El Modelo Espiral del Conocimiento de Nonaka y Takeuchi

The literature reflects global appreciation for the potential of IPE for better collaborative teamwork and quality patient/client care, which bodes well for the future development of IPE in countries beginning or endeavouring to progress their IPE agenda, and for the advancement of IPE for those with established protocols. The empirical evidence that emerged from this literature review has characterised some of the fundamental debates within the IPE discourse community, and has drawn attention to a need to add to these debates and build upon existing evidence from an Irish perspective. Underlying the attitudes towards interprofessional education and working emerged a triad of interconnected variables, that is, professional identity, professional stereotyping, and students’ readiness for IPE. These appeared to shape the formation of undergraduate healthcare students’ attitudes, a process which evidently began before they commenced their courses.

The question of whether a strong or a weak professional identity bodes well for effective IPE outcomes remains an unresolved debate in the literature. If professional identity is undeveloped or weak, many are of the view that IPE would be best initiated later on in the course, or nearer to graduation. Conversely, a high strength of professional identity among undergraduates on course commencement is suggestive of early IPE suitability; that is if one subscribes to the view that strong identity probably yields better IPE learning outcomes. In support of this idea, some argued that early exposure to the clinical setting could translate into better understanding among students for both their own roles and that of other professions from the outset.

The other issue warranting attention relates to how IPE activities can take account of differences in strength of professional identities between the professions, to yield best

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learning outcomes. It cannot be assumed that every discipline in a cohort of mixed healthcare students will present with the same level of identification. Mixed levels of professional identity between groups participating in IPE, along with fluctuating changes in levels of identity over time, pose a dilemma for group membership and timing of IPE activities. However, IPE provides a means whereby ‘interprofessional’ identities can be developed and achieving a balance between students’ recognition of their individual professional identities and their shared professional identity could be the way forward. It is expected that IPE has the potential to dismantle destructive traditional hierarchical structures embedded within the culture of healthcare delivery. However, as professional identity strengthens within a profession, boundaries inevitably develop that invariably give rise to territoriality and tribalism. These power-related dynamics pose one of the greatest challenges for the laudable goals of IPE and IPW. The broader picture of the evidence inconclusively suggested two opposing notions. The first is that weak professional identity could bring about failure of IPE or effective IPW, because students are insecure in their own roles and have yet to identify with their own profession before they can effectively engage in shared learning activities with other professions The second is that strong professional identity could bring about failure of IPE or effective IPW, as groups are so secure in their identities that they are possibly less inclined to accept learning with other disciplines. This side of the debate assumes that strong professional identity could potentially cause problematic interactions during IPE because of a greater likelihood of professional boundaries, territoriality and tribalism creating a barrier. In effect this intimates that the problems IPE aim to address, are the very problems creating barriers for effective engagement with and interactions during IPE.

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Professional identity gives rise to social categorisation with resulting production of stereotypes. Stereotypes among the healthcare professionals appear to be a product of social discourse, often devoid of logic, and may not accurately represent a profession or the individuals that represent it. Negative stereotypes are inherently destructive by nature and not only present on course commencement among undergraduate students of healthcare, but also have the potential to persist over time, show resistance to change, and become reinforced instead of modified after IPE. They are a major source of conflict between healthcare professionals and can negatively impact on communication and collaborative working. Social Identity Theory (Turner 1999) and the Contact Hypothesis (Allport 1979) have a strong presence in the IPE literature, and help to explain the basis of stereotypes and the underlying dynamics that occur among professional interactions. In line with Social Identity theory, the literature identified a natural tendency among healthcare students to rate their own professions higher than others and reflected stereotypical portraits of characteristics akin to certain healthcare professions.

Assumptions and perceptions about professions as they relate to status and hierarchy also gives rise to stereotyping, and in conjunction with strong professional identification, can engender ‘turf’ related conflict, tribalism and rivalry. This is so problematic that students sometimes voiced lack of confidence to share their learning with professional groups accredited with higher academic ability or status. The hierarchies that are frequently embedded within healthcare systems undermine shared learning opportunities and teamwork among professions, obstructing rather than enabling the goal of teamwork that is safe quality patient/client healthcare delivery.

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IPE has been well posited in the literature as potentially an antidote to negative professional stereotyping among healthcare students. However, much debate continues about whether or not IPE can in fact improve stereotyped attitudes or break down professional ‘turf’ related barriers. The potential of IPE seems to be somewhat contingent upon the way students view own and other professions. This highlights a paradox in that IPE can potentially address negative stereotypes, but negative stereotypes can also impact the potential of IPE. Considering the evidence through a theoretical lens, it would seem that in many interprofessional group situations that the Social Identity Theory (Tajfel 1978), whereby individuals favour members of their own ‘in-group’ over the ‘out-group’, is more dynamically at play than the Contact

Hypothesis (Allport 1979), whereby contact between individuals from different groups, reveals mutual similarities that result in positive modification of stereotypical standpoints. With that said, whilst a failure of IPE to improve attitudes to the other group is sometimes reported, IPE appears to have the capacity to at least moderate stereotypes, generating greater realism among perceptions. Enhanced realism in itself is possibly a positive outcome of IPE because the attainment of more realistic perceptions about the abilities and characteristics of other professions might result in more effective IPW.

A third attitudinal theme featuring prominently in the IPE literature relates to students’ readiness for IPE. The concept of readiness for IPE among undergraduate healthcare students emerged as an important variable for consideration for IPE development. Readiness for and positive attitudes towards IPE, along with positive outcomes from IPE interventions, has been associated with positive attitudes towards and outcomes for IPW. There is much global evidence to show that high readiness to learn

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interprofessionally features among undergraduate students of healthcare on course commencement, leading many researchers to conclude that IPE should take place early to captivate this positivity.

However, positivity among undergraduates towards the concept of shared learning cannot always be expected and enthusiasm among undergraduates for the prospect of IPE can decline during the course of the students’ academic programme. Also potentially problematic, as seen with strength of professional identity and stereotyping, are the differences in students’ readiness for IPE between the healthcare professions. Some healthcare professions emerged as more amenable to IPE, or susceptible to change following IPE than others. These differences could create an operational challenge for IPE, as negativity among some students, could potentially undermine the potential of IPE for others. There are various explanations among the findings for differences namely, variations in learning styles, protection of professional boundaries, presence of stereotyped views about healthcare professions, and learner characteristics such as gender, age, previous healthcare experience, previous IPE courses or degrees, family members who are healthcare professionals, and ethnicity, with gender and age featuring most prominently. In general, males indicated less positivity for IPE than females, and mixed reports were evident relating to age with some studies finding mature students more enthused by IPE and others finding school leavers to benefit more.

Statistically significant relationships between two or more of the variables that are strength of professional identity, stereotyping, gender, and readiness to learn interprofessionally, were identified in a relatively small number of studies, thus providing greater understanding about the nature of the attitudes affecting interactions

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between healthcare professions. Female gender emerged as a predictor for strong professional identity. Strong professional identity also showed potential for IPE insofar as positive correlations were found with readiness for shared learning and with higher ratings attributed to other professions, thus implying that students with a greater feeling of group membership could be more willing to learn in a shared context with other healthcare professions. Positive attribute ratings were also correlated with readiness for shared learning with most healthcare groups. The timing of IPE emerged as a potentially critical consideration, suggestive that IPE implemented early might capitalise on strong professional identity and positivity/readiness towards shared learning. It is possible that undergraduate students of healthcare have a broader identity associated with being a healthcare student or being part of a Health Science Faculty in a university, as well as a single identity associated with their own profession. This might explain the somewhat counterintuitive findings that students with strong identity are more ready for shared learning.

This literature review has brought to the fore a labyrinth of issues in the pursuit of producing a collaborative ready workforce for safer, quality patient/client care through interprofessional education. Changing negative attitudes between the healthcare professions is one of the fundamental learning outcomes for IPE interventions (Barr et al. 2005), and it is clear that IPE potentially has an essential role, but a challenging one, to modify negative attitudes among undergraduates. A triad of interconnected variables that is, professional identity, professional stereotyping and readiness to learn interprofessionally converged within the literature, helping to explain the genesis for attitudes towards IPE and IPW. These attitudes are a critical determinant for ensuring the success and sustained success of IPE, and in turn for the subsequent achievement of

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effective collaborative teamwork. Students with negative attitudes towards IPE are often those people that gain the least from it (Coster et al. 2008; Horsburgh et al. 2006). Therefore, addressing these is a crucial task for IPE researchers and educators alike. For successful IPE to be sustainable, initial difficulties encountered during IPE need to be identified and resolved (Reeves and Freeth 2002). However, it is equally important that problems are identified in advance to inform the design of IPE, and before students engage with IPE. Designing and implementing IPE interventions in healthcare programmes is logistically very difficult in terms of scheduling and timetabling due to the curriculum requirements of the relevant bodies. The importance of identifying the origin, nature, existence and persistence of negative attitudes is paramount so IPE programmes and interventions can be suitably designed and tailored in a way that can mitigate encumbering attitudes.

There is a growing body of global robust evidence to indicate that IPE is having an overall positive impact on learners’ attitudes with the trajectory in the direction of positive outcomes for collaborative teamwork (Reeves et al 2016). What is not yet known is the impact of IPE on collaborative working in the Republic of Ireland and more research is needed to inform the development of IPE programmes. The current IPE literature revealed a complete dearth of Irish studies investigating attitudes towards IPE and IPW, professional identity, stereotyping and readiness for IPE among undergraduate healthcare students in the Republic of Ireland, with no studies that have investigated relationships between these variables. There is also a dearth of evidence to indicate whether undergraduate healthcare students attribute equal importance to the presence of the different healthcare professions on the IPW team or their conceptions about the value of teamwork. Furthermore, there is limited research in the European

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and Global literature that has investigated relationships between these variables. This study is also unique because it is the first study to use these four scales in unison, that is, the Interprofessional Working Scale (While and Barriball 1999), Professional Identity Scale (Brown et al. 1986), Student Stereotypes Rating Questionnaire (Barnes et al.

2000; Hean et al. 2006a and 2006b) and the Readiness for Interprofessional Learning Scale (Parsell and Bligh 1999; Mc Fadyen et al. 2005). It is anticipated that further insights will be gleaned into the suitability of these measures. This study will make a unique contribution to the IPE field from an Irish perspective, to inform the development and implementation of effective future IPE programmes in this institution, and other HEI’s around the country. The ultimate goal is to improve interprofessional collaboration for safe, quality healthcare delivery in the Republic of Ireland.

The question remains as to whether or not new undergraduate healthcare students from various disciplines in the context of Irish healthcare education, value interprofessional education and working. It is also unclear as to whether they present with a strong or weak professional identity, hold stereotyped views of their own and other professions, or indicate ‘readiness’ to learn interprofessionally and whether any of these variables are associated with the other. On the basis of international evidence it could be hypothesised that undergraduate students in an Irish academic context will also enter their courses with pre-defined stereotyped views and present with perceptions of inequality in the way they perceive the status of the healthcare professions. It could also be hypothesised that these students will indicate pre-course formation of professional identity and readiness for shared learning. This data could yield valuable insights as to how IPE should be designed in terms of participation, content and the employment of strategies for improving and interrogating negative perceptions. The

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most appropriate time to introduce IPE in an academic healthcare course remains open to debate, and is also worthy of examination in an Irish context. The longitudinal design of this study could give an indication of when best to place IPE based on potential changes in attitudinal measures and strength of professional identity scores between the first and second year of the programme. The use of the non-healthcare comparator group should help to ascertain if the views are representative of the healthcare students from the same Faculty of Health Sciences in this university or representative of wider society.

This literature review has explored the existing field of knowledge and body of evidence that reports attitudes towards interprofessional education and working among undergraduate healthcare students. A triad of interconnected themes emerged that is, professional identity, stereotyping and readiness to learn interprofessionally. The triangulation of these themes helps to explain the origin of attitudes and depict their potentially problematic nature and impact on the goals of IPE and IPW (figure 3.1).

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Figure 3.1 Triad of interconnected influences on attitudes to IPE and IPW

The convergence of these themes in the literature has provided a framework for this inquiry and formed the basis for the study objectives. Before proceeding to the following chapters which provide the methodological details of the study, the next sections conclude this chapter with the study aims and objectives and finally some reflective thoughts on the literature review process and potential challenges ahead.

READINESS FOR IPE PROFESSIONAL IDENTITY ATTITUDES TO IPE ATTITUDES TO VALUE & IMPORTANCE OF IPW PROFESSIONAL STEREOTYPING

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