Interprofessional education challenges in medical education of Iran CURRENT STATUS: POSTED

Background Interprofessional education is one of the most important educational methods for developing team work encounter with many challenges, especially in developing countries. The purpose of this study was to identify the important challenges of Interprofessional education in Iran's medical educational system. The qualitative content analysis was used to explain the perception and experience of 15 professors and experts regarding the challenges of Interprofessional education with semi structured interviews. The interviews were analyzed with Graneheim and Lundman qualitative approach in the MAXQDA software V.12 interviews were completed. According to the participants, the important challenges to designing and implementation of Interprofessional education was: 1) educational challenges, 2) structural challenges and 3) cultural challenges.


Abstract
Background Interprofessional education is one of the most important educational methods for developing team work encounter with many challenges, especially in developing countries. The purpose of this study was to identify the important challenges of Interprofessional education in Iran's medical educational system.

Methodology
The qualitative content analysis was used to explain the perception and experience of 15 professors and experts regarding the challenges of Interprofessional education with semi structured interviews.
The interviews were analyzed with Graneheim and Lundman qualitative approach in the MAXQDA software V.12 interviews were completed.

Findings
According to the participants, the important challenges to designing and implementation of Interprofessional education was: 1) educational challenges, 2) structural challenges and 3) cultural challenges.

Conclusion
Because of the importance of Interprofessional education to enhancing medical education, policymakers need to understand the importance of IPE and address the barriers and challenges they face. Also the Structures must be created and attitudes change.

Background
The role of organizations and higher education institutions in transferring education from an single profession approach to a multidisciplinary approach in health education is undeniable ( 1 ). The interest in Interprofessional education (IPE) has increased significantly over the past few decades ( 3 2 ). At the globally level, over three decades, health policymakers have identified the key role of IPE in improving the health care system and its implications ( 3 ). Interprofessional education as one of the new, efficient and effective approaches to improving the quality of community health services and adapting with the wide changes in the world, has attracted a lot of attention on the international level and its positive consequences in various areas of health care has been confirmed ( 4 ). In recent years, professional collaboration has gained popularity as a desirable approach to provide care in the health care system ( 5 ). Effective participative care between different professions of health care is an innovative strategy to improve the quality of actions and a key factor in successful implementation of organizational changes in clinical environments ( 6 ). To better equip future professions with collaborative knowledge and care approaches, appropriate training methods should be adopted ( 7 ). Consensus suggests that Interprofessional education is necessary to break the disciplinary silos and train specialists ready for teamwork (   4   8 ). Interprofessional education develops the students' academic achievement beyond the traditional curriculum. As a result, the students' understanding of different fields of health will increase the quality of patient care. In addition to a better understanding of the quality of patient care, Interprofessional education enhances respect and positive attitude among team members, which will improve the patient outcomes ( 9  14 ). Not only medical education system of Iran has no planned Interprofessional education course for students, but also unplanned shared learning courses does not have criteria's of IPE. One of the main causes might be the lack of familiarity with IPE and recognition of the challenges and opportunities of Interprofessional education. Qualitative content analysis was conducted to explain the perception and experience of professors and experts regarding the challenges of Interprofessional education. Qualitative content analysis is a research approach whose purpose is to provide new insight, enhance the researcher's perception of the phenomena, and identify operational strategies.
This research methodology allows researchers to interpret the originality and truth of the data mentally, but in a scientific way ( 15 ). So, this study was conducted to collect and analyze the experiences and views of experts involved in Interprofessional education in Iran's medical educational system to identify the important challenges of Interprofessional education with qualitative content analysis method.

Data collection
Semi-structured interviews were used for data collection. In order to conduct each interview, the participant was contacted first and after obtaining his/her oral consent, the time and place of the interview were determined according to the participant's schedule. Because it was possible that the participant was not prepared for the interview, the letter outlined the general framework of the topics the researcher sought to investigate. After determining the time of the interview, informed consent was obtained from the participant and a brief explanation was presented about the research and its Although the main data were derived from semi-structured interviews, observations, filed notes, memos, and reminders were also used alongside the interviews. Observation notes showed what happened during an interview. Filed notes included observed interactions reported in the field and showed analytical insights when collecting data. Reminders also reflected deep thoughts about the events, and were often written after leaving the field and analyzing the data (   17   ). Although these data were not all added to the aggregate data collected from the interviews, they helped to manage and formulate further questions and better understand the relationships between the issues, and thus assisted in data collection and analysis. In this research, we tried to maximize the diversity of the participants' selection based on research and educational activities and fields.

Data analysis
To analyze the data, interviews were summarized immediately (summaries included the interviewer's perception of the most important ideas presented in the interview) and transcribed. The interviews were then entered in the MAXQDA software version 12 and analyzed. To analyze the content of the interviews, we used the Graneheim and Lundman qualitative approach ( 18 ) as follows: 1) The researcher wrote the interviews and studied those several times in order to obtain a complete understanding of them.
2) All interviews were considered as a unit of analysis. A unit of analysis is the notes that are to be analyzed and encoded. 5) The codes were compared with each other in terms of similarity and differences, and classified under abstract categories with a specific label. 6) Finally, by comparing the categories with each other and thorough and deep reflection on them, the implicit content of the data was introduced within the themes of the study.

Trustworthiness
For accuracy and robustness of the study, the proposed criteria of Guba and Lincoln were applied (   18   ). The researcher enhanced the credibility of the data through long-term engagement and interaction with participants, collecting valid information and validating the acquired information. In order to increase the dependability of the data, measures such as stepwise data collection and analysis and using the views of supervisors and counselors were employed. In order to increase confirm ability, the faculty members' complementary ideas were used. Data transferability was assured by studying and providing a rich description of the research report in order to evaluate the applicability of the research in other fields. Quotes from participants were presented as explained.
Since the data collection tool was interviews, this research was not as free from error as other qualitative research, as thoughts and opinions of the interviewer could affect the subject of the research and the process of data collection. Bracketing of the researcher's ideas done in the process of data collection and analysis.

Ethical consideration
After obtaining an introduction letter from the Research Deputy of Shahid Beheshti University of Medical Sciences, the researcher introduced the research team to the participants and explained the goals of the study. First, informed consent was obtained from all participants. All participants were assured that their responses remained confidential to the researcher to decrease the respondents' biases. Interviews were recorded after the participants' permission and transcribed with a code determined by the participants. The researcher assured them of the anonymity and confidentiality of the data.

Results
There were 15 participants (10 Female and 5 Male) in the study and 15 interviews were completed.
There were 4 participants in medicine, 6 participants in nursing and 5 participants in medical education field. The position of 10 participants was Faculty member and 5 participants was Manager.
Participants stated that development and implementation of Interprofessional education in medical education of the country is associated with many challenges that must be overcome before the curriculum of Interprofessional education is designed. According to the participants, these challenges could be categorized in three categories: 1) educational challenges, 2) structural challenges and 3) cultural challenges. (Table 1).

Educational challenges of IPE
Participants stated that educational challenges were one of the main challenges. Almost all faculty members described incapability of teachers as one of the major educational challenges. One of the professors said, Participants stated that appropriate designing and development of IPE initiatives in the country's educational system required appropriate educational environments:

"IPE cannot be translated into existing areas and environments, and new patient-centered fields should be created."
Obviously, as long as people are physically separated, they do not have the opportunity to interact well enough and will have trouble working together. Participants in the research also acknowledged the necessity of interaction and cooperation in IPE: Wrong and destructive attitudes in the society and university result in negative stereotypes in the students, leading to the students' lack of knowledge about other majors and individuals. In many cases, some students think their major is more important than other majors and are reluctant to cooperate and interact with other students, which has destructive effects on the health system after graduation: "Students of different disciplines do not have a good attitude towards each other, which causes disgust." "The culture that exists in our universities makes our medical students think that they are better and different from other students. This attitude does not make the students interactive, so students do not have a common mental model for a patient."

Discussion
According to the participants, designing IPE in an educational system is associated with several barriers such as educational, structural, and cultural barriers. Barriers to the IPE initiative occur at different organizational levels, including policy makers, managers, faculty members, and students. The findings of the study showed that cultural challenges that were mainly related to the attitude of managers, faculty members, and students influenced the design and implementation of IPE.
Developing a culture of IPE requires faculty members in various majors that value Interprofessional education and are committed to collaborative work for the creation of a shared vision. Faculty members need to engage in skill and quality improvement, patient safety, and interdisciplinary interaction within the health care system to teach the content and serve as role models and mentors for students ( 29 ). In addition to the role of beliefs and values in the essence of IPE, attitude is also an ideological element. Significant emphasis of almost all participants revealed the importance and necessity of cultural change as well as the role of attitudes and ideological elements in IPE. The process of changing the attitude and moving toward IPE requires a change in the organization's culture, which is a slow and gradual process (

Availability of data and material
The datasets during the current study are not publicly available due to confidentiality of the students' data, but they will be available upon reasonable request.