Chapter 1

Introduction

Health carers working in Malta are expected to work towards a patient-centred care and to communicate and collaborate in multidisciplinary teams even if they lack sufficient basic knowledge on the role of every team member. Sacco (2008) stated that there has to be effective team-working, communication and collaboration between professions for patients and their allied care to improve. He also stated that I.P.E. between the different professions is a way of attaining this team-work.

Much has been written over the past few years on inter-professional education (I.P.E.) and its effect on the health care system. A lot of research and promotion have been conducted. However, Lumague et al. (2006) still believes that professional programs are still not giving the appropriate importance of I.P.E. in their curricula. According to Sacco (2008), I.P.E. was never used by any of the professions related to medicine in Malta, as a way of learning.

Buttigieg stated (as cited in The Times of Malta, 2008) that “we still have a long way to go to be able to claim with confidence that interdisciplinary collaboration in teaching and research at our University is bearing the fruit that is becoming increasingly necessary in the world of today.”

Although the exercise was found to be very exhausting by the researcher, it was also an enriching experience and an introduction to the world of research. Provided that this was the author’s first attempt to research, the study has helped her develop a better understanding of the research process.

Chapter 2

Literature Review

2.1 The Current Healthcare System and the Present Situation at the FHS

Sacco (2008) stated that in the present healthcare system, patients are looked after by Multidisciplinary Teams comprising an extensive range of healthcare and other professionals. Apparently, the FHS board is not fully aware of the benefits of I.P.E. and although a lot of lip service is presented to working as a Multidisciplinary Team (MDT), not much is truly done to promote it throughout the actual education (Sacco, 2008). Sacco (2008) argues that in Malta, although the medical profession is part of the MDT, little or no integration is happening throughout the undergraduate years.

Furthermore, there has to be a clear distinction between ‘Common Core Learning’ and I.P.E. The terms should not be used interchangeably since they do not have the same meaning. Currently in Common Core study-units students are being taught together with other students from other divisions of the FHS, or other faculties within the University, which is the same as ‘multi-professional education’ as this involves learning the same content together side by side, which in turn should not be mistaken with I.P.E. (Sacco, 2008). The latter does not only comprise the subject matter, but it also involves the different roles of different professions and how professionals can work together towards a shared goal (Sacco, 2008).

Health education was somewhat inward-looking, however, owing to the altering health services, has changed from being ‘mono-professional’ to ‘multi-professional’, and then becoming ‘inter-professional’ (Sacco, 2008).

2.2 Background on I.P.E.

The need for immediate improvement of human resources was recently emphasized by the World Health Report 2006 produced by the World Health Organisation, according to which, the world is short of 4.3 million doctors, midwives, nurses and support workers. This crisis was also recognized by the 59th World Health Assembly (2006), who demanded upgrading of the health personnel production through various methods which included ‘‘innovative approaches to teaching in industrialised and developing countries”.  Furthermore, Gilbert (2005) pointed out that shortage of healthcarers in Canada were already reported in the Curtis Report, back in 1969, and the latter approved of : – considerations for replacing the training program with a more advanced one, empathetic patient care, and increased collaboration and management in delivering healthcare.

In addition to this, the requirement of numerous necessities of particular groups of facility users, the diversity of necessary service responses to these and the necessity for effective information exchange and discussion with regards to care planning and delivery, lead to the demand for cooperation between the health care professions and the social care professions, and health and welfare/ social care agencies (Towards Unity for Health, n.d.).

Robson and Kitchen, (2007), also emphasised the importance of an effective interprofessional collaboration in order to provide the best healthcare possible. The necessity of health and social care professions working together more was already highlighted for a number of years (Department of Health, 1989, 1998, 2000).  

The complexity of patient care is on the rise, thus effective cooperation between health and social care professionals is needed. However, evidence proposes that the latter two are not cooperating well with each other (Cochrane Review, 2002).

Collaboration still poses several problems especially with interprofessional coordination and communication. In a study carried out by Robson and Kitchen, (2007), students thought that communication and interprofessional relationships are the key factors affecting collaboration. I.P.E. has long been supported to be a solution to the challenges which collaboration presents (WHO, 1988; Department of Health, 2000). However, although it is evident that I.P.E. initiatives within universities have many beneficits, there were doubts to how successful the development of such initiatives could be (Oxley & Glover, 2002). The following are several problem issues that were identified by Brian O’Neill (as cited in Oxley & Glover, 2002):

Finding placements, particularly for team experiences

Differences amongst students with respect to knowledge they bring to the course, motivations for taking the course, and preferred learning styles

Evaluation of outcomes

Transferability of knowledge and skills to practice, and impact of interprofessional learning to practice.

2.3 Challenges to the Implementation of I.P.E.

Research suggests that it is very important for the professionals to have knowledge on how to work, communicate and collaborate effectively and cross boundaries between professions for a better health care system. According to the Council for the Professions Complementary to Medicine (2006), “Physiotherapists should communicate effectively with registered medical practitioners, other health professionals and relevant outside agencies to provide effective and efficient service to the patient” (p. 2).

Salvatori, Berry, and Eva (2007), reported that although barriers to implementing I.P.E. exist, the need to overcome them is critical if we are to keep pace with the changing healthcare system and better prepare health professional students for collaborative practice.

A preliminary survey of I.P.E. found that, there is a wide variability when the term ‘interprofessional’ is interpreted and that there are many barriers to I.P.E. some of which are overloaded curricula in schools of health professions, faculty and administration’s lack of support and also financial limitations (Rafter et al., 2006).

Not all of the above had been successful where endeavored. Oxley and Glover (2002) stated that in their own research some participants felt that they had not benefited from inter-disciplinary work as the course were “too theoretical”. On the other hand, most of the respondents felt that this work was successful owing to the inclusion of for example practical experience, work placements, and inter-professional projects.

2.4 What is the Best Time to Introduce I.P.E.?

The best time to introduce interprofessional learning in higher education still remains debated (Horsburgh, Lamdin, & Williamson, 2001). On the other hand, Yan, Gilbert, & Hoffman (2007) stated that it is the time to take a step forward to an I.P.E. and collaborative practice. 

Students themselves were found to be in favour of I.P.E. as early as possible that is in their first year of their course prior to the development of professional prejudice (Parsell, Spalding, & Bligh, 1998; Horsburgh, et al., 2001; Rudland & Mires, 2005) and stereotyping of other healthcare groups which may in turn have a negative impact on attitudes when it comes to collaborating interprofessionally (Hojat et al., 1997; Tunstall-Pedoe, Rink, & Hilton, 2003; Rudland & Mires, 2005). On the other hand, introducing I.P.E. early in the course may sometimes be useless when labeling has already been formed in the minds of those who are about to start the course. Rudland and Mires, (2005), reported that medical students start the course already knowing the main differences between the nurses’ and the doctors’ characteristics and backgrounds. For example medical students’ perception of the nurses is that they are more caring, have less social status, less competent and academically weaker than doctors.

According to Khalili & Orchard (2008) currently the way healthcare students are learning and socialized is via a uni-disciplinary model, which in turn may lead to in-group and out-group behavior (The Social Contact Theory).  Learning about the roles and responsibilities of just one’s profession leads to professional socialization which in turn might lead to professionals distrusting other professionals and forming myths of perceptions about them, thus professional socialization and lack of effective collaboration. Sacco (2008) stated that professional socialisation is more the training of medical students into developing as doctors and physiotherapy students into developing as physiotherapists, rather than preparing them to be able to become team members. Shared interprofessional learning may be a solution to this problem as professions come to appreciate roles and responsibilities of other professions. Thus, I.P.E. may be the key to more effective collaboration in the actual workplace. Furthermore, it would be ideal if knowledge, skills and attitudes would be passed on from the I.P.E. into the actual workplace, something that still has to be accomplished within Malta’s health services (Sacco, 2008).

Multiprofessional learning and education (now looked at as interprofessional) have been given great importance by the World Health Organisation (as being an important factor in primary health care) since 1978 in the Alma-Ata 1978 Primary Health Care Report and it was emphasized later in 1988, in their statement ‘Learning Together to Work Together for Health’.  This initiative was also supported in many countries by other legislative and policy requirements such as ‘Learning together to work together’ (Department of Health, 2000) in the UK and the Inter-professional Education for Collaborative Patient – Centred Practice Initiative, supported by Health Canada (Herbert, 2005).

2.5 Evidence Available to Support I.P.E.

Hammick, Freeth, Koppel, Reeves, & Barr (2007) states that there is limited evidence to support the proposal that learning together will aid practitioners and agencies to work better together. The effect of I.P.E. on the healthcarers’ work still needs to be re-examined since “there is no published evidence that I.P.E. promotes interprofessional collaboration or improves client relevant outcomes” (Zwarenstein et al., 2005). Campbell (2003) reported that most studies that he selected for his systematic review were deficient in their methodologic rigor. The review concluded that there was no convincing impact of I.P.E. in improving collaborative practice and/or health/well-being.

On the other hand, evidence that suggests that interprofessional learning improves interprofessional collaboration is also available (Atwal & Caldwell, 2002). Oxley and Glover (2002), maintain that there are benefits to I.P.E. for different stakeholders including employers, universities and students. For example the recruitment of a higher standard of graduate by employers will in turn have a positive reflection on the institute and its operators.

According to the Commission on the Future of Health Care in Canada (2002), “If health care providers are expected to work together and share expertise in a team environment, it makes sense that their education and training should prepare them for this type of working arrangement.”

Barr, et al. (2000) succinctly summarises the four main benefits I.P.E. can provide:

1. Enhances motivation to collaborate
2. Changes attitudes and perceptions
3. Cultivates interpersonal, group and organisational relations
4. Establishes common value and knowledge bases

Hammick et al. (2007) found that I.P.E. is generally liked, allowing knowledge and skills needed for to work in collaboration to be learnt. Furthermore, staff development is the main impact on the effectiveness of I.P.E. and can help learners bring out the unique values about themselves and others (Hammick et al., 2007). When it comes to initiatives with regard to quality improvement, I.P.E. is effective in improving practice and services (Hammick et al., 2007).

On the other hand, according to Zwarenstein et al. (2005), “there is no published evidence that I.P.E. promotes interprofessional collaboration or improves client relevant outcomes”. Thus, the need for more research on I.P.E. is needed.

2.6 Attitudes towards the Inter-Professional Teamwork and Education 

There was an amount of studies carried out to gain more information regarding attitudes of healthcare students towards interprofessional teamwork and education. Such students tend to show positive attitudes towards I.P.E. (Tunstall-Pedoe, et al., 2003; Pollard, Miers, & Gilchrist, 2004; Curran, Sharpe, Forristall & Flynn, 2008). In a research study conducted by Lumagae et al. (2006), when it comes to patient care, interprofessional teamwork was approved by all the participants who all agreed that opportunities comprising their development of skills, attitudes and behaviours required for interprofessional collaboration should be involved in their healthcare education. Salvatori et al. (2007) also stated that “It is clear that students enjoyed their experience and perceived new respect and understanding of other professional roles and the potential for interprofessional collaboration in caring for patients” (p. 80).

Most of such studies stated that there is a tendency that medical students and also postgraduate medical residents have significantly less positive attitudes towards interprofessional teamwork when compared to students from other healthcare professions (Hojat et al. 1997; Leipzig et al., 2002; Pollard et al. 2004; Tanaka & Yokode, 2005).

Attitudes of medical and nursing students towards interprofessional teamwork were studied and no significant difference was found between them two (Curran, et al., 2008). However, Curran et al. (2008) also found out that these two groups of students report significantly less positive attitudes towards interprofessional teams when compared to pharmacy and social work students.

Curran et al. (2008) also reported that medical students significantly showed less positive attitudes towards I.P.E. when compared to nursing, pharmacy and social work students. Being a female and/or a senior undergraduate also showed more positive attitudes towards interprofessional teamwork and education (the latter being more significant especially with prior experience with I.P.E.). In this study, profession, gender and year also seemed to play a role in determining positive attitudes towards both interprofessional teamwork and education.

On the other hand, Pollard et al. (2004) found that there were students who had viewed interprofessional collaboration negatively and they included mature students and those that had experience at university or of working in a health or social care settings. Curran et al. (2008), argues that although having previous experience in I.P.E. activities may not improve attitudes to it, participating in it may have more positive attitudes towards interprofessional teamwork.

2.7 Attitudes towards the Roles of their Own & other Professional Groups

Research has also tried to give answers with regard to student’s attitudes towards the roles of their own & other professions. Tunstall-Pedoe, Rink, and Hilton (2003), argue that the overall attitude of students studying medicine towards students from other professions was less positive. In a study carried out by Hojat et al. (1997), medical students were found to have different attitudes from nursing students with regard to areas of authorities and power, including professional dominance and medical responsibilities in serving patients’ needs. Furthermore, Spence and Weston, (1995) maintains that nurses were more clear in their perceptions of competencies essential for medicine, than medical students were about competencies important for nursing.   

It should be noted that literature review with regard to I.P.E. at the FHS was scarce and difficult to find. 

Chapter 3

Materials & Methodology

1 Introduction

This chapter describes the planning and development of the research study. It also explains the underlying rationale for deciding on the study’s structure.

3.2 Objectives of the Study

It is not really known whether students of the Faculty of Health Sciences (FHS) and the Faculty of Medicine and Surgery (FMS) agree to the implementation of a new I.P.E. system at the FHS.

The overall objective of the study was to understand whether students at the FHS and at the FMS know what I.P.E. is and to explore their opinions regarding the implementation or not of I.P.E. in the common curriculum at the FHS.

The goals of the study were to:

Explore the students’ understanding of the term I.P.E.

Identify whether the students agree or disagree to the implementation of I.P.E. and I.P.E. study-units at the FHS, and if they agree, the study-units or areas of study they would like to see becoming inter-professional and at what stage of their course to implement it.

Find out the students’ attitudes towards I.P.E. with regard to its benefits and challenges if any.

• Discover the students’ attitudes towards I.P.E. teams
• Discover the students’ attitudes towards other healthcare professions

3.3 Operational Definition of Terms

Table 1

Illustrating the operational definition of terms.

3.4 The Research Design

For the aims and objectives of the study to be addressed, the latter had to be descriptive, qualitative and thus, a non-experimental and explorative research design was considered to be the most suitable approach.

One-to-one interviews were preferred to group interviews since in the former more personal information about the participant could be elicited (Carter, Lubinsky, & Domholdt, 2011), the patient may feel more comfortable to speak in front of a person rather than in front of a group and thus giving more honest information especially when it comes to expressing his/her attitudes towards others. The interviews were carried out in-person, with the advantage of providing the best opportunity for building rapports and for observing the interviewees’ nonverbal cues (Carter, et al., 2011).

3.5 The Research Setting

This study was conducted in Malta with the permission of the University of Malta. The University has a number of Faculties two of which being the FHS and the FMS, from which students were chosen to participate. The courses which fall under these faculties and which were included in the study can be found in Appendix F, wherein the numbers of students present in each division is also given. The participants had a say in the choice of the research setting, and preferred meeting at places most familiar and within reach to them including University of Malta areas, Mater Dei Hospital and at certain pharmacies, which were also within reach by the researcher.

Carter, Lubinsky, and Domholdt (2011), suggest that the setting in which the research is carried out contributes greatly to an interview’s success. The interviewer made sure to choose a setting which is familiar and comfortable to the interviewee, with special attention given to the environmental setting such as quietness to avoid interruptions, adequate lighting, room temperature, and comfortable and appropriate set-up of chairs to avoid building psychological barriers.

Carter, Lubinsky, and Domholdt (2011), emphasized the importance of an appropriate introduction to an interview as this sets up the tone, affecting the rest of the interview. Furthermore, the researcher was aware of the body language at all times, keeping the appropriate distance, maintaining eye contact in line with cultural norms, showing interest and full awareness in what the interviewee was saying (by for example leaning forwards to him/her, nodding, smiling to funny comments that the subjects passed) and speaking clearly and at an adequate volume level. Attention was also given to choosing the appropriate type of clothing as in an interview the attire plays an important role.

At the end of each interview, the interviewer made sure to thank the participant for his/her contribution to the research study in order to show appreciation and to indirectly help promote and encourage participation in future research.

3.6 Target Population

In this study, the target population which is described as ‘’the entire population in which a researcher is interested and to which he or she would like to generalize the study result” (Polit and Beck, 2008, p. 767), included students from all the different divisions of the FHS and from the divisions of Pharmacy and Medical students which both fall under the FMS. When the researcher interviewed these students, the latter had already started their next scholastic year. The researcher staggered the interviews so as to gain more knowledge whilst completing the literature review and to be able to give the participants appropriate cues during the interviews. This helped the researcher to achieve better results because the cues given targeted the research question. A literature search of electronic databases including Ebsco, Cinahl and Pubmed was conducted between January 2009 and May 2011.

The inclusion criteria for this study were:

• All the students whose course fell under the FHS or the FMS.
• Male or female
• Willingness to participate in the study.
• English speaking
• Students over 18 years of age.

The study will be using undergraduate students’ opinions rather than post-graduate healthcarers’ opinions, as there is a lack of similar studies on the issue.

The exclusion criteria for this study were as follows:

• Students who never had any clinical experience.
• Students who did not fell under University of Malta
• Those who did not want to participate.

3.7 Sampling Size and Methods Used to Choose the Sample

Owing to time constraints, a method of convenience sampling was used to select a sample for the study, choosing easily accessible people who are in proximity to the researcher or who are willing to take part in the study (Castillo, 2009). This method is also the cheapest, simplest sampling form available and does not entail planning (Ellison, Barwick, & Farrant, 2010). This type of sampling offers a fast attainment of preliminary information with regard to the research question being studied and is also inexpensive (Berg, 2004; Castillo, 2009). Students who satisfied the criteria were recognized and 31 people were chosen including 12 males and 19 females whose ages ranged from 19 to 46. The following is a proportion showing the total number of medical students, is to the total number of pharmacy students is to the total number of students from the FHS, respectively: 426: 196: 823. One student per 90 students for each FHS division was interviewed in order to have a representable sample.

The researcher was aware that the selected subjects could not represent the entire population as to test the whole population it entails to interview an enormous amount of people and that would have taken an infinite amount of time to complete the study. The sampling was unrepresentative and did not offer statistical advantages (Ellison, et al., 2010).

The sampling size was mostly determined by the available time and resources. The researcher tried to find a balance between depth and breadth of the interviews. The in-depth information obtained from the research population provided rich and valuable data.

The researcher contacted subjects who satisfied the inclusion criteria of the study via e-mails or face-to-face, in order to set appointments for the interviews, and had to find a compromise between both her and the subjects’ availabilities. The researcher made sure that she would not disturb them.

The researcher used stratified sampling to make sure that a particular sample, from the known population under study, is denoted in the sample (Berg, 2004). Furthermore, the use of stratified sampling also helped the researcher to access small subgroups within the population, allowing the researcher to examine the extremes of the population (Castillo, 2009). This known population was divided into strata, chosen according to literature support, from which samples were selected. The researcher had information on the population and was able to divide it into strata, for which a sampling fraction had to be applied, which represent proportions of the whole population (Berg, 2004).

Qualitative research makes sure that informants are not manipulated in a certain way as would probably be typical in studies which are quantitative experimental, but, instead tries to access the informants’ viewpoints (Carter, et al., 2011). 

3.8 The Research Instrument

The interview guide had two parts, one of which included demographic data and the other part included fifteen open-ended questions. The latter produced the qualitative data.

The intention of establishing a rapport with the interviewees was to make them feel more comfortable. Friendly light conversations, the use of sense of humour, and common conventions for example talking about weather conditions and about the surrounding environment helped to ease any tension built by the research situation and to start building a warm rapport. Furthermore, the researcher made sure that the interviewees’ had a say in the setting of the interview by asking them their preferred place, to augment comfort of the participant (Carter, et al., 2011). Moreover, the researcher made sure that the location chosen offered the least interruptions not to prevent limitations in conducting the interviews. 

A self-preparatory semi-structured interview was the tool of the study (Appendix I). The clearest purpose of an interview is to collect information (Carter, et al., 2011). Questions were pre-designed prior to the interview and based on literature, yet, the format used in semi-structured interviews allows the researcher to elicit more information from the participant and to make questions more clear (Carter, et al., 2011).

Berg (2004), characterized semi-structured interviews as being relatively structured, as being flexible both in wording and order of the questions, as being able to allow adjustments in the language level, as allowing the interviewer to give answers to questions and to make some clarifications if needs be, and as allowing the interviewer to add/remove probes (according to subjects).

Carter, Lubinsky, and Domholdt (2011), pointed out that observation and interviewing skills were actually qualitative research methods seen regularly in clinical practice. As a physiotherapy student, the researcher was taught how to observe and assess patients thoroughly. This was an advantage to the researcher as she had already been gaining skills in observing and interviewing people prior to beginning the research study, thus, eliciting better and more reliable data. For example, being able to give relevant cues at the appropriate time during the interviews kept the interviews flowing. Carter, Lubinsky, and Domholdt (2011), stated that developing skills in interviewing when one is a student or a healthcare professional will transfer to a research study.

The researcher made sure to try to elicit as much information as possible from the interviewees without putting them in an uncomfortable position. The latter was avoided by not asking too much of the participants, by selecting the right probing and cues, by showing an attitude of healthy curiosity and care, and by not judging them and keeping in mind that others have their values and opinions too. Any non-verbal communication noted was written as fieldnotes during the interviews and added to the transcripts.

During the interviews the researcher followed a copy of the interview schedule in order to keep the interviewee on track and used probes to make it easier to elicit complete data from the interviewees (Berg, 2004). Probes were also used when the subjects used monosyllabic answers such as ‘yes’ or ‘no’. ‘Uncomfortable silence’ was also used as a sign that the researcher expected to obtain more information.

The interviewer also kept in mind to sound as natural as possible when asking questions and to remain neutral on the subject so as not to bias the participant by sharing personal judgments. Choosing facilitative techniques like providing utterances (for example ‘’uh-huh”), using ‘’reflection” by repeating some words of the interviewee’s utterance, ‘’confrontation” to point out certain physical evidence as the interviewee spoke (for example “I noticed you smiled when you told me that”), ‘’interpretation” (for example ‘’It sounds to me like you’re not happy about that situation”) were used to encourage the interviewees to continue (Carter, et al., 2011).

Goffman (as cited in Berg, 2004) noted that people do not only learn to send or receive messages during their growth but also they learn how to avoid particular types of them. Goffman called this avoidance ‘evasion tactics’. Berg, (2004) made it clear that although this has to be surmounted when conducting interviews, one has to be caref