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Abstract
Objectives While postgraduate studies have begun to shed light on informal interprofessional workplace learning, studies with preregistration learners have typically focused on formal and structured work-based learning. The current study investigated preregistration students’ informal interprofessional workplace learning by exploring students’ and clinicians’ experiences of interprofessional student-clinician (IPSC) interactions.
Design A qualitative interview study using narrative techniques was conducted.
Setting Student placements across multiple clinical sites in Victoria, Australia.
Participants Through maximum variation sampling, 61 participants (38 students and 23 clinicians) were recruited from six professions (medicine, midwifery, nursing, occupational therapy, paramedicine and physiotherapy).
Methods We conducted 12 group and 10 individual semistructured interviews. Themes were identified through framework analysis, and the similarities and differences in subthemes by participant group were interrogated.
Results Six themes relating to four research questions were identified: (1) conceptualisations of IPSC interactions; (2) context for interaction experiences; (3) the nature of interaction experiences; (4) factors contributing to positive or negative interactions; (5) positive or negative consequences of interactions and (6) suggested improvements for IPSC interactions. Seven noteworthy differences in subthemes between students and clinicians and across the professions were identified.
Conclusions Despite the results largely supporting previous postgraduate research, the findings illustrate greater breadth and depth of understandings, experiences and suggestions for preregistration education. Educators and students are encouraged to seek opportunities for informal interprofessional learning afforded by the workplace.
- qualitative research
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Strengths and limitations of this study
This study is the first to explore student and clinician experiences of work-based interprofessional student-clinician interactions.
We collected a large number of narratives from a relatively large qualitative sample of students and clinicians, enhancing the transferability of our findings.
Our reflexive approach to teamwork helped to enhance our analytical rigour.
We acknowledge the smaller subsamples of participants in our study, making comparisons by participant groups challenging.
We had relatively low numbers of male and non-white participants, thus limiting the transferability of our findings to female and white students and clinicians.
Introduction
While healthcare students often participate in interprofessional learning activities as part of formal ‘classroom-based’ curricula,1 their understanding of other healthcare professionals’ roles and interprofessional team-working are often learnt as part of work-based informal learning.2 3 Healthcare students develop their knowledge and learn skills, behaviours, attitudes and practices, both good and bad—through the structures and cultures of the healthcare workplace and work-based role modelling involving student–clinician interactions.4 Some of those student-clinician interactions will be interprofessional, with students experiencing (often informally) supervision, feedback and support from clinicians from other healthcare professions.2 4 5 While the interprofessional learning literature is vast, very little research has explored the content or impact of work-based interprofessional student-clinician (IPSC) interactions. What research has been conducted has focused on postgraduate rather than preregistration learners.6–10 Furthermore, preregistration studies typically focus on formal and structured interprofessional work-based learning rather than informal learning.11–15 Therefore, this study sought to provide an original contribution to the literature by addressing this gap through exploring informal work-based interprofessional learning of preregistration healthcare students through investigating student and clinician experiences. We felt that this endeavour was important in order to identify potential opportunities and challenges within IPSC interactions (and therefore interprofessional learning), which might serve to inform educational strategies to improve the preparation of students for positive interprofessional practice in the workplace.
Informal workplace learning
Much work-based learning can be described as informal,16 defined as: ‘learning that comes closer to the informal end than the formal end of a continuum… [and including] implicit, unintended, opportunistic and unstructured learning and the absence of a teacher’.16 Eraut17 describes three types of informal learning varying by level of learning intention: implicit, reactive and deliberative learning,16 which is perhaps why students and teachers do not always recognise informal learning as education.2 9 Eraut18 outlined a range of informal workplace learning outcomes including task performance, awareness and understanding, personal development, teamwork, role performance, academic knowledge and skills, decision-making and problem solving and judgment.16 He suggested four key types of work activity giving rise to informal learning: participation in group activities; working alongside others; tackling challenging tasks and working with clients.16 Much of these informal learning activities are embedded in acts such as listening, observing, reflecting, problem solving, practising skills, receiving information, asking questions and giving and receiving feedback.16 Factors affecting learning in the workplace include both learning factors such as challenge and value of the work, confidence and commitment and feedback and support and context factors such as allocation and structuring of work, expectations of everyone’s role, performance and progress and encounters and relationships with people at work.16 Interestingly, Eraut’s16 work has been taken up by many interprofessional healthcare scholars6 9 10 13 19 who argue that more attention be paid to direct learners to seek out informal interprofessional workplace learning opportunities.
Informal interprofessional workplace learning
Interprofessional workplace learning offers preregistration students realistic, complex and authentic experiences focusing on patient-centred collaboration and engagement.19 20 As mentioned above, current informal interprofessional workplace learning research has centred on postgraduate rather than preregistration learners.6–10 21 Therefore, we summarise key literature from this next closest level of learners in this section: junior doctors learning from nurses6 or pharmacists7 8; residents learning from nurses and senior doctors10 and residents learning from nurses, allied health professionals and senior doctors.9 These studies have employed various methods including qualitative methods such as interviews6–8 or non-participant observation9 and quantitative methods such as a survey asking social network questions.10 While some of these studies found low levels of informal interprofessional workplace learning, for example, between residents and nurses,9 10 many of the papers highlight the important informal learning that can occur through interprofessional learner–clinician interactions.
Burford et al 6 found that nurses helped junior doctors’ orientation into their new roles. Junior doctors learnt much from nurses such as their roles, interprofessional hierarchies and skills development. Nurses also helped identify junior doctors’ errors relating to paperwork and prescribing. Noble and her colleagues determined that pharmacists helped junior doctors build their prescribing capabilities, that junior doctors sought advice and guidance from pharmacists, plus received feedback about their prescribing including errors and explanations about prescribing practices.7 8 Finally, Varpio et al 9 noted that informal interprofessional education from nurses to residents mostly related to: (1) nurses highlighting concerns with residents relating to patient care, (2) nurses sharing knowledge with residents about how certain tasks should be done, (3) nurses giving advice to residents about how best to manage patients and (4) nurses assuming the role of resident resource with trainees seeking assistance with knowledge or skills.
While these studies have begun to shed light on informal interprofessional workplace learning, to our knowledge, no studies exist exploring work-based informal interprofessional learning with preregistration students. Indeed, the burgeoning literature on work-based interprofessional learning with preregistration students11 12 typically focuses on formal and structured learning opportunities such as case-based activities, workshops, interprofessional training wards, student-led clinics and so on.19 Furthermore, the interprofessional relationship explored in these studies is typically student-student rather than IPSC interactions.
Research aim and questions
This study aimed to better understand students’ and clinicians’ experiences of work-based IPSC interactions. We sought to answer the following research questions:
RQ1. What are participants’ understandings of IPSC interactions?
RQ2. What are participants’ experiences of IPSC interactions?
RQ3. What are participants’ suggestions for improving IPSC interactions?
RQ4. What are the similarities and differences in understandings, experiences and suggestions between students and clinicians and across different professions?
Methods
Design
A qualitative design involving group and individual semi-structured interviews with students and clinicians was undertaken. The study employed a social constructionist perspective, which acknowledges multiple interpretations of reality as individuals make sense of their experiences through social interactions and the surrounding environment.22 We employed narrative interviewing techniques to help us understand participants’ experiences and how they constructed themselves and others through their stories.23 The findings relating to student and clinician identity constructions will be presented elsewhere.
Sampling and recruitment
Following ethics approval, we collected data from students and clinicians (April 2016–March 2017) representing six healthcare professions (medicine, midwifery, nursing, occupational therapy, paramedicine and physiotherapy). Maximum-variation sampling was used to obtain a diverse range of understandings, experiences and suggestions. Students and clinicians were recruited through multiple methods including: e-notices on virtual learning environments; hard copy notices on notice boards; email; snowballing and face-to-face advertisements after formal lectures. Overall, 12 group (6 with students, 6 with clinicians) and 10 individual semistructured interviews (5 with students, 5 with clinicians) were conducted yielding a sample of 61 participants (38 students and 23 clinicians) and amounting to 10 hours and 16 min of student data and 7 hours and 31 min of clinician data. Whether participants took part in group or individual interviews depended on pragmatic considerations such as participant availability and thus ease of organisation. See table 1 for participant characteristics.
Participant characteristics
Data collection
A discussion guide helped to achieve consistency across the interviews facilitated by two authors (CR and FK). After welcomes, introductions and ground rules, interviews began by exploring students’ and clinicians’ understandings of workplace IPSC interactions. Then, using narrative interviewing techniques, participants were asked to narrate workplace experiences of IPSC interactions. A series of prompts were used around these narratives (eg, ‘what was the impact of that experience on your understandings of interprofessional practice?’). Once participants had fully shared their experiences, we asked for their suggestions for improving workplace IPSC interactions. The interviews were audio-recorded with participants’ permission. The interviews were drawn to a close by asking participants to complete a brief personal details questionnaire. A copy of the interview schedule can be requested from the corresponding author.
Data analysis
The data were analysed using an inductive five-step process of framework analysis.24 In step one, familiarisation, we initially selected a sample of five diverse transcripts with each transcript being reviewed by two members of the research team. In step two, identifying a thematic framework, we came together to compare, contrast and negotiate our individual interpretations of the transcripts to develop an initial coding framework. In step three, indexing, one author (PC) used the coding framework to code all data using NVivo 11. PC both read the transcripts and listened to the data thereby attuning to linguistic cues such as emphasis, intonation and laughter that were not wholly apparent from the transcripts.25 During this coding, PC and CR met five times to double-check coding, clarifying points of uncertainty and discussing any ambiguities within the transcripts in relation to the coding framework. This checking was conducted across approximately 20% of the coded data. In step four, charting, PC interrogated patterns in the data by different types of participant groups in discussion with CR. Note that while we quantify some of our qualitative data in order to make sense of the patterns across our participants groups, as has been done in other research,26 27 we maintain a qualitative interpretative approach.28 Finally, in step five, mapping and interpretation, CR and PC interpreted findings in light of the research literature. Note that the interpretations of PC and CR were shared fully and agreed among the team through the iterative processes of writing-up the results and preparing the manuscript.
Team reflexivity
We conducted team reflexivity prior to data analysis, in order to acknowledge members’ prior experiences, beliefs and attitudes that might influence our interpretations.29 This exercise highlighted that we had diverse academic and clinical backgrounds, representing many different healthcare professions. While we had a range of experience with qualitative research (novice to expert), we all held similar positive beliefs about the power of qualitative research to unpack complexity and we shared similar theoretical frameworks (eg, social constructionism). Undertaking this reflexivity exercise enabled us to work better collaboratively, to understand each other’s perspectives and to add to the rigour of the analysis.30
Patient and public involvement
Given the focus on student-clinician interactions in this study, patients and the public were not involved in the design, data collection or data analysis.
Results
We identified six themes in relation to the research questions: one theme relating to RQ1 called (1) conceptualisations of IPSC interactions; four themes relating to RQ2 called (2) context for interaction experiences, (3) the nature of interaction experiences, (4) factors contributing to positive or negative interactions and (5) positive or negative consequences of interactions and finally, one theme relating to RQ3 called (6) suggested improvements for interactions. Postcoding interrogation of data allowed us to examine RQ4 across themes 1–6 to explore the similarities and differences across participant groups; this is presented below across RQ1–3. Interested readers can request a copy of the coding framework from the corresponding author.
What are participants’ understandings of IPSC interactions? (RQ1 and RQ4)
The participants had many different understandings of IPSC interactions. The most frequent conceptualisation across the whole dataset was that IPSC interactions were about facilitating student learning, both formally and informally. Some participants described IPSC interactions as professions working together to deliver patient care and others suggested that interactions facilitated understandings of how professions worked together. Fewer participants described clinicians providing psycho-social-emotional support for students (see table 2).
Understandings of IPSC interactions
The similarities and differences in understandings of IPSC interactions between students and clinicians and across different professions are summarised in box 1.
Similarities/differences in understandings by participant group
While clinicians most commonly conceptualised interprofessional student-clinician (IPSC) interactions as student learning, students most commonly conceptualised them as working together to deliver patient care and student learning.
All professions most commonly conceptualised IPSC interactions as education and least commonly as psycho-social-emotional safety.
Working together to deliver patient care was the second most common conceptualisation across all professions (with clinician and student data combined) except nursing and occupational therapy participants. Facilitating understandings of the healthcare team was the second most common for nursing participants and equal first for occupational therapy participants.
What are participants’ experiences of IPSC interactions? (RQ2 and RQ4)
We identified four crosscutting themes across the narratives in relation to the second research question. The narrators’ evaluations of their experiences were interpreted based on their language such as using mainly positive (eg, ‘fantastic’) or negative emotion talk (eg, ‘horrible’) and/or if they explicitly stated whether their experience was a ‘very good’ or ‘negative’ one.
Contextual features of IPSC interactions
Two hundred and eight narratives were identified in the dataset, with most occurring in hospital settings. The highest frequency of IPSC interaction narratives involved students from any profession interacting with medical clinicians followed by nursing, then physiotherapy, paramedicine, midwifery and finally, with occupational therapy clinicians. The highest number of IPSC interactions involved clinicians from any profession interacting with nursing students, then medical, followed by occupational therapy, midwifery, paramedicine and finally, physiotherapy students. The top five most frequent IPSC dyads discussed in the narratives were (in decreasing order of frequency): medical student-nurse; midwifery student-doctor; nursing student-physiotherapist; nursing student-doctor and occupational therapy student-physiotherapist. Interactions between medical and allied health professions (ie, paramedicine, physiotherapy and occupational therapy) were uncommon. Narratives were more likely to be evaluated positively by narrators than negatively, although some narratives included both positive and negative evaluation. The similarities and differences in the contextual features of IPSC interactions between students and clinicians and across the different professions are summarised in box 2.
Similarities/differences in the contextual features of interprofessional student-clinician interactions by participant group
While students and clinicians evaluated their narratives as negative in similar numbers, students tended to evaluate their narratives more positively than clinicians.
Midwifery, nursing, paramedicine and physiotherapy participants (student and clinician data combined) most frequently evaluated their narratives positively.
Occupational therapy participants evaluated their narratives as equally positive and negative, while medicine participants most frequently evaluated their narratives as negative.
Conceptual themes of IPSC interactions
The narratives were most frequently about IPSC interactions facilitating student learning. Also common in the data were narratives about roles and delivering patient care. However, there were fewer narratives on dignity, hierarchies, conflict and communication (see table 3).
Conceptual themes of the 208 IPSC interaction narratives
The similarities and differences in the conceptual themes of IPSC interactions between students and clinicians and across the different professions are summarised in box 3.
Similarities/differences in the conceptual themes of interprofessional student-clinician interactions by participant group
While students’ narratives were most commonly about team working, student learning and roles (in roughly equal proportions), clinicians’ narratives were most commonly about student learning.
Across the professional groups, narratives were most commonly about student learning, apart from stories narrated by occupational therapists and physiotherapists, which were more commonly about roles and team working.
Factors contributing to positive or negative IPSC interactions
There were many contributory factors identified within the data relating to positive and negative IPSC interactions at the individual, interactional and organisational levels. A total of 465 positive contributory factors were identified across the dataset (note that the numbers here refer to the number of distinct statements alluding to positive contributory factors within the narratives). The most frequently identified positive factors across the narratives related to the interactional level, followed by the individual and organisational levels. At the interactional level, narrators mostly talked about positive student-clinician relationships. At the individual level, they most frequently talked about the clinician as a positive contributory factor, followed by the student. Finally, at the organisational level, the most frequently mentioned positive contributory factors included physical space (ie, shared break rooms) and having sufficient time for education alongside service provision.
A total of 241 negative contributory factors were identified across the whole dataset, with the most frequent factor related to the interactional level followed by the individual and organisational levels. At the interactional level, narrators mostly spoke about negative student-clinician relationships. At the individual level, the most frequent negative contributory factor was the clinician, followed by the student. Finally, at the organisational level, the most frequent negative contributory factors related to high workloads contributing to insufficient time to teach, plus limited physical space (see table 4).
Positive (n=465) and negative (n=241) contributory factors to positive or negative IPSC interactions
The similarities and differences in factors contributing to positively and negatively evaluated IPSC interactions between students and clinicians and across the different professions are summarised in box 4.
Similarities/differences in contributory factors for interprofessional student-clinician interactions by participant group
There were similarities between clinicians and students in the positive contributory factors identified but differences in the negative contributory factors: clinicians cited a lower proportion of negative organisational factors and talked proportionately more about negative individual and interactional factors than students.
Positive contributory factors were similar across the professions but more variation existed across the professions in terms of negative contributory factors: Although interactional factors were the most common negative contributory factors for medicine, nursing, occupational therapy and physiotherapy, the most common negative contributory factors for paramedicine and midwifery were organisational.
The consequences of positive and negative IPSC interactions
We identified a total of 343 positive consequences of IPSC interactions across the data (note that the numbers here refer to the number of distinct statements alluding to positive consequences within the narratives). The most frequently narrated were better learning, such as students practising clinical skills and enhancing their knowledge, students learning how to work effectively in the healthcare team and their better understanding of patient care pathways. Other positive consequences of IPSC interactions included better patient care, the development of better interprofessional attitudes, increased student well-being, better future interprofessional interactions and more positive career decision-making. In contrast, we identified a total of 187 negative consequences across the dataset. In decreasing order of frequency, narrators outlined the negative consequences of negative IPSC interactions as: worsening student learning, worsening patient care, decreasing student well-being, negative future interprofessional interactions, developing poorer interprofessional attitudes and more negative career decision-making (see table 5).
Consequences of IPSC interactions
The similarities and differences in consequences resulting from positively and negatively evaluated IPSC interactions between students and clinicians and across the different professions are summarised in box 5.
Similarities/differences in consequences from interprofessional student-clinician (IPSC) interactions by participant group
While clinicians and students identified better learning as the most frequent positive consequence, students outlined many more positive consequences of IPSC interactions than clinicians.
Although students identified decreased well-being as the most frequent negative consequence, clinicians identified this consequence least frequently.
Across the six professions, the most common positive consequence identified was better learning, apart from among physiotherapy participants who identified better interprofessional attitudes more frequently.
The six professions did not appear to differ in terms of the frequency of negative consequences identified.
What are participants’ suggestions for improving IPSC interactions? (RQ3 and RQ4)
The participants suggested a wide variety of ways to improve IPSC interactions aimed at, in decreasing order of frequency: students, organisations, interactions and clinicians. Suggested interventions targeted at students included formal preparation and teaching initiatives in the classroom and the workplace. This often included groups of students being taught about the different roles of healthcare professionals and shared tasks such as handovers. There were also interventions suggested at the organisational level, which included timetables, orientations for students and clinicians and protected time for interprofessional teaching in the workplace. Interventions aimed at relationships included developing formal interventions such as guides about one another’s roles and scopes of practice and informal interventions such as increasing informal opportunities for students to observe other professions at work. Finally, participants also suggested interventions aimed at clinicians including initiatives to help them develop their educational knowledge, skills and attitudes and thus improve their clinical teaching with students from other professions (see table 6).
Suggested improvements to facilitate effective IPSC interactions
The similarities and differences in suggestions for improving IPSC interactions between students and clinicians and across the different professions are summarised in box 6.
Similarities/differences in suggestions for improving interprofessional student-clinician interactions by participant group
Clinicians and students most commonly recommended interventions aimed at students, followed by organisational, then relationship and finally, clinician-level interventions.
Interventions at the student level were most commonly suggested by medicine, midwifery, occupational therapy and physiotherapy participants.
Nursing participants most frequently suggested interventions at the relationship level, while paramedicine participants most frequently suggested those at the organisational level.
Discussion
Summary of key findings and comparison with literature
RQ1. Participants’ understandings of IPSC interactions
Participants had varied understandings of IPSC interactions with the most common relating to facilitating student learning. While this finding seems contrary to others’ assertions that students and teachers do not always recognise informal workplace learning as learning,2 9 our findings were influenced by our interview questions, which often included probing questions about the nature of students’ educational relationships with other professions. Furthermore, while work-based learning environments typically privilege patient care needs and service delivery over and above that of student learning,31 students and teachers will necessarily understand students’ primary role within the workplace as learner rather than carer.4 32 Interestingly, the informal learning activities discussed by participants in their conceptualisations included observation, practising skills and receiving feedback, consistent with Eraut’s16 observations on informal workplace learning as well as other interprofessional workplace learning research with employees.21
RQ2. Participants’ experiences of IPSC interactions
Participants narrated a wide range of IPSC interaction experiences but they most commonly possessed five key features. First, they most typically involved IPSC dyads between medicine and nursing/midwifery, possibly reflecting the centrality of these professions in healthcare and the functional proximity (task interdependence) and spatial proximity (close physical distance) of the working relationships between these professions.10 Second, the IPSC interaction narratives were mostly evaluated positively, supporting previous research, which has found that junior doctors were mostly positive about their learning experiences with nurses and pharmacists.6 8 Third, the IPSC interaction narratives were mostly about student learning, again reflecting our probing questions about the nature of student-clinician educational relationships and the primary role of students in the workplace as learners.4 32 Interestingly, the informal learning activities discussed within our participants’ narratives were similar to those outlined in their conceptualisations such as observation and practising skills and receiving feedback, but also included discussions and role modelling, again consistent with Eraut’s16 observations on informal workplace learning, alongside previous research in informal workplace learning with postgraduates.6 7 9 Fourth, the IPSC interaction narratives typically cited interactional contributory factors for positive and negatively evaluated IPSC interactions. Other researchers have also flagged the importance of relationships in terms of facilitating or hindering learning at work.7 16 Finally, the consequences of the IPSC interaction narratives mostly related to student learning, that is, improved student learning for positively evaluated IPSC interaction narratives and worsened student learning for negatively evaluated narratives. Other researchers have similarly highlighted the positive learning consequences of interprofessional relationships such as postgraduates learning about roles, hierarchies and developing skills.6–8 13
RQ3. Participants’ suggestions for improving IPSC interactions
Participants suggested a multiplicity of ways to improve IPSC interactions but most common suggestions related to developing interventions aimed at students including both formal and informal interventions, as suggested by previous researchers.2 6 7 13 Also highly salient were organisational interventions such as protected time and co-located space, also supporting previous research.2 9 10
RQ4. Similarities and differences in understandings, experiences and suggestions
An assortment of similarities and differences existed between students and clinicians and across the professions in relation to understandings, experiences and suggestions. Indeed, we felt it was crucial to explore such similarities and differences in order to identify potential problems with the enactment of IPSC interactions in the workplace. For example, if students and clinicians report different understandings and experiences of IPSC interactions, this could hint at future difficulties with IPSC interactions in the workplace. In fact we identified seven notable differences between different types of participants that are worthy of further consideration.
In terms of differences between students and clinicians, we found four key differences. First, clinicians most commonly conceptualised IPSC interactions as student learning and narrated IPSC interactions involving student learning, whereas students more commonly understood IPSC interactions as team-working to deliver patient care and narrated IPSC interactions involving team-working, student learning and roles. This suggests that clinicians might not fully appreciate the diversity and breadth of interprofessional learning opportunities afforded by the workplace, meaning that they might miss opportunities with students from other professions to facilitate their learning of interprofessional team-working and roles. Second, students evaluated their IPSC interaction narratives more positively than clinicians, plus students outlined many more positive consequences of IPSC interactions than clinicians, indicating that students more readily realised the benefits of IPSC interactions than did clinicians. This is perhaps consistent with uniprofessional research illustrating some clinicians’ reluctance to teach healthcare students in the workplace.4 However, this finding again points to the notion that some clinicians do not fully appreciate the benefits of informal interprofessional learning for students. Third, clinicians talked more about negative individual and interactional contributory factors for negative IPSC interactions than did students, who mostly focused on organisational contributory factors. This suggested that clinicians more readily blamed individuals (often students) and relationships for negative IPSC interactions, whereas students seemed more comfortable to blame the system. Indeed, students’ articulated contributory factors related to the culture of healthcare, which sees innumerable healthcare hierarchies existing—including levels of training, specialties and healthcare professional groups—all of which have the potential to affect interprofessional learning and working.4 33 While students in our study may have censored their narratives given that some of their teachers were involved in this research as co-investigators, this difference between student and clinician perceptions of contributory factors might mean that negative IPSC interactions are hard to resolve. Fourth, students were much more likely than clinicians to cite decreased well-being as a negative consequence of IPSC interactions. This illustrates that clinicians perhaps do not realise the importance of students having positive interprofessional interactions in the workplace in order to protect their well-being. Indeed, clinicians may be unaware of the extent of psychological distress caused to students by negative IPSC interactions.4
In terms of differences across the professions, we identified three noteworthy differences. First, medicine participants most frequently evaluated their stories as negative, perhaps aligning with others’ research suggesting that doctors may be reluctant to learn from other healthcare professionals and are less ready for interprofessional learning.21 34 35 However, an alternative interpretation might relate to medical students experiencing negative interactions due to the hierarchy in the workplace.4 33 For example, one medical student reported being warned not to get on the ‘wrong side’ of other professionals and was given a hard time on placement, and another was warned not to treat others badly like their senior medical colleagues when they qualified in the future. Second, while most professions cited interpersonal contributory factors for negative IPSC interactions, paramedicine and midwifery typically cited organisational factors, possibly reflecting the more unpredictable and emergent nature of midwifery and paramedicine practice.36 Finally, all professions suggested interventions at the individual level, except nursing and paramedicine who instead recommended relationship or organisational level interventions, respectively. These differences may reflect the enculturation of nursing for extensive interprofessional team-working (learnt from day one of nursing student placements) versus the relative independent practice of paramedicine, as well as paramedicine education taking place in typically uncontrolled and variable learning environments.36 Altogether, these profession differences speak to Eraut’s16 context factors believed to affect workplace learning and indicate future possible challenges around IPSC interactions in the workplace.
Methodological strengths and limitations
To our knowledge, this is the first study of its kind to explore students’ and clinicians’ experiences of work-based IPSC interactions. While our most common study findings are largely consistent with previous research at the postgraduate level,6–9 our findings illustrate greater breadth and depth of understandings, experiences and suggestions and in a previously under-researched context, that is, preregistration learning. Furthermore, unlike these previous studies, which tend to focus on medical learners, our study focuses on both learners and clinicians from six different healthcare professions and has made comparisons between students and clinicians and across professions. Moreover, we have collected a large number of narratives from a sufficient sample size of students and clinicians. Indeed, given our: (1) focused study aim; (2) drawing on informal learning theory;16 (3) strong dialogue between interviewers and participants and (4) thorough team-based approach to framework analysis,24 we believe our sample has sufficient information power.37 Finally, we believe our reflexive approach to teamwork throughout the study,29 from study conception through to recruitment, data collection, analysis and finally, write-up, has helped us to work better collaboratively and added to the rigour of our analysis and interpretation of the data.30
In terms of the methodological challenges of this study, while we use a qualitative interpretative approach, we have quantified some of our data to explore patterns in what is a reasonably large qualitative dataset. Although this is methodologically legitimate28 and has been carried out in other published qualitative studies,26 27 purist qualitative researchers may baulk at our approach. Second, while our total sample size could be considered large for a qualitative study, our numbers of students and clinicians representing each profession (eg, three midwifery students, four midwifery clinicians) were reasonably small making comparisons at the level of clinician/student and profession challenging. Furthermore, our sample size of students (n=38) was larger than clinicians (n=23) meaning that our comparisons between these two groups are tentative. Although our sample of students and clinicians was diverse in terms of professions, age, gender and ethnicity, our sample had disproportionately higher numbers of white and female participants, meaning that our findings may be less transferable to non-white and male students and clinicians. While our diversity as a research team was an analytic strength, some of the investigators had educational relationships with student participants, meaning that some students might have been more careful to censor their shared experiences. Finally, while we mostly collected narratives in our study (through narrative interviewing techniques), we analyse our data for this paper using thematic analysis.24 While it is perfectly legitimate to analyse narratives using thematic analysis,38 narrative researchers might prefer narrative analyses to explicate more fully how narrators make sense of their experiences and identities through narrative. Such analyses are outside the scope of this paper but will be presented elsewhere.
Implications for educational practice
Despite the study methodological challenges, we are able to provide recommendations for further educational practice. We would urge both preregistration educators and students to pay more attention to informal interprofessional learning opportunities afforded by the workplace. Indeed, our study suggests that we need to invest time and energy in creating such opportunities for students through what Eraut16 might call deliberative learning. Therefore, we recommend that work-based interventions are developed directed at students (eg, guiding students to seek out meaningful IPSC interactions), clinicians (eg, encouraging clinicians to volunteer supervision and feedback to students from other professions), student-clinician relationships (eg, increasing opportunities for healthcare students to shadow other professions) and organisations (eg, facilitating co-located space for students and other professions to interact).8 While formal interventions might appear burdensome for already hard-pressed clinicians balancing patient care delivery with student learning,29 we believe that healthcare professionals could harness opportunities for informal interprofessional learning13 and without significant increases in time or workload. We think the positive outcomes from these interventions (including improved interprofessional attitudes and future interprofessional interactions) are well worth any extra investments in time and workload—for clinicians, students and patients alike.
Implications for further research
Further qualitative research is now needed across multiple sites and countries in order to ascertain the transferability of our study findings beyond our Australian context. Further research should include larger samples to allow for clinician/student and profession comparisons plus a greater proportion of male participants should check the transferability of the study findings to a broader population of male students and clinicians. Furthermore, as with research conducted at the postgraduate level,9 we would recommend the use of observational methods such as video-observation39 or video-reflexive ethnography40 in order to observe IPSC interactions in the workplace to better understand informal interprofessional learning through a multiplicity of relationships including IPSC interactions and interprofessional student-student interactions. Without such further research, it will be challenging to understand more fully the complexities of (and improve opportunities for) informal interprofessional learning for preregistration healthcare students.
Acknowledgments
We would like to thank all our student and clinician participants for sharing their understandings, experiences and suggestions with us so candidly.
References
Footnotes
CER and PC are joint lead authors.
Twitter Follow Charlotte Rees @charlreessidhu and Paul Crampton @DrPCrampton.
Contributors CER, FK, TB, ML, JN, KH, MS and BW designed the study and secured funding. CER, PC and FK secured ethics approval. All authors helped recruit study participants. CER and FK conducted all individual and group interviews. All authors participated in the preliminary analysis of data to develop the coding framework. PC coded all data and CER checked 20% of coding. CER and PC wrote the paper with all remaining authors editing and commenting on various iterations of the paper. All authors approve the final version. CER is Principal Investigator and PC Research Fellow and both act as guarantors for the paper.
Funding This study was funded by a grant from the Monash University Faculty of Medicine, Nursing and Health Sciences Learning & Teaching Research Grant Scheme 2016.
Competing interests None declared.
Patient consent Not required.
Ethics approval We received approval for this study from both Monash University (CF16/622-20160000301) and Monash Health (RES-16-0000547XL) Human Research Ethics Committees.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement We do not have ethics approval to make raw data from this study available for sharing.
Correction notice This article has been corrected since it first published. The joint lead authors statement has been added in.