3.5 Healthcare students’ attitudes towards and readiness for interprofessional
3.5.4 Differences between the healthcare professions
When it comes to explaining differences in attitudes about interprofessional learning and working among undergraduate healthcare students, ‘healthcare profession’ presented as an important variable for consideration. Whilst composite scores for an entire healthcare group of students comprising all the various professions often yielded high scores, individual scores from some professions are frequently significantly lower than other groups. This potentially renders IPE more difficult to execute, becoming more challenging to achieve IPE goals in the face of differences in positivity towards this educational strategy between participating disciplines (Horsburgh et al. 2001;
89
Tunstall-Pedoe et al. 2003; Pollard et al. 2004, 2005, 2006; Horsburgh et al. 2006; Coster et al. 2008; Curran et al. 2008; Rose et al. 2009; McFadyen et al. 2010; Curran
et al. 2010; Ryan 2010; Simin et al. 2010; Baker et al. 2011; Wilhelmsson et al. 2011). The majority of studies investigating attitudes towards and readiness for shared learning reported differences between healthcare groups before and after IPE. There are varying reasons put forward in the literature for differences. Earlier studies by Horsburgh et al.
(2001, 2006), revealed less enthusiasm for IPE among medical student than other professional disciplines. Horsburgh et al. (2006) argued this could have been a result of nursing students more inclined to think in collaborative terms, whilst medical students were more inclined to think in individualistic terms. However, other factors could be at play. Fallsberg and Hammar (2000) and Ponzer et al. (2004) found medical students to be more cynical about IPE, feeling that this strategy of learning was in conflict with their ambition to assume their physician roles. Concurring with these results, Morrison
et al. (2004) found more positive attitudes among nursing students than medical students observing medical students to be more protective over their own learning. Later studies conveyed similar findings. Coster et al. (2008) reported that readiness for interprofessional learning scores deteriorated among students during the first 3 years for all groups except nurses. The nursing students maintained positive attitudes to IPE throughout their course, and emerged as the most amenable group to change following IPE. In a vague attempt to explain this finding, Coster et al. (2008) argued that some healthcare professions are possibly just more susceptible to change following IPE than others. This view is corroborated among the findings by Judge et al. (2015) who also reported significantly improved RIPLS scores after IPE among the nursing group. Using a different validated scale to investigate attitudes to IPE, i.e., Attitudes towards
90
Interprofessional Health Care Teams Satisfaction Survey (Heinemann et al. 1999)21, Curran et al. (2010) conducted a longitudinal, time series study involving nursing, medicine pharmacy and social work students (n=1179). Students participated in IPE modules that were placed from first year through to the fourth year of their training. The medical group retained lower scores on attitudes towards IPE for each year, than all other disciplines. Nursing and medical students had lower scores than pharmacy at baseline in first year the study was conducted, but medicine and pharmacy were lower than nursing in by the second and third year. McFadyen et al. (2010) reported some differences to the aforementioned studies. They found occupational therapy and physiotherapy students became increasingly more positive to teamwork after IPE more so than nursing, radiography, podiatry, and prosthetics and orthotics. They argued that the differences in positivity between groups were due to different experiences encountered by clinical placements. In the study by Judge et al. (2015), pharmacy had higher RIPLS scores than both nursing and medicine before IPE. Scores were also higher among the dietetics group before IPE than medical students. Judge et al. (2015) suggested that the way disciplines are grouped and the nature of the IPE interventions were important considerations for successful IPE outcomes.
Whilst the aforementioned studies are useful in that they spotlight how some professions will maintain their positive attitudes to IPE after an IPE intervention and that others will deteriorate, they are somewhat limited in their ability to explain these differences and why they occur. There is a sense that stereotyped views could be at the root of the differences. Hence, there is value in scrutinising how the disciplines rate
21 This likert scale was developed based on the Readiness for Interprofessional Learning Scale (Parsell
91
some of the individual items on the RIPLS to glean more insight as to the root of the attitudes. A few studies reported such items. In line with much evidence mentioned from the geographical perspective, Rose et al. (2009) reported generally high RIPLS scores among students of medicine, nursing, occupational therapy and physiotherapy (n=474). However, scrutiny of two items on the RIPLS exposed a possibly stereotyped belief among medical students that ‘the function of nurses and therapists is mainly to provide support for doctors’ (item 17), and that medical students need ‘to acquire more knowledge and skills than other healthcare students’ (item 19). Similar results were later reported in studies by Wilhelmsson et al. (2011) and Keshtkaran et al. (2014). Rose et al. (2009) concluded by arguing for the educational system to support medical students in particular to learn more effective collaboration and communication with other healthcare professionals. Whilst, it is questionable how this recommendation could be best executed in practice, there would appear to be some logic to the suggestion since these stereotyped beliefs expressed by medical students resonated with additional literature investigating or discussing the origin and problem of stereotypes (Hall 2005; Hean et al. 2006a; Baldwin 2007; Nisbet et al. 2008; Bradley et al. 2009; Ryan et al. 2010; Ajjawi et al. 2009).
It appears that cultural differences could sometimes explain differences in attitudes between professions to IPE. The Iranian cross sectional study by Keshtkaran et al.
(2014) highlighted how cultural differences could play a part in how professions view IPE and IPW. As with aforementioned studies, this study also revealed significantly lower RIPLS scores from medical students than either nursing or science in surgical technology students. There was very wide disparity in the mean RIPLS scores between nursing and medicine. Nursing presented with exceptionally high mean scores of 93.68
92
out of a total scale score of 95, whereas medical students' total mean score was comparably low at 63.30. The medical group also produced lower scores on the first RIPLS subscale ‘teamwork and collaboration’ than the other groups. As regards the individual subscale item 19, they felt they needed to acquire more knowledge than the other groups. Factors relating to Iranian culture could play a role in these results. In Iran medical students have the authority to provide medical treatment to patient/clients and refer patient/clients to other disciplines for aspects of care. Perhaps these lower readiness scores were a result of perceived authority over other professions resulting from these greater responsibilities. Furthermore, the authors pointed out that whilst nurses are considered a vital component of the IPW team, they are viewed as dependent upon the medical profession in Iran (Keshtkaran et al. 2014).
Some very recent studies corroborate the earlier data reporting higher RIPLS scores among nursing students, and nursing scoring higher on the teamwork and collaboration RIPLS subscale than medicine, thus indicating greater appreciation for IPE and IPW (Talwalkar et al. 2016; Wong et al. 2016). To revert back to the potential of cultural differences playing a part in attitudinal differences towards IPE, the later Asian study conducted by Ahmad et al. (2013) was incongruent with these previous findings. They found that while composite RIPLS scores revealed much enthusiasm for IPE, first year medical students were the group with the highest RIPLS scores, more so than nursing, pharmacy and dentistry students. The pharmacy and dentistry students also seemed to consider IPW less important than the nursing and medical students. The researchers argued this could have a basis in the popular belief or stereotype that nurses and doctors are the most critical professions on the team. However, this study did not explore
93
stereotyped attitudes among the sample with a view to correlating them with readiness for IPE scores, so this argument cannot be supported with any degree of certainty.
3.5.5 Summary
This evidence generally depicts high readiness to learn interprofessionally among undergraduate healthcare students on course commencement, at least in the absence of IPE. However, there is evidence demonstrating that readiness for IPE can diminish over time, often after an IPE intervention. The value of some IPE programmes must be called into question if they yield little improvement in attitudes, spotlight deteriorating positivity, or result in reinforced original negative attitudes. However, some researchers argue deteriorating attitudes result from an original naive idealistic and/or unrealistic expectation of what IPE can offer, or indicate greater realisation among students of the immense barriers to IPE. As with the aforementioned themes, these studies demonstrated that some healthcare professions have more positive attitudes towards IPE and IPW than others. The reasons for these differences vary and are not entirely conclusive in the literature.
The remaining two sections of this literature review provide further insights into attitudes towards IPE, considering potential influences of learner characteristics and socio-environmental experiences, and reporting correlations between professional identity, professional stereotyping, and readiness for interprofessional learning.
94