INTRODUCTION

One of the defining features of a collaborative interprofessional culture is good teamwork, particularly when under pressure, and this is facilitated by factors that include effective leadership and relationships, a core language of communication and a clear understanding of roles (Driskell et al., 2018; Keller et al., 2020; Sheehan et al., 2007). There is concern that by separating the tertiary organisation of the education of specific professions, the collaborative model of healthcare becomes more difficult to achieve (Beard et al., 2015; Khalili et al., 2014). Incivility within and between professional groups remains a concern and has the potential to impact on the provision of patient care as well as the mental and physical wellbeing of individual healthcare practitioners (Felblinger, 2009; LaGuardia & Oelke, 2021).

Interprofessional education is commonly defined as learning with, from, and about each other (Centre for the Advancement of Interprofessional Education, 2016). The integration of IPE into healthcare has been discussed for over 50 years (Szasz, 1969) and evidence for using IPE continues to accumulate (S. Reeves et al., 2016; Thistlethwaite, 2016). Despite this, many academic tertiary institutions have not been able to fully integrate interprofessional education in a coordinated and sustainable way. Some of the reasons for this may be the challenge of aligning timetables, questions regarding the most effective intervention, and concerns about whether IPE should occur in the undergraduate curriculum and exactly when (Holland et al., 2013; McKimm et al., 2010; Thistlethwaite & Jones, 2020). It is known that the development of an interprofessional identity (also conceptualised as interprofessional responsibility) can be developed at the same time as a uniprofessional identity during the pre-registration years (Hudson et al., 2017; Khalili et al., 2013).

Interprofessional education interventions have been piloted with pre-registration students in Aotearoa New Zealand and were considered as having the potential to improve relationships with students from other professions and collaborative practice (Flood et al., 2014; Pullon et al., 2013). These findings provided motivation for the IPE intervention study described here which was undertaken between 2016 and 2018 (following feasibility and pilot studies in 2014 – 2015). This paper reports on some of the questions asked by nursing and medical students of each profession during the ice breaker socialisation activity of this study.

BACKGROUND

A collaborative inter-organisational (Te Pūkenga/Ara, Te Whatu Ora Waitaha - Canterbury, and the University of Otago) and interprofessional (nursing and medical) academic group was established in 2012 to investigate the possibility of introducing an IPE simulation for nursing and medical pre-registration students. This interprofessional faculty met together on at least a monthly basis to conceive, design, and plan the intervention which was aimed at 3rd year (final year) nursing students and 5^th year (pre-final) medical students who had minimal exposure to IPE. The intervention was preceded and followed by the completion of the Readiness for Interprofessional Learning Scale (RIPLS) (Parsell & Bligh, 1999). The intervention included the following:

• Completion of the RIPLS questionnaire.

• Socialisation (see below).

• A static simulation entitled Ward of Errors based on the “Room of Horrors” (Shekhter et al., 2012).

• A dynamic real-time simulation based on a deteriorating patient scenario.

• Repeated completion of the RIPLS.

Two initial interprofessional simulation sessions were held in October 2014 to establish the feasibility of bringing these students together. The faculty met following the feasibility study to further develop the educational intervention to allow more time for socialisation. This is when the idea of using post-it notes to explore the views of students was suggested as the socialisation activity and was successfully piloted in October 2015. This paper reports the outcomes from the 2016 – 2018 interprofessional socialisation sessions.

Research Aim

The overall aim of the full educational intervention was to explore the role of interprofessional simulation in promoting positive interprofessional attitudes, communication, situational and role awareness, and teamwork in pre-registration health professionals' education. This paper provides a unique contribution by exploring the results from a socialisation activity where students could anonymously ask open-ended questions of the students from each profession.

METHODS

The Study

Between 2016 and 2018, the ice breaker socialisation activity, which occurred at the beginning of the educational intervention, involved students being invited (not mandated) to write their questions on a post-it note for the profession other than their own. The post-it notes were colour coded for each profession and students were made aware that some of these questions would be read out during an interprofessional group discussion for each professional group to answer. This conversation was facilitated by nursing faculty. The aim was to describe and thematically analyse students’ questions (Braun & Clarke, 2006).

Setting

The location of this study was the Health Simulation Centre used by the local health care provider where both sets of students were gaining pre-registration experience. This was a deliberate strategy to remove students from their own specific educational institution’s context to an interprofessional context.

Sampling

Convenience sampling was used to recruit participants for the study by inviting fifth year medical students and third year nursing students during previous teaching sessions. They were invited to participate by the faculty, who were teaching the students, with all details provided by the researcher, who was of the same profession. These student groups were chosen as they were towards the end of their health professional programmes before entering practice as a provisionally (medical) or fully registered (nursing) practitioner. The total number of students across these years of the programmes was approximately 110 medical students and 200 nursing students per annum. Due to timetable constraints, different strategies of recruitment were used to enrol and consent each professional group. All received a verbal description of the research aims and what it would entail if they chose to participate. They were provided with a written consent form. Dates were timetabled to align with scheduled simulation activities for the medical students. The activity was mandatory for the medical students, though participation in the research was voluntary. In each year of the study, four of the eight potential groups of medical students were invited to participate (50% of the total number of students). The nursing students who were invited to participate were available on the dates allocated to the intervention. This was approximately six weeks after the briefings were provided, which meant they had sufficient time to decide whether to participate or not.

Ethics

Ethical approval was received in September 2015 from the University of Otago Human Ethics Committee (UoO D15./266). Although the educational intervention was part of the medical students’ quality and patient safety curricula, informed consent was obtained for the collection, analysis, and publication of data. The data published as part of this paper was completed within professional groups and could be completed as an individual or as a result of group discussion and was anonymised.

RESULTS

The findings presented in this paper were collected between 2016 and 2018 from six groups of students from three cohorts of preregistration nursing and medical students).

Participants

The total number of students who participated in the interprofessional educational intervention was 220, of which 94 were nursing students and 126 medical students. The total number of completed post-it notes collected during the initial ice breaker from the six separate interprofessional sessions held between 2016 and 2018 was 166, of which 89 were completed by medical students and 77 by nursing students (Table 1).

Thematic Analysis

Two members of the teaching faculty, one with a nursing background (PS) and one with a medical background (MM), followed a process of independent data familiarisation and began to code data (the students’ questions on post-it notes) and derive preliminary themes grounded in the context of their own clinical and teaching experience using an inductive descriptive analysis approach (Braun & Clarke, 2014; Creswell & Poth, 2016; Thomas, 2006). These two faculty members then met to review initial themes before continuing a process of independent review followed by collaborative review until they were satisfied that the themes reflected the grouping of the students’ questions. The three main themes identified were: knowledge, perceptions, and relationships. Subthemes for each category were then defined and named.

Descriptive themes and subthemes

The three themes and between two and five subthemes for each are shown in Table 2.

Theme 1: Knowledge

Questions aimed at eliciting information about the pre-registration education and the professional role as well as the personal experiences of each profession were interpreted as seeking knowledge. The subthemes making up this theme were divided into whether the question demanded an objective reply grounded in the professional education (Subtheme 1) or professional role (Subtheme 2), or a subjective reply (Subthemes 3, 4 and 5); The questions contributing to the first two subthemes required factual answers that could be externally validated. Subthemes 3 and 4 described questions that related to the experiences of the ‘other’ profession as either a pre-registration student or in the professional role. The final subtheme, within this theme, related to individual student experiences of professional education and future professional role. There was no right or wrong answer in these situations and the questions seemed to imply a desire for a more personalised response (Table 3).

Theme 2: Perceptions

This theme included questions that asked each professional group to share their perception of the questioning student’s ‘own’ professional group. They could be divided into those that were open ended questions that were enquiring of a perception (Subtheme 1) and those that were more explicit in suggesting a possible prior perception (Subtheme 2). This second theme was categorised as perception, with subthemes organised around whether a possible perception was volunteered in the question or not. There was a difference between the type of question asked by each profession in this category with the word ‘annoying’ being used disproportionately by medical students - one question from a nursing student and eight from medical students (Table 4).

Some of these questions in this subtheme also explicitly referred to medical hierarchy. For example: “Do you find or perceive that medical students think they’re higher up on the hierarchy than nursing students?” (medical students). Similarly, nurses asked “Do you believe that there is a medical hierarchy and where do nurses sit on it?” (nursing students).

Theme 3: Relationships

The final theme included questions reflecting their shared identity as students and their position as students within the clinical environment (Subtheme 1) and where each professional group explored their role in making interprofessional relationships better (Subtheme 2) (Table 5).

DISCUSSION

One of the important outcomes of IPE is the socialisation of professions to each other (Bloomfield et al., 2021). The early socialisation of students to teamwork in health professional programmes is understood as having a positive contribution to collaboration within the workplace and the development of an interprofessional identity (Price et al., 2021). The students in this study were given the opportunity to ask anonymised questions of their professional colleagues during an initial socialisation experience that occurred prior to a planned interprofessional intervention.

The thematic analysis showed consistent themes over the three years of the study with the questions asked validating the purpose of IPE; students wanted to learn more about each profession and explore their relationship and shared experiences. The questions categorised under ‘knowledge’ (Theme 1) were questions focused on the education or professional role of their colleagues or were aimed at understanding their experiences of education or practice. Questions that focused on the education or professional roles received unambiguous answers, while questions which focused on their colleagues' experiences of education were less predictable. This could be interpreted as a genuine curiosity or desire to know more ‘about’ their colleagues ‘from’ their colleagues in both an objective and subjective sense. Despite the fact that IPE was noted to be originally suggested as a useful educational intervention for healthcare students over 50 years ago (Szasz, 1969), the questions that these pre-registration students asked, showed a significant lack of knowledge about both the education, and perhaps of more concern, the professional role of each profession. The reasons for this remain unclear; these were pre-registration students who are likely to have had some formal learning about the roles of each profession as well as some more informal learning from others within the work environment. They are also likely to have had their own experiential encounters with colleagues from other professions.

Theme 2, perceptions, suggested that students may already have developed a perception about how their own professional group was viewed. The intent behind some of the questions asked in Subtheme 1 would be interesting to explore further as questions such as, “What do you think nurses do?” may have implied a belief that some doctors did not value nurses as they should. The fact that some medical students are beginning their career with the belief that they will be portrayed as annoying (Subtheme 2) was more explicit. There is some evidence that professional groups have developed stereotypical views of other professions at early stages in their career (Khalili et al., 2014; Liaw et al., 2014; Sollami et al., 2015). The reasons for this are likely to be complex but may include individual life experiences as well as media influences in the portrayal of professional groups, which aligns with group socialisation theory. Group socialisation theory refers to the influence of peers on adult behaviour; there is a pattern of behaviour amongst primates, including humans, that instinctively recognises other humans as ‘us’ or ‘them’ (Sapolsky, 2017). This pattern of response can be stimulated by behaviour as simple as mirroring or reflecting body language to more complex identifying features such as an easily visible code for a group (for example, doctors’ white coats/nurses’ uniforms) (Shaw & Timmons, 2010; Timmons & East, 2011). Healthcare organisations and healthcare education systems need to recognise the potential impact of this on collaboration and teamwork (McKethan & Brammer, 2010; Weller et al., 2014). This reinforces the importance of these organisations working together to facilitate the development of an interprofessional identity with early socialisation amongst healthcare students (Price et al., 2021).

The questions that contributed to the theme ‘relationships’ (theme three) involved talking about shared experiences that were not necessarily occurring at the same time or in the same physical locality but which, nonetheless, implied a commonality between the students from different professions. This aligns with the concept of a community of practice, defined as a group of people who share a concern or a passion for something they do, and learn how to do it better as they interact regularly (Li et al., 2009; Wenger, 1998). Unfortunately, some of the questions asked within this theme validated the continued concern about incivility in healthcare with both medical and nursing students asking whether the charge nurse was ‘rude’ or ‘challenging’ and nursing students asking if medical students also ‘felt intimidated by older, more senior, doctors’. This information needs to be taken seriously. There were also questions asked by nursing students exploring the concept of hierarchy which is a term that has both a formal definition that refers to the relative status of ‘things’ or ‘people’ and an informal use in common language where it can be used as a derogatory term referring to perceived power. The use of non-hierarchical structured communication techniques, such as “this is a safety issue”, has been identified as an important interprofessional approach to promote patient safety (S. A. Reeves et al., 2017).

As the evidence for IPE increases, tertiary healthcare educational institutions must endeavour to collaborate and embed a sustainable evidenced-based IPE curricula (Darlow et al., 2017; McKinlay et al., 2020). If a phased curriculum model is utilised which enables developmental exposure to IPE, commencing in a non-clinical environment and concluding in the clinical workplace (Grace, 2021), providing a psychologically safe non-clinical environment is important. As well as the timing, it is necessary to reflect on the optimal nature of an IPE intervention (Lapkin et al., 2013; S. Reeves et al., 2013) and consider those that reduce persistence of inaccurate professional stereotypes (Liaw et al., 2014). In the questions categorised as ‘perception’ the construct was a ‘them’ and ‘us’ based on the professional role while the ‘relationship’ theme started to suggest that the students were conceptualising of themselves as ‘us’ with the already registered healthcare professionals as a ‘them’. The importance of individual socialisation in developing collaboration is well known (Khalili et al., 2013) and the concept of a community of practice can help different professions identify within the same group of healthcare providers to collaborate more effectively and to recognise the unique and overlapping roles of each profession in the delivery of healthcare. The practical implications of early socialisation and IPE present a potential for enhanced communication and reducing incivility, with its associated adverse effects, in the clinical setting.

Limitations

This work was part of an interprofessional patient safety session, and the students may have been primed by that context to ask questions of specific relevance to IPE. Secondly, a greater number of nursing participants could have been included if schedules were more compatible. Thirdly, it was a deliberate strategy for students to undertake this activity communally as a social informal ice-breaker. Some students may have arrived after the ice-breaker started, influencing the number of post-it questions collected. The data for this study was collected pre-COVID and may not capture changes in IPE due to COVID-19.

Implications for further research

It is recommended that further IPE research is necessary at the pre-registration level to facilitate health professional students to clarify unknown aspects of each profession. This exercise should also be repeated with a larger group of students from a wider group of professions. The use of focus groups and individual semi-structured interviews may also enable a deeper understanding of the root causes of the questions, particularly those in Theme 2 (perceptions).

CONCLUSION

In conclusion, this study revealed findings of a lack of understanding of both the professional role and pre-registration education of each discipline. In addition, pre-existing stereotypical views of each profession emerged from the pre-registration nursing and medical students participating. Both educational and professional organisations should be mindful of these knowledge gaps and potential biases and misunderstandings. Their curricula need to include explicit educational opportunities to help pre-registration students understand the roles of their professional colleagues. Laying the foundation for this collaborative interprofessional practice can maximise the understanding of how professions can work most effectively together. The significance of early IPE and socialisation is to enable the sustainable development of health professionals to work together outside of pre-conceived stereotypes and hierarchal barriers and maintain optimal levels of patients’ safety and staff wellbeing.

Acknowledgments

We would like to thank the following colleagues for their contribution to initial discussions as well as practically in the execution of the intervention; Christine Beasley, Julie Bowen-Withington, John Dean, Karen Edgecombe, Mary-Leigh Moore, Jo Saunders and Deb Sims.

Declaration of interest statement

None

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.