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.

Term

Definition

FHS

This is the Faculty of Health Sciences at the University of Malta

IHC

This is the Institute of Health Care presently known as Faculty of Health Sciences

FMS

This is the Faculty of Health Sciences at the University of Malta

I.P.E.

“Inter-Professional Education occurs when one or more professions learn with, from and about each other to improve collaboration and the quality of care'' (Centre For The Advancement of Interprofessional Education, 2002, Defining I.P.E.)

MDT

“Multidisciplinary is used to describe, for example, types of teams or education and indicates that people from different disciplines are involved in the given activity. It is a term often confused with multiprofessional despite the clear difference between these two descriptors. Multidisciplinary health professionals represent different health and social care professions - they may work closely with one another, but may not necessarily interact, collaborate or communicate effectively” (Atwal & Caldwell, 2006).

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 careful not to endanger the evolving situation meaning and relationship with the subject or the subject's extent of falsification and sheen which a participant may feel to use whilst being interviewed. Thus, the researcher had to face the challenge of being really careful not to overtly violate social norms linked to communication exchanges and to avoid putting the subjects into situations in which they have to lie (Berg, 2004).

Furthermore, leading questions were avoided to avoid bias. ‘'Why'' questions were used carefully due to possibility of being seen as threatening or challenging (Carter, et al., 2011), but being able to establish a good rapport with the interviewees helped to elicit a lot of vital information from these questions. The participants were allowed to speak freely and the researcher made sure not to interrupt them with her thoughts or questions to keep them focused on what they wanted to say.

All the interviews were carried out in English, but with the odd Maltese expression being used frequently, since the interviewees being students of the University of Malta, were all fluent in English.

Both the participant and the interviewer gain from an interview as the latter can be exceptionally rewarding and also interesting situation (Berg, 2004). In fact, most interviews raised so many interesting points that even after they were finished, the interviewer and the participant still continued to discuss the points raised, and were both oblivious to the time passed. The interviews took an average of 30 minutes. Berg (2004), made it clear that not all subjects took the same amount of time to conduct the interviews.

On the other hand, interviewing carries with it a number of drawbacks. It is a time consuming, data-collecting technique yet valuable (Berg, 2004).  

3.9 Validity and Reliability

Validity relates to “the extent to which the researcher measures what it purports to measure without bias or distortion'' (Gerrish and Lacey, 2006, p.28). To improve validity of this research study, the researcher concentrated on face and content validity. The researcher applied face validity by for example reading relevant literature in order to formulate the research instrument that is the interview schedule.

According to Polit and Beck, (2008), the term reliability means ‘'the degree of consistency or dependability with which an instrument measures an attribute'' (p. 764). Pilot work improved reliability as it helped to pinpoint problems that could have arose in the actual study. Careful listening to the recordings for a number of times and writing exact transcriptions also enhanced the reliability and validity of the study.

3.10 Ethical Considerations

Prior to commencement of the study, permission was given by the Faculty Research Ethics Committee and the University Research Ethics Committee (Appendix A), the Registar (Appendix B), the Director of the FHS (Appendix C), the Dean of the FMS (Appendix D) and the co-ordinator of the Physiotherapy Division (Appendix E).

Speziale, Streubert & Carpenter (2010), believed that participants should be treated with dignity and also respect. Prior to each interview each participant together with the researcher went through a self-prepared informed consent form (Appendix G) and a verbal explanation was given to the interviewees. The informed consent form was a necessary ethical obligation. Informed consent involves the participants' full awareness of the dangers and benefits of their participation in the research study (Broussard, 2006). Thus, consent was obtained and signed by all those that the researcher interviewed.

The researcher made sure to share information about the research with the participants, specifying the purposes of the research to the interviewees. Furthermore, the latter were told that there participation was voluntary and that they had the right to refuse participation and thus they were given the freedom to choose whether to participate or not. They were also informed that they can chose to stop the interview at any time, without penalty, so as to respect their rights. The researcher also stated that all the information that the participants kindly chose to provide will not be used for any other purpose, will be strictly confidential and that they will remain anonymous, even when excerpts are used. The participants were informed about the digital recording to record all the verbal data and were reassured that the digital recorded interviews were to be kept confidential and to be erased in front of the supervisor after completion of the study. The interviewer made sure to tell all participants that the interviews were going to be transcribed. The researcher made sure to prevent breaching of confidentiality, which according to (Carter, et al., 2011) is the participant's primary risk when conducting research via interviews. Furthermore, the participants were given the name, address, mobile and home number, and email address of the researcher, for any queries that they could have had, even after the study has started. Beneficience and non-malificience were also given importance at all times.

3.11 The Pilot Study and Modifications

A few days to the actual data collection, a small-scale pilot study was carried out in order for it to highlight any potential problems that the researcher might end up facing in the study for example misinterpretations in the wording of the interview schedule and problems with the recording equipment. A copy of the former interview schedule (that is the one used for the first pilot study) is provided in Appendix H.

The researcher chose a person who was very good in English language so as to correct any ambiguities in the questions that were to be asked during the interviews. Then, a student was chosen from the relevant population. The student did not form part in the main study. The second session gained the researcher some interview-training. Furthermore, the researcher took the opportunity to use the digital recorder to train using it and for self-evaluation.

3.12 The Methods of Data Analysis

Demographic data were represented in raw figures as the numbers were too small for any statistical tests. Volumes of data were collected and stored in an organized manner on a personal laptop, so as to be easily retrieved. A verbatim transcription was carried out in preparation for data analysis. This was done shortly after each interview by the researcher herself, in order for the interviews to still be fresh in the interviewer's mind, thus there was more chance of obtaining more precise information, decreasing bias. Then, the recordings were listened to carefully several times so that qualitative data could be analysed. In order to extract themes from the data obtained, a manual thematic analysis was carried out, and the subsequent main themes were organized into categories yet, without identifying the actual respondent to ensure anonymity. Colour coded markings were used to organise data and themes were extracted, reread and revised, and the excerpts put in a copybook. Relevant segments were extracted from the data collected as guided by numerous research authors. Lastly, the researcher elicited theoretical conclusions regarding the context. The researcher mainly followed Polit and Beck (2008) to analyse the data.

3.13 Conclusion

This chapter gave details on how the study was carried out. The following chapter presents a discussion of the findings elicited from the conducted interviews.

Chapter 4

Findings & Discussion

4.1 Introduction

This chapter discusses the results derived from the interviews with regard to I.P.E. Demographic data, categories, themes and sub-themes are included, together with a discussion of the categories. The use of direct quotations from the respondents was used to enrich the findings. Tables and graphs were also appropriate for this study and thus included. 

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 possible implementation or not of I.P.E. in the common curriculum at the FHS.

4.2Demographic Data

Figure 1: Gender of research population

In Figure 1, one can see that from 31 participants chosen by convenience sampling, the majority being females, (n=12) were males and (n=19) were females, (n=number).

Figure 2: Gender, Age, & Year of Medical Students

In figure 2, the number of participants by gender of the respondents is demonstrated. Age varied between 22 years and 23 years, with a mean age of 22.4 years.

Figure 3: Gender, Age, & Year of Pharmacy Students

Figure 3 shows the number of participants by gender of the respondents. Age varied between 22 years and 24 years, with a mean age of 22.6 years.

Table 2

Gender & Year of Students from the FHS

Number of Participants/ Year of course

Division

Number of Males

Year of course

Number of Females

Year of course

B.Sc. (Hons) Applied Biomedical Science

1

2nd

B.Sc. (Hons) Community Midwifery and Community Nursing

1

2nd

B.Sc. (Hons) Communication Therapy

1

3rd

Diploma in Health Science Dental Technology

1

4th

Preparatory Course for Diploma in Health Science Environmental Health/ Diploma in Health Science Environmental Health

1

2nd (Diploma)

B.Sc. (Hons) Health Science

1

2nd

B.Sc. Midwifery

1

4th

B.Sc. Mental Health Nursing

1

Preparatory Course for Diploma in Health Science Nursing Studies/ Diploma in Health Science Nursing Studies

1

3rd (Diploma)

B.Sc. (Hons) Nursing

1

4th

2

4th

B.Sc. (Hons) Occupational Therapy

1

4th

B.Sc. (Hons) Physiotherapy

1

4th

B.Sc. (Hons) Podiatry

1

3rd

B.Sc. (Hons) Radiography

1

4th

Total number of males/ females

5

11

Table 2 includes all the different courses currently present at the FHS from which participants were chosen to take part in the study. The table includes the participants' gender and year of course.

Figure 4: Gender, Age, & Year of Students from the Faculty of Health Sciences

In the figure 4, the number of participants by gender of the respondents is demonstrated. Age varied between 19 years and 46 years, with a mean age of 24.5.

4.3 Qualitative Findings: Themes and Categories

Face to face interviews were used to elicit the following data. The interviews were conducted at different places - Mater Dei Hospital, University of Malta, and a local pharmacy. From the interviews, the students' knowledge with regard to I.P.E., together with the rationale of their opinions relating to the implementation or not of I.P.E. in the common curriculum at the FHS, was discovered. Five categories came out from this study and they were supported by different themes and subthemes. This chapter discusses the findings in depth and contain direct quotations in English which were extracted from the interviews' transcripts. The subjects' quotations were identified by a code, known only by the researcher. The code comprised a randomly chosen number and the year of study, for example (P10, 2010) is equivalent to the 10th participant.

Five main categories were extracted from the interviews. A set of major themes was identified, each broken down into sub-themes wherever relevant.  Figure 5, is a summary, in the form of a list, of the categories that were identified from the study and are going to be discussed in more depth.

Figure 5: Categories, Themes & Subthemes.

Category 1: Different levels of awareness and understanding of what I.P.E. is

  • Theme 1.1 - I.P.E. meaning collaboration & communication
  • Subtheme 1.1.1 - Amongst healthcare professionals
  • Subtheme 1.1.2 - Amongst students
  • Theme   1.2 - I.P.E. meaning knowing the roles of other healthcare professions

Category 2: Current situation at the FHS

  • Theme 2.1 - Are students prepared to work in a MDT?
  • Subtheme 2.1.1 - Common core subjects do not teach students the role of other healthcare professionals
  • Subtheme 2.1.2 - Lectures given to students by different healthcare professionals
  • Subtheme 2.1.3 - Students are not taught how to work in a team, but expected to do so in the workplace
  • Subtheme 2.1.4 - No I.P.E. learning in Malta as opposed to abroad
  • Subtheme 2.1.5 - Students are aware that every healthcare profession has areas in which no other profession can interfere
  • Theme 2.2 - The workplace
  • Subtheme 2.2.1 - Little communication between healthcare professionals
  • Subtheme 2.2.2 - Healthcarers are unaware of the existence of certain professions
  • Subtheme 2.2.3 - Healthcarers making inaccurate referrals
  • Subtheme 2.2.4 - Hierarchical system
  • Subtheme 2.2.5 - Healthcare professionals threatened by overlapping roles
  • Subtheme 2.2.6 - Certain healthcare professions are limited to how much they can collaborate with other people

Category 3: Benefits of I.P.E. if implemented at the FHS and the FMS

  • Theme 3.1 - Patient
  • Subtheme 3.1.1 - Holistic care
  • Subtheme 3.1.2 - Efficient service
  • Subtheme 3.1.3 - Facilitating the referring of patients to the right healthcare professional
  • Subtheme 3.1.4 - Decreased patient confusion
  • Subtheme 3.1.5 - Pleasant atmosphere in which to be treated
  • Subtheme 3.1.6 - Opening possibilities for patients
  • Theme 3.2 - Students and Healthcarers
  • Subtheme 3.2.1 - Gaining and sharing of knowledge/ experiences
  • Subtheme 3.2.2 - Lower risk of making mistakes
  • Subtheme 3.2.3 - Increased job satisfaction
  • Subtheme 3.2.4 - Healthcare professionals filling in for each other
  • Subtheme 3.2.5 - Stronger relationships with colleagues
  • Subtheme 3.2.6 - Understanding, appreciating, tolerating and respecting other healthcare professionals
  • Subtheme 3.2.7 - Learning the roles of different professions
  • Subtheme 3.2.8 - Pleasant atmosphere to work in
  • Subtheme 3.2.9 - Improve communication, collaboration & team building within the MDT
  • Subtheme 3.2.10 - I.P.E. prepares students for work
  • Subtheme 3.2.11 - Learning when to refer to other healthcarers & for what
  • Subtheme 3.2.12 - Friends from other healthcare courses will eventually become your colleagues
  • Subtheme 3.2.13 - Getting to know other students
  • Subtheme 3.2.14 - Change in attitudes
  • Subtheme 3.2.15 - Decreased workload, more productive work
  • Theme 3.3 - Healthcare System
  • Subtheme 3.3.1 - Good reviews
  • Subtheme 3.3.2 - Less complaints
  • Subtheme 3.3.3 - Financial benefits

Category 4: Challenges of I.P.E. if implemented at the FHS

  • Theme 4.1 - Attitudes of professions towards other professions
  • Subtheme 4.1.1 - Qualifications
  • Subtheme 4.1.2 - Uniforms
  • Subtheme 4.1.3 - Students/ professions not wanting to mingle with others
  • Subtheme 4.1.4 - Individual students dominating the I.P.E. team
  • Subtheme 4.1.5 - Professions dominating the I.P.E. team
  • Subtheme 4.1.6 - Pride and haughtiness of professions
  • Theme 4.2 - Attitudes of students towards I.P.E
  • Subtheme 4.2.1 - Pressed for time and therefore not wanting anything extra
  • Subtheme 4.2.2 - Reluctancy to change
  • Theme 4.3 - The Learning System
  • Subtheme 4.3.1 - Different professions, different course structure
  • Subtheme 4.3.2 - Difficulty in co-ordinating the great number of students
  • Subtheme 4.3.3 - Some professions would be outnumbered by other professions
  • Subtheme 4.3.4 - Administration
  • Subtheme 4.3.5 - Costs

Category 5: Recommendations/ Suggestions

  • Theme 5.1 - Stages of implementation of I.P.E.
  • Subtheme 5.1.1 - I.P.E. from the beginning of the course
  • Subtheme 5.1.2 - I.P.E. not from the beginning of the course
  • Theme 5.2 - The need of a leader in the I.P.E. team
  • Theme 5.3 - The I.P.E. team should be a product of collaboration rather than led by one profession
  • Subtheme 5.3.1 - Coordinated by higher administrations
  • Subtheme 5.3.2 - No profession knows it all
  • Subtheme 5.3.3 -Avoiding domination and bias by one profession
  • Subtheme 5.3.4 -Each profession has its own importance
  • Theme 5.4 - Modification of course structure
  • Subtheme 5.4.1 - I.P.E. study-units replacing credits which are not very important
  • Subtheme 5.4.2 - The implementation should not be seen as something extra
  • Subtheme 5.4.3 - I.P.E. becoming compulsory
  • Theme 5.5 - Meeting the needs of all the students from different healthcare professions
  • Subtheme 5.5.1 - The need for further research
  • Subtheme 5.5.2 - The need of a specialised course
  • Theme 5.6 - Further suggestions on the implementation of I.P.E.
  • Subtheme 5.6.1 - Study-units or areas of study which students would like to see becoming inter-professional
  • Subtheme 5.6.2 - Practising how to work in a team
  • Subtheme 5.6.3 - Being able to collaborate with every healthcare professional
  • Subtheme 5.6.4 - Home visits, conferences, meetings
  • Subtheme 5.6.5 - Enforcing communication
  • Subtheme 5.6.6 - Learning the roles of one another
  • Subtheme 5.6.7 - Promoting I.P.E.

4.3.1 Category 1:

Different levels of awareness and understanding of what I.P.E. is. 52% (n=16) of the students were not familiar with the term I.P.E.  The level of understanding of the rest of the participants was collected in category 1: Different levels of awareness and understanding of what I.P.E. is. This category generated two themes, the first one being I.P.E. meaning collaboration and communication which in turn yielded two subcategories: Amongst Healthcare Professionals and Amongst Students, and the second one being I.P.E. meaning knowing the roles of other healthcare professions.

It was made clear that there is unfamiliarity with the term I.P.E. amongst students at both the FHS and at the FMS, “It's not very clear what it exactly is” (P23, 2010). However, some important points with regard to I.P.E. meaning were mentioned including that it involved communication between healthcare professionals, “I think it's more the communication between the team itself, about the disciplinary team” (P14, 2010).

I.P.E. was also perceived as the collaboration between healthcare professionals at work to provide a better service,“I'm not familiar to it but from the name I assume it's collaboration between different disciplines of different professions” (P26, 2010).

“Aaa it's aaa people that are different, different professions but in the same bigger group so to speak working together, for example in the same of healthcare you have different professions as well- doctors, nurses, physiotherapists and they all work together to basically buy the better service.” (P9, 2010)

Others had this idea that I.P.E. was more of a relationship between different healthcare professionals wherein they interact and learn from each other, “Emm yes we have some modules where we mention it in pharmacy. It's basically emm the relationship between different healthcare professionals and their interactions, what they can learn from each other etc” (P18, 2010).

The participants suggested that it had something to do with the MDT, “I know it might have something to do with multidisciplinary team but I mean that's it” (P1, 2010).

I.P.E. was also described as a tool with the aim of “Learning together to work together”(P23, 2010), to help ease the transition of healthcare students from the studying period to the world of working as healthcare professionals - “...learning with other students from other professions, to work together when we graduate” (P2, 2010).

Learning the roles of others was also suggested to be a meaning to I.P.E.:

“Well in a few words, it would mean that you learn what other, some of your colleague professions are all about, so if I'm in Occupational Therapy, I would learn what the nurses job is, what the physios do, what the speech language pathologists do, and everybody else I guess” (P8, 2010).

Some common core subjects were perceived as I.P.E.:

“Emm I think that it means that there will be like lectures or seminars or emm other things of educational matters not only between your course but with other professions, example us midwifes we have emm some lectures in the first three years with the nurses and some core credits like physiology or pharmacology with the whole emm professions in the Faculty of Health Sciences” (P16, 2010).

“What I know emm is regarding emm Inter-Professional relationships being in healthcare is is the collaboration that I see at the Institutions like hospitals so as such that's all I know about how they work together. Emm but about education perse not really...” (P19, 2010).

4.3.2 Category 2:

Current Situation at the FHS. As opposed to many countries abroad, I.P.E. is still not a method of learning in Malta and is not being given importance,

“Inter-Professional learning is not given is not being given enough importance, emm right now. Yes, of course, I think there is much more one can do emm for example when I was in England emm different professions used to have different lectures and they sort of used to be given a sort of problem solving em question and they used to resolve it altogether so that they can actually interact together...”(P11, 2010).

The students' only exposure to what other professions entailed were lectures given by professionals from other healthcare professions. The participants suggested that these lectures were very useful.

“The only similar thing we had was when we were doing psychiatry...and there was the psychiatrist, there was a nurse, there was I think a speech therapist, an occupational therapist, it was just a lecture and they all taught us about what they would do and how would they help us”(P28, 2010).

Furthermore, the outcome of this research indicated that common core subjects are not teaching healthcare students the role of other healthcare professionals, which in turn has an effect when it comes to referring patients to other healthcare professionals:

“I share classes with emm BSc. Nursing students. We didn't learn about each other's profession or where the limits of one end or begin or how we could help each other for example in clinical practice” (P3, 2010).

“A lot of times we hear the phrase, ‘Refer to physio or for OT' concept, but we don't really know I think what the physio does and what the other professions actually have to offer... We should be told more about it during our teaching.”(P13, 2010)

“...we know where our limitations are but we don't know where the other health care students or professions could help us out, and that's really really important. One example I can give you which I've been reading about is management of pain. So, management of pain, I know... quite a bit about management of pain with drugs but I didn't know how much a physiotherapist could help with management of pain until I spoke to a physiotherapist who told me about it and then about nursing practices that can help with alleviation of pain. And so it's, in the case of pain for example, it cannot work without an an interdisciplinary approach, and although we are expected to have an interdisciplinary approach in practice we're not taught that at university or in our colleges, so, we have no idea how to make that happen when it actually comes to the real case.”(P3, 2010)

The healthcare students pointed out the fact that they are not being taught on how to work in a team, but then, they are expected to do so in the workplace, “I don't think it makes sense to study on your own and do everything on your own and then when you graduate you are forced to work with other people because of the multidisciplinary team” (P23, 2010).

In the workplace, most healthcare professionals refer patients to other healthcare professionals. The doctor is usually the professional who has the most say in referring patients to other services. Apparently, the problem is that not even doctors themselves know what other disciplines might offer - “...sometimes you'd be amazed, we as doctors don't know what other disciplines offer...” (P26, 2010).

Having said all this, the interviewees were aware that every profession has its limits and that although there is overlapping of roles, everyone has its place in healthcare:

“I know that the value for example in my case a pharmacist it cannot be taken over by anyone else... I don't feel insecure about pharmacy technicians for example because they are doing something I am doing something else and we can help each other have a more efficient process and at the same time I know for example I cannot do a physiotherapist's job, a physiotherapist cannot do my job, there is a place for everyone and everyone has a lot of knowledge which is overlapping a bit but just a bit so it's I I think everyone has a place basically”(P3, 2010).

On the other hand, the participants mentioned that there seems to be healthcare professionals who feel threatened by overlapping of roles. It seems that the boundaries of healthcare professions are not clear, which in turn might be producing some conflicts amongst healthcarers.

“...let's say I'm a nurse, if somebody let's say a physio sees a skin condition or a bed sore and he goes and asks for the nurse to have an opinion or something like that, the nurse would say it's my job, it's not your job... The old school individuals, colleagues, sometimes they say ‘That's my job only, it is my job, do your job, do your business, you know?'”(P22, 2010).

The lack of knowledge with regard to other professions was also pointed out in the interviews, which in turn, might be a reason for inaccurate referrals.

“From fromemm my profession's stand point, from an occupational therapy stand point, the problem lies with other professions not knowing enough about us, so we normally end up being shadowed by other, sort of professions, especially by people who should know more such as the consultants, the doctors and it would also mean if if people were more informed that our referrals would be more structured in the sense that people would know why they're referring to an occupational therapy and not a speech therapy therapist for example or not the physiotherapist''(P8, 2010).

Little communication between healthcare professionals from different professions, could also contribute to further unfamiliarity with the latter and as a result, mistakes in the workplace.

“Between doctors, the medicine area with the biomedical science because they need to in the end there's the post-analytical phase where the biomedical scientists need to emm produce the report of that particular patient but there are some instances where the doctor emmmisinterpretes the report so that's an example basically, so there must be more communication. Sometimes even the reports are emm led to different, to the wrong doctor, so their need to be more communication”(P5, 2010).

The fact that certain professions have limited collaboration with other professions or even with the patients, such as the Applied Biomedical Science course and the Health Science Environmental Health course, results in this being more difficult to understand what other professions do.

“... radiographers... they have a lot of theory and not so much patient contact for example nursing students, midwifery students, physiotherapy students I meet a lot on the wards, but radiotherapy students they're very much limited to like wherever there's there are radiographers needed and they don't have time to interact so maybe those would I don't know... Cause of the way their course is structured...”(P9, 2010).

4.3.3 Category 3:

Benefits of I.P.E. if implemented at the FHS and at the FMS. All the participants managed to come up with several benefits of I.P.E. if it were to be implemented at the FHS and at the FMS. Beneficiaries of I.P.E. include the patients, the healthcare professionals and the healthcare system. Unanimously all the participants agreed that the patient was the ultimate beneficiary due to the improved quality of care - “...the quality of care that is provided to the patient it's enhanced, the care would be much better given to the patient”(P14, 2010).

The participants expected that with I.P.E., a more holistic approach towards the patients' needs would be implemented in the workplace. “You'll look in the patient the holistic way, so you'll identify all problems the patient has, not just diseases or pathology but even psychiatric...”(P6, 2010).

The interviewees also agreed that I.P.E. would affect the service provided to the patient in the workplace. The patients would gain “time efficiency” (P26, 2010). Furthermore, subjects mentioned that patients “will have a better idea of what's going on” (P8, 2010) and would not get confused since they would know that they are being treated by a team rather than a single profession, trusting more in each and every healthcare professional.

Participants also commented that the patients would also benefit from the fact that different professionals would have knowledge of other professionals' roles. This would in turn provide a more efficient service since patients would be directed in the right direction and would have further possibilities.

“I don't know what are the capabilities of a physiotherapist, I I know some of them, I don't know all of them, so I I don't feel I can I can go to a physiotherapist in clinical practice and say ab- I don't know what I can ask the physiotherapist about. But I 'd like to know because I'd like to open possibilities for patients” (P3, 2010).

It was agreed that having better relationships between healthcarers would make the atmosphere in which the patient is treated more pleasant - “I think the fact that there is a good relationship between the healthcare professionals is a good sign. I mean it's a pleasant atmosphere for the patient”(P18, 2010).

According to the participants, patients would not be the only ones who would enjoy a pleasant atmosphere. I.P.E. would help students to get to know more people from the healthcare setting, to be more prepared for work, and to change attitudes towards other professions. With I.P.E., chances are that those involved would gain and share knowledge and experiences with other professions, thus learn the roles of others and hopefully understand, respect, appreciate and tolerate other professions.

“getting to know each other emm will make the atmosphere of the workplace better... it makes the work more fun...”(P4, 2010).

“... first of all you get to know other students, so I think that's the most basic benefit of such sessions...” (P11, 2010).

“... when we graduate we have to face these people, the other professionals and work with them so as we can provide this care to the patient” (P4, 2010).

“You'll learn much more from experiences of one another, maybe, and sharing of knowledge, sharing of experiences...” (P29, 2010).

“It could help us learn more about other professions... and how they care for the patient from their side...” (P7, 2010).

“I think that understanding what the other professionals do, helps to foster respect between the professionals...” (P7, 2010).

“... you'd understand each other more, you'd be working more together and so you would actually I think, see the work of other professions and be able to appreciate it” (P13, 2010).

“... I believe that I.P.E. will eventually make students listen to each other's opinion...” (P4, 2010).

This is reflected in the words of Sacco (2008), who stated that sharing such learning experiences would help the people forming the team to appreciate each other's roles.

Interviewees agreed that friendships will be built during I.P.E and that these would also transfer to stronger relationships at work with colleagues - “If you have a good relationship as students I think it would transfer also once you're working as a professional”(P9, 2010).

All this would improve “the mode of collaboration” (P5, 2010), collaboration and team building which might in turn increase job satisfaction, decrease the risk of healthcarers making mistakes - “less errors” (P5, 2010), decrease the workload and increase productive work. The possibility of professionals filling in for others was also mentioned.

“If you know someone's character well, it would be easier to talk and maybe to ask as well and get feedback” (P24, 2010).

“...when a lot of people are working on a thing together, pulling one robe, the work load is even less, at work”(P26, 2010).

“I think everyone will benefit the most because finally you're an adult you get some satisfaction from it and I think everyone will get some satisfaction if they see that as a team they are being successful” (P3, 2010).

“...when people are happy and comfortable with each other, I think the output is much better, I think”(P26, 2010).

“... any things that maybe happening to the patient which might not have been noticed, if there is a good I.P.E. I things they would come to the attention of the healthcare professionals... there's higher chance of these problems being solved...” (P18, 2010).

“The working relationship should be stronger because you're building a bond with each other... and when you're working towards the same aim, hopefully you should... end up with a stronger relationship...”(P8, 2010).

The participants stated that I.P.E. would also help professions learn when and what to refer to in the workplace - “... I think what you actually learn out of the I.P.E is when to refer patients and for what. To know what services are available for that patient”(P7, 2010).

All this would reflect well on the health system as a whole, in that it would get “good reviews” (P1, 2010), “less complaints” (P10, 2010) and would also gain “financial benefit” (P10, 2010).

4.3.4 Category 4:

Challenges of I.P.E. if implemented at the FHS and at the FMS. I.P.E. is in itself a challenge since unavoidably participants introduce their essential differences into the inter-professional learning.

Students emphasised that one of the biggest challenges that the FHS would have to face for I.P.E. to be implemented is the attitudes of professions towards other professions. The participants mentioned that there is an obvious “...psychological divide between different professions” (P9, 2010). This was brought to light via numerous examples of superiority complex. Some participants mentioned that since different professions may require different entry qualifications, some students might see other professions, which require lower qualifications, as inferior then their profession:

“... between dentists and dental technology as I can say from my point of view, there is a good communication but still there is like a stigma that we are dental technologists and they are dentists, therefore they are better, because when it comes to qualifications of a course... There's this thing about who is better than who? Or will the nurses, being for some of the doctors just nurses, be willing to work to work with medical professions? ... they will be willing to work with someone like a physiotherapist or a podiatrists, but are they willing to work with nurses or with us, the diploma students?”(P4, 2010).

Participants also deemed the uniforms as something depicting superiority:

“We still see student doctors wearing the tie by force. They force them to wear the tie from the first day. That's a non-verbal communication - listen I'm superior, you know. Which I don't think it is superior, but I think and I feel, that is the message that they want to portrait”(P22, 2010).

Another challenge to the possible implementation of I.P.E. would be that students/ professions would show reluctance to mingle with other students/ professions.

“I think you'd still see the same divisions kind of the medical students stay on their own, the nurses together, because they have similar things in common they stick together so that there still be that certain separation, so I think it will be challenging”(P27, 2010).

Some interviewees also pointed out that certain professions might dominate the I.P.E. team for various reasons including better communication skills, students who are over-confident while others feeling insecure, in-built opinions towards others, and professions having better understanding of the patients care/ treatment than others. Malta's healthcare system could also contribute to this. Reasons comprise the doctor being in charge in the ward, being the one who is ultimately responsible to make the final decision and being the one who other professionals have to refer back to - “I think the medical medical students would dominate cause it's the sys- the way the system is, cause you have to refer always to them...” (P21, 2010).

The perception of the majority of the participants when referring to medical students was quite pessimistic and one could easily sense the sarcasm and annoyance in their responses. The majority of the participants (52%) presumed that students from the medical profession would dominate the I.P.E. team if I.P.E. were to be implemented.

“I'm being biased by saying medical students will dominate but from what I've seen on the ward, the doctor is usually in charge because he has the overall more responsibility emm on the patient. If something happens he is the one responsible”(P27, 2010).

It is interesting to note that, the I.H.C. Board is in favour of I.P.E. for both medical students and the associated professions, however, certain members fear medical dominance and believe that it is not the right time for it to be implemented (Sacco, 2008).

Others believed that it all comes down to an individual's character whether to dominate over others or not. Being more confident, charismatic, outgoing, having more knowledge about the subject and being from a different school year, may all contribute to this:

“The ones who are outgoing for sure, and the ones who you know have a grip in the subjects more than another, the ones who are not laid back especially I think” (P25, 2010).

The participants mentioned that “... nobody sees the other professional maybe as professional as theirs...” (P14, 2010), and that “... we're all too proud in order to conceive that we need each other...” (P8, 2010).

“I think because sometimes you are brought up to believe that because we're going to be doctors we're going to know everything, and sometimes there are some doctors who have this sort of over-inflated opinion that they don't need anybody else's help, and this might get passed on to the medical students and they might think, “Listen I know best, why should I listen to what the nurse wants to tell me to do. I got better grades than the nurse so I know better'”(P28, 2010).

Attitudes of students towards I.P.E. were also worth noting. The interviewees stated that they were “... pressed for time...” (P6, 2010) and that students might not like the idea of the implementation of something extra.

“You can't keep on adding more things without reviewing the whole curriculum... if you just try to add something more, it will from the beginning, from the start create a negative image, so the student will not come for the Inter-Professional Education with a smile anzi (on the contrary) would say this is something extra, something the years before us didn't have, and they want to give us more now”(P15, 2010).

Getting accustomed to I.P.E. might also prove to be difficult:

“As any new thing that involves change yes, because people are resistant to change always, people don't like change, people are habitual creators so nobody likes change, everybody feels threatened by change, everybody feels he won't be up to it, everybody feels things are going to change in the bad way cause a lot of people are negative”(P31, 2010).

Participants declared that the learning system also has a lot of challenges to face if I.P.E. were to be implemented. The fact that different professions have different course structure such as different time-tables and different lectures may pose even more challenges to I.P.E.

“It is because they have different lectures, different times, their seminar rooms they're a bit you know separated and they don't have the same time for breaks, so even though we have a canteen, but the thing is that everyone has his or her own time of taking a break”(P5, 2010).

Moreover, participants mentioned that to co-ordinate the great number of students would prove to be very difficult:

“It will be tough because since there is a good number of students at the moment, for everyone to cooperate it would it would take time...” (P4, 2010).

Having unequal number of students per course would render it even more difficult for I.P.E. to be implemented and easier for a profession to dominate over another if it were to be implemented.

“If a course has fifty students and the other has six students it would be difficult for them to be equal sort of. With the participation it would mean that probably there will be more domination from the number you know, from the number of students in the course... Because if there are fifty students they would be probably two or three teachers lecturers not not, and with six there's only one so probably the leader would be from the other group, from the bigger group... like midwifery for example it would always be a small group, and nursing group is always bigger. Physiotherapy is in the middle probably. Mental nursing I don't know how how... what the number of students will be in the course but I don't imagine it will be a big number either, so probably it will be the nursing one that would be the dominating course”(P24, 2010).

The interviewees also mentioned that for I.P.E. to be implemented, the higher administrators of the Faculties involved would have to face a number of challenges themselves such as “...  to arrange timeslots and lecture rooms...” (P13, 2010) and therefore it “... depends on the Deans of the Faculty if they're up for it” (P12, 2010). Furthermore there is the challenge of costs - “I think there is a lot of, there will be a cost of time, of energies, of teachers...” (P3, 2010).

4.3.5 Category 5: Recommendations/ Suggestions.

Participants had different ideas on the stage of implementation of I.P.E. 52 % of the participants (n=52) agreed with the implementation of I.P.E. from the first year of the courses for various reasons including that “You'll be part of a team from the beginning” (P31, 2010) and so that “...it gets ingrained into you like it's an attitude” (P19, 2010). This is supported by Sacco (2008) who stated that it would be ideal to implement I.P.E. from an early stage as this would promote team spirit from the beginning.

On the other hand, participants also made it a point that, “...it would be a bit useless knowing about other professions when we don't even know really what our profession is”(P13, 2010). Those involved have to “know more about their own clinical abilities and competencies...” (P3, 2010), become familiar with the course and build an identity before starting I.P.E.

“You have to do it when you have already gained a lot of understanding about your subject”(P18, 2010).

Some interviewees suggested starting I.P.E. as soon as clinical placements start, since in some courses like the Medical, students do not have patient contact or students are“... only taught the basic anatomy and physiology...” (P13, 2010) in the first couple of years.

The majority of the students agreed that the I.P.E. team should be a product of collaboration rather than led by one particular profession, for example by being co-ordinated by higher administrators of the Faculties participating in I.P.E. Reasons given by participants included that no profession knows it all and that every profession has its own importance. If one profession would control the I.P.E. team, the I.P.E. would be biased.

“... if one leads it then there will be the idea of bias or there wouldn't be inter-professional, it would be more led by one so there'll be ine- inequality” (P2, 2010).

Furthermore, when no profession dominates over another and “...when everyone works together no one feels threatened...” (P25, 2010).

Having said all this, the participants mentioned the need for leadership.

“There should be a leader, but it shouldn't be determined by a particular profession. More by the person who has most the most leadership skills and again there should be a leader simply because the group would need a direction...”(P8, 2010).

The students also commented on the need for course structure modification if I.P.E. were to be implemented. They argued that it should not “...look as being something extra...” (P15, 2010). It should be integrated with the present study-units or replacing “...those other credits that we don't really need” (P4, 2010). Furthermore, students suggested that if I.P.E. were to become compulsory it would be more beneficial:

“... if it's a compulsory study-unit, to make this I.P.E. thing work, I think it would be beneficial” (P4, 2010).

The interviewees were very keen on suggesting ideas to include in I.P.E. They all agreed to the implementation of inter-professional study-units and they gave a lot of suggestions, which are found in more detail in Appendix J. Participants would be interested to know how to work in a team - “It comes also with some social skills therefore the study of I.P.E. should include also communication exercises, presentation work - to get the students more flexible when it comes to actually work in a team” (P4, 2010) - and would be willing to collaborate with every healthcare professional -“... actually the more people work with each other it doesn't matter which course or which study unit cause everyone has something to share and everyone has something to learn. Therefore it doesn't matter which course” (P4, 2010).

Participants recommended that students from different professions would meet up to discuss or observe each other's roles in order to learn from each other.

“I think if there'll be some sort of a programme where each student from each speciality teams up with another student for example a week in a whole year and one witness the work of any other. This is the exact way how one can identify what each healthcare worker can do”(P6, 2010).

According to Sacco (2008), this initiative was already tested between 1976 and 1982 (physiotherapy students observing the nursing profession), however was discontinued due to time constraints.

Joint sessions wherein home visits, conferences and meetings would be held up were also suggested by the participants:

“... creating joint session or it would be interesting for example to see a course implemented where we'll work as a team, creating a joint session, going to a home visit together... trying to figure out how to carry out a conference meeting...”(P8, 2010).

One participant also suggested that communication is essential for I.P.E. to be successful and that it should be enforced -“...effective communication should be the tool and it should be enforced” (P31, 2010). Sacco (2008) mentioned that the modern healthcare system which involves working in a MDT with a lot of different professions, requires the professionals to collaborate and communicate, for the patients to benefit from the service, not only, between medical and their allied professions but also with the social care professions. 

All the participants believed that it was important to promote I.P.E. Promotion is essential to increase awareness about it and for people to “... recognise the benefits...” (P5, 2010).

Students from different healthcare professions have different knowledge, thus, in order to meet their needs, I.P.E. has to be specialised,

“It have to emm, the course have to be specialised in terms of, because different students will have different knowledge... so it has to be specialised to meet all the needs of the different students coming from different professional backgrounds”(P29, 2010).

and a pilot study ought to be carried out:

“You'd have to obviously make a pilot study before to see what are the needs of every emm single different health care group...” (P3, 2010).

More utter responses can be found in Appendix J.

4.4 Conclusion

The conclusion for this research study, including its strengths, limitations and recommendations, is presented in the following chapter.

Chapter 5

Conclusion

5.1 Conclusion

The findings indicated the lack and possible necessity for the implementation of I.P.E. at the FHS and the FMS. Recognising that there are not only benefits but also challenges to the implementation of I.P.E. is important. It is intended that the outcome of this research will be shared with the Registrar, the Dean of the FHS, the Dean of the FMS and all the participants that formed part of this study. It is hoped that this study will shed light on the context of inter-professionalism. It is being stated that the researcher recognises the small sample size and hopes that the outcome of the study would serve as a pilot study for future research. Successful learning would not only render students more knowledgeable with regard to the roles of each member of the MDT but would also promote better care and cure of patients.   It would prepare the students better for what they will be facing later in their workplaces, which in turn might affect the way patients will be taken care of. Every possible effort must be taken to improve patient care.

5.2 Strengths and Limitations of the Study

The identification of the strengths and limitations of a study should be taken into consideration when generalising findings.

5.2.1 Strengths of the study.

Unlike any type of questionnaires, the one-to-one semi-structured interviews offered the interviewer the possibility to be receptive to non-verbal cues, to help respondents in understanding the questions, and to gain more responses accordingly using probing, therefore extracting very rich and deep information. During the interviews the researcher avoided to react verbally or non-verbally to any comments made by the participants to avoid bias, instead, the former tried hard to keep the interviews objective as much as possible. Being familiar to most respondents, the researcher was able to create a welcoming and a warm atmosphere wherein she managed to encourage the participants to talk freely about the subject. A degree of openness was tolerated in order for the subjects to disclose possible important points, which were not considered by the researcher, with the result of gaining a rich understanding and a broader view on the subject being studied. Non-verbal communication was also very helpful with providing the researcher with hints on how much to encourage the subjects into speaking.

In addition, there was a degree of consistency throughout the study as the same tool was used for everybody, transcripts were all shown to the supervisor and the latter all transcribed in the same manner. Another asset of this study was the fact that the participants were very compliant when it came to accepting to be interviewed and when they were actually interviewed. In fact, during the interview the participants were very interested in the subject and most of them kept discussing with the researcher even after the interviews finished. Furthermore, to improve reliability of the study, after transcripts were done, they were shown to the respondents who all approved what was transcribed.

5.2.2 Limitations of the study.

The major limitation of the study was its small sample size, however, the reader has to realise that this is an educational exercise. An increase in the sampling size and conducting more interviews may have helped to obtain more data and to enhance further understanding of the subject studied. By the end of the study, the interview technique was really improved, the limitation being that the researcher could only do so many. Furthermore, the data were collected by the interviewer herself. This might have given way to the Hawthorne Effect which is the process responsible for a change of behaviour that is usually seen when participants of a study are being observed, thus creating a bias which is very difficult to eliminate (Shuttleworth, 2009). The subjects' cognition, knowledge, and feelings may have been exaggerated and abated, in an attempt to display a particular image to the interviewer. Bias could have also been introduced due to the fact that the subjects were so unfamiliar with the topic that the researcher had to explain what the topic is about for example by defining to them what I.P.E. is, when they disclosed that they were unfamiliar to it.

Although the researcher applied face validity by for example reading relevant literature in order to formulate the research instrument, no actual tests for reliability and validity were done apart from the pilot work, due to time constraints.

A further constraint lies in the fact that only one method of attaining data was applied (therefore lack of triangulation). Due to financial constraints the researcher had to type all the transcripts manually using Express Scribe Transcription Playback System instead of making use of a digital system whereby the digital recording is transcribed automatically, which would in turn have saved the researcher a lot of time.

Hence, taking into consideration these strengths and limitations, the findings of the study can only be taken as suggestions. Although it generated a considerable amount of information and several points were certainly recognised, the need of a study comprising a larger sample would prove to be much more reliable.

After considering these limitations, the need for further studies in this area, so as to draw up a broader and a more accurate picture, is more pronounced.

5.2.3 Recommendations.

  • The findings give light to the following recommendations:
  • More awareness on I.P.E. is essential. In-service continuous education regarding I.P.E. including Continuous Professional Development lectures, conferences, group discussions and University lectures could be carried out, and those who could be involved if I.P.E. were to be implemented would be invited. Furthermore, charts, brochures and posters could also be used for the promotion of I.P.E.
  • Further studies could be carried out to identify the academic stuff and healthcarers' views with regard to I.P.E.
  • Unstructured interviews could be used in future research, so that richer and more in-depth investigation of issues that were extracted from this study would be further explored.
  • It is suggested that this research study be repeated on a large scale, including participants selected through another sampling method and using different criteria, not to limit the target population, therefore to provide more representative and conclusive results.

The implementation of such recommendations could contribute towards a better holistic care for future patients. Once implemented, those involved with the care of patients would be able to enhance the quality of life and provide a better service, increasing the patient's satisfaction and also the healthcare professional's job satisfaction.