The effect of interprofessional education on interprofessional professionalism behaviors of the surgical team members

The present study was conducted at Shahid Sadoughi University of Medical Sciences in 2020–2021. In our context, surgical physicians, surgical residents, and nurses in surgical technology and anesthetics participated in surgical teams. Clinical education was just used as a uni-professional strategy in the context. In addition, the planned professionalism education is considered in no clinical education programs for different professions.

In this study, 150 participants were divided into intervention (n = 78) and control (n = 72) groups. Different professions represented were surgical technology nursing, anesthetics nursing, and residences of surgical specialties in general surgery, ENT, ophthalmology, and orthopedics that work in the operating units of Shahid Sadoughi hospital. Four operating units in the hospital, and their respective surgical staff, were used for this study and divided into the intervention and control groups. Those assignments were made random. Accordingly, two units were assigned to the intervention group and the other two to the control.

The demographic information of participants in the intervention and control groups showed in Table 1.

The components of the educational intervention are explained in Table 2.

In the first training session, an interactive lecture helped participants become familiar with the concepts of interprofessional professionalism, values, and cooperation.

In the preparation phase of CLB, the cases were developed based on the principles of creating good cases [14]. Criteria such as reality, alignment with educational objectives, cases’ educational values, and content coverage were considered. Interprofessional critical incidents in communication, respect, altruism, and excellence were deliberated. The educational cases (N = 18) were developed by clinical teachers (n = 3) in surgery, surgical technology nursing, anesthetics nursing, and expert in health professions education (n = 1). The validity of cases was reviewed by experts in a panel of clinical teachers from different professions who had working experience in surgical teams (n = 8). The CBL is conducted in seven steps: presentation of a case, analysis and discussion by the interprofessional group, formulation of learning objectives related to IPP, dividing topics among students, reviewing the literature and educational materials by self-study, sharing of opinions among the participants [15].

In the implementation phase of CBL, participants were divided into ten interprofessional small groups. The educational cases were presented at first. The participants were asked to identify ethical challenges, recognize possible causes, and find suggested solutions to solve ethical challenges in interprofessional teams. They experienced the cased-based learning in the seven steps. Finally, the participants discussed and summarized their findings among participants in all groups. Two faculty members facilitated the steps.

The step aimed to share the experienced issues related to IPP among different professions. The participants were asked to reflect on the experienced IPP challenges and share them with other group members. The members discussed the possible causes of the mentioned challenges and proposed their solutions to solve them.

Each interprofessional group in the mentioned methods included 3–4 surgical residents and 4–5 nurses. Two faculty members in medical education and medical ethics who were experts in professionalism facilitated the group activities and directed their discussion.

Over six months, participants met six times: 1^st meetings = interactive lecture and interprofessional small group discussion, 2^nd-6^th meetings = interprofessional case-based learning.

Two clinical teachers who were affiliated with the surgical departments participated as assessors. The assessors with no working experience in the studies units were selected to control bias based on assessors’ working relationships with some subjects. Moreover, in order to control bias in assessment, we used different methods that recommended to control of subjectivity [16, 17] such as using two evaluators, training evaluators, evaluating in multiple situations in the surgery units, using a specific checklist, determining the way of scoring and agreeing on how the scoring of checklist’s items. Our study held two educational sessions for the assessor’s training. The session was facilitated by an expert in Health Professions Education who had experience in professionalism, interprofessional professionalism, and interprofessional collaboration. In the first sessions, the assessors discussed the IPP concepts and domains. The items of interprofessional professionalism assessment (IPA), the scoring method of the instrument, and the principles of observational evaluation such as time and frequency were argued in the sessions. In the second session, the assessors discuss the practical description of IPA items and their scoring to enhance their agreement about items. Afterward, we showed a video about interprofessional teamwork in the surgical unit. The video displayed a healthcare team’s performance in managing a patient with Hip fraction. The assessors were asked to evaluate the performance of members of the team (a surgical physician and a surgical nurse). This was an exercise in a simulated situation. Afterward, the facilitator debated assessment results with the assessors, and individual feedback was provided to them. In order to ensure the reproducibility of the evaluations, the evaluators’ agreement coefficients were calculated. (Kappa = 0.87).

In order to assess the IPP behaviors of the participants in the intervention and control groups, each assessor completed the IPA form after observing the participants’ performance (at least after three observations) in the operating rooms. The assessors observed each participant one month prior to the intervention. In addition, participants’ performances were assessed twice after the educational interventions (one month and three months later).

The original IPA was designed and validated by Frost et al., and included two sections: 1) demographic questions, and 2) 26 behavioral items representing six domains of Interprofessional Professionalism (RMSEA = 0.055, 90% CI: 0.042 – 0.067; CFI = 0.991; SRMR = 0.030)[18]. Authors recommended revision and further testing of a shortened instrument using 18 of the items representing 4 domains; altruism, excellence, respect, and communication (RMSEA = 0.064, 90% CI: 0.055– 0.078; CFI = 0.991; SRMR = 0.027 and Cronbach’s alpha = 0.96) [18]. The present study used the 18-item version of the instrument with demographic questions of age, gender, and profession. The validity and reliability of the questionnaire were approved in the investigated context. (CVR = 0.71, CVI = 0.91, Cronbach’s alpha = 0.83 and ICC = 0.74). Scoring on each item is on a scale of 1–5 for the competency scores where poor = 1, moderate = 2, good = 3, very good = 4, excellent = 5. The mean score of the items in each domain was reported. The IPA was validated in the previous study. (Cronbach’s alpha coefficient = 0.83 and ICC = 0.74). [19].

The descriptive statistics, Mean (SD) of the total score, and number (%) were used to describe the data. For each participant, five scores were calculated: one means item score over each of the four domains and one grand mean score over all the items. All mean scores were between 1–5.

Based on Table 3, comparisons were made between control and intervention groups for the baseline data and both post-intervention observations. The group comparison was conducted after adjusting the demographic variables, including age, gender, and profession. To compare the crude and adjusted scores of IPP domains across the study (baseline measurements, after one month and after three months), used the RM-ANOVA test (Repeated Measure of Variance). The effect of intervention groups over times on scores of domains including altruism, excellence, respect, and communication was calculated. The results showed the minimum p-value of interactions was 0.22 that was not significant. Partial eta-squared (η2) was used for effect size calculations in RM-ANOVA. Based on a general ‘rule of thumb,’ the effect sizes are considered small, medium, and significant effects if the calculated partial η2 are approximately equal to 0.01, 0.06, and 0.14, respectively [20]. The significance is considered at p < 0.05.

The present study was quasi-experimental, involving limitations such as a non-equivalent control group. Performing the study at only one institution can also impede generalizability. Another limitation could be the use of only two assessors for the evaluation of participants’ behavior.