Challenges Facing Proper Application of Interprofessional Education in Sudan: Perspectives of Candidates of Master of Health Professions Education (2020-2023)

doi:10.21203/rs.3.rs-5140051/v1

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Challenges Facing Proper Application of Interprofessional Education in Sudan: Perspectives of Candidates of Master of Health Professions Education (2020-2023)

https://doi.org/10.21203/rs.3.rs-5140051/v1

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Introduction

Traditional medical and health schools used to teach students in separated setup. However, gap appeared between the evolving challenges of health requirements and the static educational system. The latter has failed to keep in pace with the everyday changes in health needs. Interprofessional education (IPE) indicates interaction between various professions and creates a strong base for teamwork and collaboration. The model of IPE is innovative method that might need planning and groundwork prior to execution.

Aim of the study

To determine the challenges that might face application of interprofessional education in Sudanese medical and health schools.

Research method

Design of the current study is descriptive cross-sectional study that conducted via questionnaire. The questionnaire divided into two parts. The first for personal information and second part to assess thoughts and views of the participants to the anticipated challenges for application of IPE in Sudan.

Population were candidates of program of health professions education in Sudan. One hundred and one candidates from various specialties participated in the study; (response rate of 51.53%) The results of statistical analysis use Statistical Package for the Social Sciences (SPSS) - version 28.

Results

Majority of participants believed that integrating 𝐈𝐏𝐄 curriculum content into existing curriculum represents an obstacle and suggested that learning approach and styles need adjustment for smooth implementation. Majority of participants supported that additional time is crucial to accommodate IPE curriculum. Significant differences in these finding differ according to academic rank, specialty involved and years of experience.

The participants believed in the negative impact of compromised funding, inadequate premises. Majority of the participants irrespective of their specialties, experience or rank assumed that enthused and motivated students -reasonable number of- would facilitate the application.

Conclusion

IPE is an innovative appealing model in adult education that needs meticulous planning and preparation prior to execution.

Clinical trial number: not applicable.

In a growing world of new challenges and risks that accompany the growth and transformation of population, a gap appeared between the evolving challenges of health requirements and the old static educational system. The latter has failed to keep in pace with the everyday changes in health challenges. Therefore a need emerges to more radical, advanced and comprehensive health system.⁽¹⁾ This, in turn, necessitates a new and more innovative educational model that take on the growing challenges.⁽²⁾

Background

Few decades earlier, in mid 1980s, healthcare educators began to delve into the importance of working as a team rather than in isolation. They observed that lack of communication and collaboration among health care providers eventually resulted in disjointed services -full of fighting spirit, and flawed outcomes in patient care. ⁽³⁾ In spite of the importance and early consideration of the concept, IPE evolved slowly until 21^st century, where actual steps took place in different countries and among all health professions. ⁽⁴⁾

Interdisciplinary approach is different from multidisciplinary where different specialties contribute independently to service provision. The former is distinct and characterized by concept of relational coordination that encompass respect, value, mutual support and trust, and shared goals that increase the effectiveness of the team.^{(5, 6)}

Professionals are convinced that each of them has a role to play. When they work together in harmony to achieve a specific goal, they can expect a better outcome.⁽⁷⁾ Research supports the concept that working in team is beneficial in problem-solving, sharing workload, reducing mistakes, promoting innovation, enhancing personal support and increasing opportunities for creativity.^{(8, 9)}

Interprofessional education (IPE) indicates interaction between the various professions and constitutes a strong base upon which teamwork and collaboration might stand. ^{(3, 10)}

Problem Statement

There is global consensus that interprofessional collaboration is crucial for better healthcare outcome. Interprofessional education is vital to improve and enhance the collaboration later in work field between different disciplines. During undergraduate and postgraduate study, it is essential that students’ of various colleges interact together such as school of medicine, dentistry, pharmacy, nursing, and public health, medical laboratory, imaging technology, physiotherapy, anesthetic technology, health informatics, biomechanics, biomedical engineering and others.

In Sudan, the model of interprofessional education is scarce. The problems that face its wide implementation are not clear. This study aims to explore anticipated challenges and obstacles that might face proper application of interprofessional education in universities in Sudan.

The study consider some challenges that relate to the three main pillars; the learners themselves, the institute and the teachers.

The design of the study is descriptive cross-sectional study. The study took place in Sudan Medical Specialization Board (SMSB), among participants in master of health professions education where different fields of health and medical schools and medical teaching setting (e.g. teaching hospitals) from both private and governmental universities and colleges from all over Sudan gathered in one program. To attain the objectives of the study and explore faculty’s perspectives about difficulties, the participants were selected as they joined in a setting of IPE and have actually experienced the model.

All candidates registered and successfully joined the program- regardless of age, gender, specialty- were invited to participate in the study (total coverage -comprehensive). Those who successfully completed the questionnaire are included.

Candidates who withdrew after registration, those who did not fill the questionnaire, registered candidates who were out of reach (e.g. switched off cellphones) were excluded.

The study took place over the period of 2020 to 2023.

Method and Data Collection

The current study aims to investigate the obstacles and difficulties that may impede the application of the model in Sudan, including institutional factors. The study conducted via electronic questionnaire (Google form), that was adjusted specifically for the purpose of the study and modified from many studies ^{(11, 12, 13)}. Before administering the questionnaire to the participants, it was validated by a number of content experts -to ensure suitability with the context- who read and made amendments to the questionnaire. The study involves personal opinions therefore Likert rating scale used with five options that range from ‘strongly agree’ to ‘strongly disagree’.

The link for the questionnaire sent to all participants via electronic emails, text messages and through different social media applications.

The questionnaire structured into various sections to address the different objectives of the study The first part (Section A) of the questionnaire formulated to include questions to record the affiliation and academic rank of the participants and years of experience of teaching.

The second part (Section B) of the questionnaire composed of three subsections B.1 and B.2). It was designed to find out the thoughts and views of the participants with regard to the anticipated challenges for application of interprofessional education in Sudan. This part of the questionnaire was constructed by the author of the current study with reference to two studies, the first explored the difficulties involved in the implementation of interprofessional education in Iran ⁽¹¹⁾, and another conducted to assess the difficulties in developed and developing countries ⁽¹⁴⁾.

At the end of each of the subsections B, there are qualitative study with open-ended questions that give a chance for a participant to add factors that he / she belief to be an obstacles to IPE. In order to give an opportunity and open the door for other, yet unseen, challenges.

Data management and Analysis

Descriptive analysis applied to the results using Statistical Package for the Social Sciences (SPSS) - version 28. Inferential analysis were using Chi-square test with cross tabulations. The differences considered statistically significant when P. value ≤ 0.05. Description of the qualitative data made using text data

Ethical consideration

Ethical clearance obtained from the ethical committee of EDC in Sudan Medical Specialization Board (R2020/3). Detailed information about research was given to participants and consent obtained. All participants had the right to quit the study at any point without any consequences. Questionnaires were anonyms to ensure confidentiality of participants. All information taken from participants kept confidential and used only for the purpose of the study.

The number of respondents was 101 out of 196 that are approximately 51.53%. The distribution of the participants revealed that majority of them belong to faculty of medicine (55.4%) while participants from dentistry represents (22.8%), medical laboratories (8.9%), pharmacy (7.9%), and physiotherapy (2%)

The study revealed that years of teaching (i.e. experience) for majority of the participants fell in the category of 5-10 years (35.6%), while 26.7% of the participants reported to work in teaching for less than 5 years, and 21.8% of them have an experience of 10-15 while the remaining 15.8 % of participants have experience for more than 15 years.

Challenges, obstacles and factors related to institution

In Section B1, the questionnaire considered challenges and obstacles of the application of IPE that of concern for institute itself. Among all participants, 61.4 % believed that integrating 𝐈𝐏𝐄 curriculum content into existing curriculum represents an obstacle. While 26.8 % considered integrating the model into the existing curriculum is not an obstacle and 11.9 % were indeterminate i.e., neutral. Correlating this response in relation to different colleges, using Chi-square test this finding was significant (P value 0.01).

With regard to traditional curriculum, 79 of the participants (78.2%) supported that it impedes the implementation of the model of IPE, 14.9% were neutral while 4% of them disagreed. The response to years of teaching was significant (P value 0.017).

Most of the participants (96%) believed that learning approach and styles need adjustment to ensure smoothness of implementation, 3% were neutral while 1% of the participants disagreed with that. On correlating this response to academic rank was significant (P value 0.001).

Majority of the participants 60.4% supported that additional time is crucial to accommodate the IPE curriculum, 26.8 % disagreed and the rest (12.9%) were neutral. On correlating this response in relation to various colleges and academic rank, using Chi-square test the result were found to be significant (P value 0.013, 0.001 respectively)

Majority of the participants (98%) believed that the coordination and support of the administrators and top management of the institute are essential to apply IPE smoothly. On correlating management support with three variables; various colleges, years of experience. and academic rank, only academic rank was significant (P value 0.005).

Among the participants, 68% considered that lack of adequate funds to support the model may negatively affect its application, 19% of them disagree while the rest (13.9%) were uncertain about that. The response to adequate funding was found to be significant (P, 0.001) in certain colleges, for other colleges this was insignificant or not essential.

The last question in the category of the challenges related to the institute is concerned with the premises, the participants asked if special premises to accommodate students are essential for application of IPE, 82.2% agreed, 6% disagreed and 11.9 % were indeterminate. These results revealed statistically insignificant relation with years of teaching 0.419, academic rank 0.829 and specialty of colleges 0.075.

The participants believed that political and economic instability of the country lead to phenomenon of so-called “brain drain” that result in lack of necessary adequate staff as they stated rather than extra number of teachers. They suggested that training is necessary to staff and students and they counted that objectives, roles and responsibilities, duties and values should be clear, shared and agreed upon to reduce conflict and alleviate friction.

Concerning factors related to learner (section B2), 70.3% believed that various health students with different level of knowledge might face different obstacles to application of 𝐈𝐏𝐄, 19.8% disagreed, while 9.9% were uncertain. In this regard, years of teaching showed significant relation (P 0.020). Other elements (various colleges and academic rank) showed statistically insignificant relation. (P value 0.252, 0.132 respectively)

The questionnaire contains a section where participants were given chance to express their opinion with regard to the factors related to learner, one of them claimed that academic levels of student may affect the application. In other words, students in early years may differ from those in the advanced year (junior vs. senior). Therefore, some stated that IPE should be introduced early at an early level.

Clarification of the objectives for this learning model and availability of a strict action plan is an essential factor for smooth application of the paradigm. Motivation and communication skills of the learners are important for facilitating the implementation. Some of the candidates pointed out that training of IPE model in work place and hospitals, so those who have no idea will know the benefits to patients.

Some of the participants believe that students have to learn and practice problem solving first to be ready for IPE application. Some of the participants claimed that learner –as for staff- need training and briefing about IPE.

Some other candidates believe that it is essential to match the levels between students, i.e. matching the academic level (clinical, preclinical and basic sciences….etc.) to avoid attitude difficulties.

The present study conducted to find out the difficulties that may impede IPE application in Sudan. Participation of the study necessitate that subjects are familiar with the concept of IPE. Therefore, selection of the study area and research subjects has been based on the factor that participants being exposed to the model through the program of master of health professions education in Sudan Medical Specialization Board, where various disciplines learn from, with and about each other. This conforms with the definition of IPE, which is focused on the three main elements of the interaction, when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes in the future ⁽¹⁰⁾

Although response rate of the study was 51.53% and number of participant is 101 but in medical literature scientist accept studies with small sample especially if they test presence of effect rather than the effect size. Political instability and network interruptions in Sudan attributed partially to reduced response rate. Efforts exerted to encourage participation in spite of the fact that the duration of data collection extended.

Implementation of the model is a bit complex process that requires inputs from multiple factors operating simultaneously. Issues related to the satisfactory application of IPE grouped into factors pertinent to the institute, learners and teachers. Those related to institute can further categorized into aspects related to the curriculum, top management enthusiasm, commitment, allocation of funds and availing suitable premises. The curriculum components are content, structure, timeline, strategies and implementation.

The IPE necessarily links various specialties in a common course where all of them must learn. In IPE, meticulous planning of calendars, learning approaches and coordinated sequence of courses are very important factors prior to execution. The courses need meticulous planning and design before the start of the academic year. The phases and venues are coordinated to suit students from all disciplines. In our study, many of the participants thought that introducing the model into existing curricula –especially if traditional- might need adjustment. There is significant difference in the responses among participants from different specialties (P 0.01) and this could be due to condensed curricula of certain schools compared to others. Time allocated for them, as reported by 60.4% of the participants, need modification. On correlating this response in relation to different variables, various colleges and academic rank showed highly significant association (P value 0.013, 0.001 respectively). Likewise, the diverse curricula of various specialties and their emphasis may be behind this response.

In our study, the majority of the participants (96%) believe that learning approach and styles need modification. Correlating approach and styles to academic rank found to be significant (P value 0.001). This in agreement with certain studies which pointed out that in most of IPE setting simulation-based instruction, e-learning and problem solving are the commonly used as effective methods ⁽¹⁵⁾. This result also consistent with the study conducted by Rosenfield and his colleagues in 2011, in which the participants were dissatisfied with delivering IPE in large group lecture that detracts from the interaction of groups and distorts the image of IPE/⁽¹⁸⁾

In the present study, 98% of the participants believed that the coordination and support of the administrators and top management of the institute are essential to apply 𝐈𝐏𝐄 smoothly, while the rest (2.0%) were neutral. Academic rank found to be significant factor (P value 0.005). This finding resembles the conclusion stated by other workers, that commitment of the program directors and top management and their enthusiasm to model are crucial for the success of application. ⁽¹⁰⁾ The support of the leaders is crucial, as IPE especially in the early stages of implementation needs financial support, adjustment and modification of the plans, academic calendars and policies, training for the staff and learners as well as authority.

Participants express their opinion with regard to the institute, they enforced that committed, and dedicated leadership is crucial because modification of the institute policies and adjustment of the strategic plan are necessary to allow induction of the model. They assumed that presence of many health schools in one institute is considered an advantage to facilitate the application, and presence of health schools within geographic vicinity is considered by some author as factor that ensure easy and smooth application⁽¹⁶⁾. This contention is understandable in a country like Sudan where transport represents an obstacle. However, Buring ⁽¹⁷⁾ and his co-worker pointed out that the model should be implemented even if in isolated school. They suggested collaboration with other institutions or community service facilities. For the didactic component, online education might be an attractive solution.

In our study, some of the participants believed that collaboration across different institutes might not succeed due to the differences in socioeconomic status and physical distances. The participants emphasized the role of the institute in organizing and preparing the environment and availing the funds and resources needed to recruit and train extra staff.

For IPE the teachers or facilitators represent a fundamental element for application ⁽¹⁷⁾. Implementation of the model is a new experience for educators, even the experts. This is because IPE involves work as a member of a team from different disciplines, as well as facilitation in groups of different background ⁽¹⁷⁾. Therefore, training of the teachers to familiarize them with the model seem crucial step for success of implementation. In our study majority of the participants, believe that teachers involved need training prior to implementation. Sufficient number of trained staff members is considered mandatory in agreement with other study ⁽¹⁶⁾.

In the process of IPE, various professions brought to work together. Unfortunately some of them might fetch their professions’ ego with them and this represents a major obstacle for the smooth application of IPE ^{(18, 19)}. Because it negatively affects both sides, the arrogant and the other who may either play a defensive and aggressive mode to support their professional identity or withdraw and retract leave their space empty and this will subsequently put the success of experience at risk. An essential factor for the success of the model includes motivation and enthusiasm of the staff. This idea is consistent with the findings of the current study where most of them agreed that this factor is essential for the application. Other obstacles that mentioned by the staff include political and economic instability of the country lead to phenomenon of so-called “brain drain” that resulted in lack or inadequate staff. They considered that objectives, roles and responsibilities, duties and values should be clear, shared and agreed upon to reduce conflict and alleviate friction among team members⁽¹⁶⁾.

The third pillar of IPE is the learner. The factors related to this aspect play a major role in application of the model. In our study majority of the participants (approximately 71%) believed that candidates with different levels of knowledge might face different obstacles to application of 𝐈𝐏𝐄. Other candidates assumed that it is essential to match the levels between different students, i.e. the academic level (clinical, preclinical and basic sciences….etc.) to alleviate this obstacle and avoid attitude difficulties. This is actually resolvable if the IPE model carefully planned at the optimum part of the curriculum where participants are in the same level i.e. that is to say in basic, preclinical or clinical phase. Other studies found that selection of the joint professions should be based on mutual collaboration of the specific course e.g. medicine, nursing, dentistry, nutrition etc⁽¹⁶⁾ Moreover, the model should be designed and prepared precisely with clear objectives and strict responsibilities, duties and solid restricted values⁽²⁰⁾. Students and their attitude to the model considered essential factors and this is rational since transformation or innovation take place successfully if the stakeholders are motivated and willing to join.

Large number of the students is considered by majority of workers and even learners to be a risk factor for the model ⁽¹⁵⁾. The reason is that implementation of the model may be easier if the number of learners is small to facilitate control and distribution of the duties and responsibilities. Small number of learners enables instructors to draw their enthusiasm and motivation to the model. In the current study, most of the participants assumed that learners with previous experience affect application. This may be a double-edged sword. The learners who have good experience will be motivated and willing to be part of the model and will have the concept of teamwork. While those learners who exposed to bad experience will be a focus of negative consideration and will be reluctant to partake in the application of the model. Some of the participants believe that motivation and communication skills of the learners are essential factors in facilitating the implementation. In an study conducted in Canada, learners underwent brief exposure to IPE and indicated that small group activities promote dynamicity among group and is preferable over lectures ⁽¹⁵⁾.

In the present study, participants had chance to share their thoughts and opinions. Some of the participants believe that students have to learn and practice problem solving first to be ready for IPE application. Others claimed that learners-as the case for staff- need training for IPE. Other participants argued that academic levels of student might affect the application. In other words, students in early years may differ from those in the advanced year (junior vs. senior/ clinical vs preclinical). Some stated that IPE must be introduced at an early level. In authors opinion meticulous planning of the model and selection of the most appropriate part or theme of the curriculum to implement it can address all these concerns.

IPE can be implemented in different setting and different phases of the curriculum such as lecture (least preferable)⁽¹⁵⁾, simulation based laboratories and clinical setting.

Participants emphasized the crucial role of clear objectives and strict action plan for the success of the model. As teams with many members of different background can easily miss the direction with subsequent failure of the model ⁽²¹⁾. Therefore, some of the participants suggested that IPE model need to be introduced in training and work place as well, so those who have no idea will know its benefits to patients⁽²²⁾. IPE although suggested as an essential concept of medical education but it is a complex procedure, the success of it rely in different factors

Recommendations

Further studies needed to determine the awareness of medical and health school about the concept of IPE and to determine the perception and attitude of other stakeholders such as ministries of health, higher education, health related partners and organizations. More studies to address other obstacles and difficulties that face IPE and explore ways to overcome them.

The current study conducted with the main objective to determine the challenges that face proper application of interprofessional education in Sudanese schools offering medical and health professions education.

The results documented:

Participants with longer years of experience think that traditional curriculum impedes the implementation of the model.
Staff of higher academic rank in various colleges believed that additional time is essential to execute the model.
The majority of participants valued the role of top management, staff number and training, and student motivation and enthusiasm in supporting the application of IPE.
Participants believed in the negative impact of compromised funding, inadequate premises. Large number and professional preference or dominance.

Ethics approval and consent to participate

Ethical clearance obtained from the ethical committee of EDC in Sudan Medical Specialization Board (R2020/3). Detailed information about the research was given to participants and consent obtained. All participants had the right to quit the study at any point without any consequences. Questionnaires were anonyms to ensure confidentiality of participants. All information taken from participants kept confidential and used only for the purpose of the study.

Consent for publication:

Obtained from EDC in Sudan Medical Specialization Board and from second authors).

Competing interests

Not applicable'

Funding

Not applicable'

Author Contribution

Both authors (E.K and Q.A) have made substantial contributions to the conception and design of the workE.K responsible for the acquisition, analysis, and interpretation of data; E.K and Q.A have drafted the work and revised itE.K and Q.A approved the submitted version

Acknowledgement

Not applicable'

Availability of data and materials

Not applicable'

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No competing interests reported.

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Challenges Facing Proper Application of Interprofessional Education in Sudan: Perspectives of Candidates of Master of Health Professions Education (2020-2023)

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Abstract

Introduction

Methods

Results

Discussion

Recommendations

Conclusions

Declarations

Ethics approval and consent to participate

Consent for publication:

Competing interests

Funding

Author Contribution

Acknowledgement

Availability of data and materials

References

Additional Declarations

Supplementary Files

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