance with the We also thank all the students who participated in this study. study by Abu-Rish et al. [20]. Funding This study was funded by grants from Karolinska Institutet and Stockholm Strengths and limitations County Council. The people who funded the study were not involved in the One strength of our study was that students from all design of the study and collection, analysis, and interpretation of data or four of the most common programmes in primary writing of the manuscript. healthcare participated, which increased credibility. The Availability of data and materials research group came from different professions, two dis- For requests of the dataset used in the current study, please contact the trict nurses and one medical doctor (HS). There were corresponding author. also discussions between KB (an occupational therapist), and HS (a medical doctor), after every group interview. Authors’ contributions HS and PK planned the study. CT, HS and PK analysed the data and were HS was responsible for the primary care component of deeply involved in all steps. All authors were involved in the writing of the the medicine study programme at Karolinska Institutet manuscript and have approved the final version. but had no direct contact as a teacher with the students in the present study. The interviews were not performed Authors’ information Carrie Tran (CT), District nurse, Stockholm County Council, PhD student, by the first author. It was not known whether the stu- Department of Neurobiology, Care Sciences and Society, Division of Family dents felt equal to the other students during the inter- Medicine and Primary Care, Karolinska Institutet, Sweden. views. It was likely easier to include the students who Päivi Kaila (PK), RN, PhD, Senior Lecturer, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Sweden. were interested in IPE than those with less interest. An- Helena Salminen (HS), MD, PhD, Associate Professor and Senior Lecturer, other limitation was that three of the students had not Department of Neurobiology, Care Sciences and Society, Division of Family had their clinical placement in primary healthcare so Medicine and Primary Care, Karolinska Institutet, Sweden. they spoke from their conceptions about how IPE in pri- Ethics approval and consent to participate mary healthcare should be rather than actual experi- Ethical approval was obtained from the Regional Ethical Review Board, ences. Their contributions to the interviews were Karolinska Institutet, Stockholm, Sweden (Dnr: 2012/1011-31/5). All perceived as valuable so it was decided that their data participants gave their written informed consent. would be included in the analysis. The present study was Consent for publication conducted in 2012. 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Conditions for interprofessional education for students in primary healthcare: a qualitative study

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Abstract

Background: Primary healthcare in Sweden and worldwide has a diverse structure with many kinds of healthcare units involved. This is a challenge for collaboration between different professions in primary healthcare, as the different healthcare professions often work in silos. Interprofessional education (IPE) in the context of primary healthcare is less studied than IPE at hospitals and most of the studies in primary healthcare have focused on collaboration between general practitioners and nurses. The aim of this study was to describe how healthcare students perceived conditions for IPE in primary healthcare. Methods: Qualitative group interviews were used and a total of 26 students, recruited on a voluntary basis participated in four group interviews with students mixed from study programmes in nursing, physiotherapy, occupational therapy and medicine. Students from the study programme in medicine were in their second to eleventh semesters of 11 semesters in total, whilst students from the occupational therapist, physiotherapist and nursing programmes were in their fourth to sixth of six semesters in total. Results: Our findings indicated one theme: Students perceived a need for support and awareness of IPE from both study programmes and clinical placements. Five categories were found to belong to the theme. Students’ tunnel- vision focus on their own profession may have affected their ability to collaborate with students from other professions. The nature of the patients’ healthcare problems decided if they were perceived as suitable for IPE. Clinical supervisors’ support for and attitude towards IPE were important. The hierarchy between different professions was perceived as a hindrance for seeking help from the other professions. The students asked for more collaboration between different study programmes, in order to gain knowledge about the roles and responsibilities of the other professions. Conclusions: In conclusion, students in this study considered it essential for different study programmes and clinical placements to be more aware of the opportunities for and importance of IPE. The study identified conditions that were required for IPE in primary healthcare that may be helpful for healthcare teachers and clinical supervisors to better understand how students perceive IPE in primary healthcare, thus facilitating the planning of IPE. Keywords: Interprofessional education, Primary healthcare, Healthcare students, Qualitative study, Content analysis * Correspondence: carrie.tran@ki.se Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Alfred Nobels Allé 23, 141 83 Huddinge, Sweden 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. Tran et al. BMC Medical Education (2018) 18:122 Page 2 of 8 Background students similar to the present study. Kent & Keating [8] Patient safety and quality of care would be improved if could only find two such studies in their systematic lit- there was increased collaboration between healthcare erature review from 2015. Moreover, according to San professions [1, 2]. Most healthcare educations involve a Martín-Rodríguez et al. [9], seven of ten studies have large number of students and take place in isolation been conducted in hospital contexts but only three in from each other, reducing possibilities for interaction be- primary healthcare settings. Collaboration in hospitals is tween the different student categories [1, 3]. This ten- usually easier since most of the staff work in the same dency for both healthcare professions and educations to building. Hammick, Freeth, Koppel, Reeves and Barr work in silos makes collaboration between different pro- [10] reviewed more than 21 scientific papers, most of fessions a challenge [3]. them in a hospital context. In Sweden, IPE had been In Swedish primary healthcare, some healthcare profes- studied in clinical education wards in hospitals [11–14]. sions rarely have direct contact via meetings in person It was difficult to find studies about IPE in primary about the individual patient’s care, since they do not work healthcare in a Swedish context. We have only found close enough to each other. Furthermore, most of the time one study in Sweden that investigated undergraduate students do not meet students from other professions students’ experiences of a full day practicing teamwork since they do not have their clinical placements at the with a fictitious home care patient [15]. Most of the pre- same time. IPE occurs by definition “when students from vious studies in primary healthcare have focused on cre- two or more professions learn about, from and with each ating interprofessional learning activities. Students have other to enable effective collaboration and improve health rarely taken part in creating IPE and their views of what outcome”. The World Health Organization stated that is required for IPE to take place having not been previ- once the students understand how to work interprofes- ously explored in the context of primary healthcare. This sionally, they will have increased readiness to work collab- indicates a gap in knowledge regarding how students oratively when entering a workplace [4]. perceive prerequisites for IPE in primary healthcare. According to the Declaration of Alma-Ata [5], primary This study used an interprofessional approach in meth- healthcare is the first level of healthcare contact for indi- odology and had students in mixed groups from four viduals who live in the community. It brings healthcare different study programmes. The purpose of the present as close as possible to where people live and work. The study was to describe how students from study pro- main health fields that primary healthcare deals with are grammes in nursing, occupational therapy, physiother- preventive, curative, supportive and rehabilitative ser- apy and medicine perceived the conditions for IPE in vices. There were about 200 primary healthcare centres primary healthcare. and a total of around 500 units (including rehabilitation, child and maternity care units) in primary healthcare in Methods Stockholm, Sweden, when the present study was con- Design ducted. Most of the nurses and medical doctors work at This was a qualitative study and data was collected primary healthcare centres, whilst occupational thera- through group interviews. The data was analysed using pists and physiotherapists generally work at rehabilita- qualitative content analysis since this method provided tion units. It is uncommon for primary healthcare knowledge and gave new insight into how the students centres and rehabilitation units to be co-located. Coun- perceived conditions for IPE in primary healthcare [16]. sellors, psychologists and dietitians also work at some of In order to obtain rich data from the interactions be- the primary healthcare centres. tween the students from the different study pro- There has been an increased focus on IPE because grammes, group interviews was chosen as a method. there exists a growing recognition and evidence of com- The analysis had an inductive approach and focused munication and collaboration improvements in interpro- mainly on the manifest content. fessional teams [6]. Social engagement is important for the students’ learning process and ability to make sense Context and participants of new information and ideas. Learning takes place in a The context of this study was primary healthcare in community of practice [7] and is a part of a social prac- Stockholm, Sweden. Nursing, physiotherapy, occupa- tice. Through social interaction with peers and clinicians tional therapy and medicine students from one medical in a clinical environment, the students construct new university (Karolinska Institutet) had clinical placements knowledge and are introduced to their future profession in primary healthcare. Some nursing students were from by doing and acting. two other universities in Stockholm that also had place- There are several previous studies about IPE in pri- ments in primary healthcare. The period for these place- mary healthcare [8] but there still exists a lack of re- ments in primary healthcare varied between 1 and search that relates to IPE involving several professions’ 6 weeks and took place at different periods of the Tran et al. BMC Medical Education (2018) 18:122 Page 3 of 8 semester. The students were recruited on a voluntary “meaning units”, were highlighted. The analysis was first basis via information given to all four programmes, and done by the first author (CT) identifying the meaning the students passed on information to other students via units from the text. CT then condensed the meaning their Facebook pages. units and gave names with codes and then sorted the Four group interviews with five to nine students in data into categories [17]. The codes were aimed to stay each group were carried out as follows: two group inter- as close as possible to the text and were then grouped views were conducted at the Centre of Family Medicine into categories and higher order categories. All authors and the remaining two groups at one Academic Health agreed that the main theme covered the categories. Centre. Medicine students were in the second to elev- Graneheim & Lundman [17] described category as a enth semesters of their 11 semester study programme, group of content that shares commonality and a theme whilst students from the occupational therapist, physio- can be found in several categories, describing the under- therapist and nursing programmes were in their fourth lying meanings. In order to increase trustworthiness, all to sixth of six semesters in total. The groups were mixed authors who were from different professions identified with the aim to get participants from different study main categories independently and then discussed simi- programmes in the same interview. As all the partici- larities and differences until consensus was reached. pants still had the same student status, we did not an- ticipate any problems with hierarchy among the Ethical considerations students. Three groups had students from all four study The Ethical Review Board in Stockholm had no objections programmes included and one group had students from to the study. All participants were informed about the aim three study programmes (with no nursing students). The and method of the study and gave signed informed consent. intention was only to include undergraduate students with prior experience of a clinical placement in primary Results healthcare but unintentionally three students who were A total of 26 students participated, 18 females and eight included in the study had not had their clinical place- males. The mean age of the participants was 26.8 years ments in primary healthcare. The majority had experi- (range, 25–44 years). Students represented medicine (n = ence of IPE from their clinical placements at hospitals in eight), nursing (n = four), occupational therapy (n = nine), interprofessional student wards. physiotherapy (n = five). See further Table 1.All students considered IPE in primary healthcare important. At the Data collection same time they found it difficult to collaborate in primary A semi-structured interview guide was used consisting healthcare because the different professions did not work of five open-ended questions (Additional file 1): What close to each other, and therefore it was difficult to get to does IPE mean to you? What possibilities do you see to know each other and begin collaboration. As an answer to learn with, from and about each other in primary health- our aim to describe how healthcare students perceived the care? What hindrances do you see to learn from each conditions for IPE in primary healthcare, our results showed other in primary healthcare? What can you learn from one theme that immersed all underlying categories: Students each other in primary healthcare? How can you learn perceived a need for support and awareness from both study with and from each other in primary healthcare? Two programmes and clinical placements. Five categories were people with different roles conducted all four interviews. found related to this main theme, representing the students’ KB acted as a moderator while the third author (HS) perceptions of conditions needed for IPE in primary health- acted as an observer. The interviews were recorded and care; students’ tunnel-vision focus on their own profession, transcribed verbatim. Each session lasted approximately patients’ healthcare problems, clinical supervisor’s support 90 min. After the fourth group interview, the recorded and attitude to IPE, hierarchy between different professions data showed little new information and the data had lit- and collaboration between different study programmes.The tle variation so saturation was considered to have been main theme could be found in every category. Support and achieved. The data was collected in autumn 2012. awareness from study programmes and clinical placements, could help students to change focus from their own Data analysis Table 1 Descriptive characteristics of the participating students Data was analysed using qualitative content analysis in- All participants (n = 26) N OT PT M spired by Krippendorff [16]. As there was not enough Male 8 1 1 3 3 knowledge about how students perceived prerequisites for IPE in primary healthcare, an inductive approach Female 18 3 8 2 5 was used. The analysis started by reading the text several Previous experiences in IPE 23 3 9 3 8 times in order to get a sense of a whole. Sentences and N nursing, OT occupational therapy, PT physiotherapy, M medicine, IPE phrases with content relevant to the aim known as interprofessional education Tran et al. BMC Medical Education (2018) 18:122 Page 4 of 8 profession to be more aware of other students’ professions. placements. The students did not feel comfortable, without This support could facilitate for the students to get in touch support from the programme or the clinical supervisors, to with patients suitable for interprofessional learning. It could initiate IPE activities themselves in clinical environment. also break down hierarchy and provide role models for the students. This increased awareness and collaboration could I think there ought to be more – we have a lot of facilitate for the students from different study programmes placements but I think there should be a bit more to meet and learn together more often. See further Fig. 1. cooperation with the other programmes, that you should have the placements at the same time Students perceived a need for support and awareness (occupational therapy student, group 1) from both study programmes and clinical placements This main theme that immersed the collected material, showed that study programmes and clinical placements It must be brought into the education in some way, I were perceived by students as in need of support and in- mean actively, if it is to have any effect because creased awareness of IPE, otherwise IPE would not take otherwise nothing happens (medical student, group 3) place. According to the students, it felt strange that they did not see or collaborate with each other during their edu- cation but that they were expected to collaborate later Students’ tunnel-vision focus on their own profession when they had graduated. IPE was perceived important by Students spent most of their time focused on learning all participants and they asked for more opportunities for their own profession and they had no time to spend on IPE. They suggested some interprofessional learning activ- learning from other professions. They found it difficult ities, for example, case seminars and interprofessional dis- to know what exactly their own professional role was at cussions around patient cases. They thought that primary the clinical placements; hence they were busy attempting healthcare centres either facilitated or hindered IPE de- to find out how to act in their own profession. The stu- pending on what attitude the staff had towards IPE. The dents were so pre-occupied with learning the responsi- students also argued that something had to be done about bilities of their own profession that this may have the logistical problems. Most of the students interviewed affected their ability to collaborate with students from did not meet any other students during their clinical other professions. The students believed that if they were Fig. 1 Students’ perceptions of IPE in primary healthcare: theme, categories and subcategories Tran et al. BMC Medical Education (2018) 18:122 Page 5 of 8 expected to collaborate with other professions’ students, it Perhaps not those who come on one visit, but for the would have made it easier for them to change focus from kind of people who come several times, to have more their own profession. During the interviews the students team conferences (medical student, group 4) seemed unaware of their own attitude of not having time to learn from other professions. Some students felt stressed Some of the patients’ healthcare problems in primary about having very short clinical placements of around a healthcare were more suitable for IPE and others were week, most often medical students, so they preferred to do not, according to the students. things that only concerned their own profession. Clinical supervisor’s support and attitudes to IPE I can imagine that it’s very much a matter of an Students did not often experience that the primary attitude you have, even my own attitude, you know, healthcare worked in teams or strove for collaboration that I come to the healthcare centre and I become because of several reasons. Different health professions rather narrow in my thinking because I say to myself, had their own localities and each profession worked in- you know, what should I do to start thinking like a dependently and collaborated mainly by referring the pa- doctor (medical student, group 4) tient to the others when needed. However, the students perceived a need for role models. If their supervisor interacted with other professions the students also You’re terribly locked, you know, you don’t think that wanted to do so. The students perceived that the whole you could do that too, or that you can follow primary healthcare had to be a good example for the someone else when you’re on a placement. You’re students by showing how to work in teams so that they really geared to learning your own thing (occupational were able to follow good examples of best practice. As a therapy student, group 1) student they found it hard to introduce something new at a workplace. Nurses collaborated mainly with doctors The students’ focus on their own profession was per- while physiotherapists collaborated with occupational ceived as an obstacle to IPE. therapists, but those two different constellations rarely collaborated. One occupational student said it could Patients’ healthcare problems happen that she never met a medical or a nursing stu- In primary healthcare, the students came across a wide dent during her clinical placement. range of patients and perceived that only a subset of the patients required collaboration with more than one pro- In a place where they don’twork inteams,across fession. Many of the patients that the students had en- professional boundaries, it can be hard as a student to counters with in primary healthcare had healthcare get into the work and as a student to start working problems of low severity that did not seem urgent ac- more in teams when you’re so fresh and you don’thave, cording to the students. Those patients who did not you know (occupational therapy student, group 2) need collaboration came perhaps for just a cold, wanting antibiotics from the doctor, or they just wished to have their blood pressure measured by a I agree with that, actually, you get very much influenced nurse or to have a blood test in the laboratory. How- by what your supervisor is like. If they focus only on ever, patients in primary healthcare with pain, elderly their tasks and aren’t interested in collaborating with people with several diseases and complex problems other professions, it ends up that you do the same who needed care in their homes, patients who were yourself there (nursing student, group 4) frequent visitors and patients with undiagnosed or not easily defined problems, were considered by the The students found it important that all the healthcare students as suitable for IPE. Those patients were per- staff in primary healthcare were good role models for IPE. ceived to need collaboration and it seemed to be more natural to involve other professions in the care of those patients. Hierarchy between different professions The students had experiences of hierarchy between differ- But it’s a bit like this, some groups, you hear ‘I need a ent professions in health care. In their opinion, hierarchy penicillin that works well’, and then maybe you don’t made people feel too proud of themselves and prevented need to get involved, but if there’s someone who takes them from seeking help from other professions. According a lot more time or something like that, then you to the students, prejudices existed among all professions. know there’s something to be found there The students perceived that increased knowledge of other (occupational therapy student, group 3) professions would help to prevent these prejudices and Tran et al. BMC Medical Education (2018) 18:122 Page 6 of 8 help to break down the hierarchy. In primary healthcare the start, where you study theory together the professions worked in isolation. Therefore, the stu- (physiotherapy student, group 1) dents suggested that students from different professions together with their supervisors would meet with the aim The students perceived a need to know more about to increase knowledge about each other. When the differ- each other from the beginning. They also wanted their ent professions had gained an increased knowledge about teachers to remind them about IPE before their clinical each other, obstacles relating to hierarchy could be over- placements. come. Further, students stated that hierarchy prevented the professions from communicating and reduced the op- Discussion portunities to learn from each other. The students be- The aim of this study was to investigate how students lieved that hierarchy hindered them from seeing the other perceived the conditions for IPE in primary healthcare, professions as resources. and the main finding was that students perceived a need for support and awareness of IPE from both study pro- Hierarchy creates so much status that’s unnecessary, grammes and clinical placements. This was essential you know, creates attitude in a way that makes since both study programmes and clinical environments cooperation difficult, I think (medical student, group 4) could either hinder or enhance possibilities of IPE for students in primary healthcare. Students did not always According to the students, hierarchy between profes- encounter exemplary teamwork at their clinical place- sions was an obstacle to collaboration and learning from ment. Our study showed, in accordance with a previous each other. study by Thistlewaite [18], that if IPE was going to take place, it needed support and awareness from both study Collaboration between different study programmes programmes and clinical placements. The students felt that there was lack of knowledge re- Our most interesting finding was students’ tunnel-vision garding the roles and responsibilities of other profes- focus on their own profession. Since they were preoccupied sions. The students would like to have had with their own profession and wanted to only learn and do interprofessional learning activities together with other things related to their profession, this created an obstacle to healthcare programmes. If they had the opportunity to learning with and from other professions. Fifty-five percent learn more about each other from different programmes, of medical students in the study by Morison, Boohan, Mou- it would have increased their willingness to ask for help tray and Jenkins [19] expressed that they did not want to from the other professions in future when they had wastetimelearning with other healthcare students but they graduated. They wanted to start early and carry on with did not explain the reason. Abu-Rish et al. [20]found that interprofessional learning activities during their whole the most frequently reported barrier to interprofessional education. They thought that, in order to make them col- education implementation was scheduling, followed by dif- laborate better with other professions, increased know- ficulty in matching students of compatible levels. Our find- ledge was required about each other. If they knew what ing of students’ tunnel-vision focus on their own profession knowledge and competence the other professions had, it adds to these previous studies, since this finding has not would be easier for them to ask for help, refer to the other been described previously. professions when needed and to collaborate. Otherwise, Another interesting finding in our study was how the they rather preferred to ask their supervisors. Students nature of the patients’ healthcare problems affected the perceived that their study programmes did not pay students’ interest in IPE. Our findings differ considerably enough attention to IPE. Therefore, students needed to be from studies made in hospital settings where patients reminded about IPE from their teachers in both verbal were sicker or perceived as having health problems of a and written instructions, before their clinical placements. higher urgency. Several studies have mentioned that chronically ill patients need collaboration, which stu- That it’s more integrated somewhere in the education, dents in our study also suggested [21]. All students in that you get to learn what the others do, because I our study agreed about interprofessional learning being don’t know (nursing student, group 3) crucial and important but complex and difficult for sev- eral reasons. The students in our study called for interprofessional The important thing is to bring it in more often and learning activities in concordance with the study by Tsa- both early and late, I feel, because now you say it’s kitzidis et al. [22]. According to the students in the study very late because we’re also in the last semester as above, interprofessional learning should be included in physiotherapists. If, for example, you were to start undergraduate courses. The best timing for IPE whether perhaps together with doctors and have a course from early in the students’ education or later when they have Tran et al. BMC Medical Education (2018) 18:122 Page 7 of 8 formed their professional identities – is a question where pre-understanding of all the authors, who represent pri- there exists no consensus [23]. IPE should not be an mary healthcare and teachers from the medical school “add-on” educational activity, it should be included in with experience of working in primary healthcare, may the curriculum because there could be problems regard- have influenced in interpreting the collected data. There- ing the time required for IPE [24]. Students from differ- fore, results and interpretations were continuously dis- ent study programmes usually have their clinical cussed between all authors until consensus was reached. placements at different periods and most of the time the students do not meet students from other study pro- Conclusions grammes in the clinical learning environment. This lo- Our results indicated that IPE was perceived as import- gistical problem seems to be a challenge all over the ant but it required support and awareness from both world and difficult to solve [1, 25]. Chen, Delnat and study programmes and clinical placements. The study Gardner [26] found that the lack of connection between identified conditions that were required for IPE in pri- education and clinical workplaces resulted in less oppor- mary healthcare. Our findings may be helpful for health- tunities for students to experience structured IPE in care teachers and clinical supervisors to better their clinical placement. Students in the present study understand how students perceive IPE in primary appreciated meeting and having discussions with stu- healthcare, thus facilitating the planning of IPE. dents from other professions, which rarely happened. According to the students in the present study, clinical Additional files supervisors’ support and attitude towards IPE were im- portant. The supervisors, through their support and atti- Additional file 1: Interview guide. (DOCX 12 kb) tude, could be either enablers or barriers to IPE since they acted as role models [27]. Abbreviations Students in our study experienced hierarchy among IPE: Interprofessional education healthcare professionals, and from their perspective this Acknowledgements hindered collaboration, communication, and shared The authors thank Karin Björklund (KB) who undertook the data collection. knowledge; findings that were in concordance with the We also thank all the students who participated in this study. study by Abu-Rish et al. [20]. Funding This study was funded by grants from Karolinska Institutet and Stockholm Strengths and limitations County Council. The people who funded the study were not involved in the One strength of our study was that students from all design of the study and collection, analysis, and interpretation of data or four of the most common programmes in primary writing of the manuscript. healthcare participated, which increased credibility. The Availability of data and materials research group came from different professions, two dis- For requests of the dataset used in the current study, please contact the trict nurses and one medical doctor (HS). There were corresponding author. also discussions between KB (an occupational therapist), and HS (a medical doctor), after every group interview. Authors’ contributions HS and PK planned the study. CT, HS and PK analysed the data and were HS was responsible for the primary care component of deeply involved in all steps. All authors were involved in the writing of the the medicine study programme at Karolinska Institutet manuscript and have approved the final version. but had no direct contact as a teacher with the students in the present study. The interviews were not performed Authors’ information Carrie Tran (CT), District nurse, Stockholm County Council, PhD student, by the first author. It was not known whether the stu- Department of Neurobiology, Care Sciences and Society, Division of Family dents felt equal to the other students during the inter- Medicine and Primary Care, Karolinska Institutet, Sweden. views. It was likely easier to include the students who Päivi Kaila (PK), RN, PhD, Senior Lecturer, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Sweden. were interested in IPE than those with less interest. An- Helena Salminen (HS), MD, PhD, Associate Professor and Senior Lecturer, other limitation was that three of the students had not Department of Neurobiology, Care Sciences and Society, Division of Family had their clinical placement in primary healthcare so Medicine and Primary Care, Karolinska Institutet, Sweden. they spoke from their conceptions about how IPE in pri- Ethics approval and consent to participate mary healthcare should be rather than actual experi- Ethical approval was obtained from the Regional Ethical Review Board, ences. Their contributions to the interviews were Karolinska Institutet, Stockholm, Sweden (Dnr: 2012/1011-31/5). All perceived as valuable so it was decided that their data participants gave their written informed consent. would be included in the analysis. The present study was Consent for publication conducted in 2012. According to our knowledge, there The participants in the study provided written informed consent for have been no major changes in IPE in primary health- publication; non-identifiable participant comments are reported in the care in Stockholm since this study was conducted. The manuscript. Tran et al. BMC Medical Education (2018) 18:122 Page 8 of 8 Competing interests 19. Morison S, Boohan M, Moutray M, Jenkins J. Developing pre-qualification The authors declare that they have no competing interests. inter-professional education for nursing and medical students: sampling student attitudes to guide development. Nurse Educ Pract. 2004;4(1):20–9. 20. Abu-Rish E, Kim S, Choe L, Varpio L, Malik E, White AA, Craddick K, Blondon K, Robins L, Nagasawa P, et al. Current trends in interprofessional education of Publisher’sNote health sciences students: a literature review. J interprof Care. 2012;26(6):444–51. Springer Nature remains neutral with regard to jurisdictional claims in 21. Reeves S. 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BMC Medical EducationSpringer Journals

Published: Jun 4, 2018

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