The Impact of an Intervention on the Medical, Dental and Health Sciences Students About Interprofessional Education and Collaboration; A Quasi-experimental Study

Interprofessional education and collaboration (IPEC) fosters patient safety and encompasses integration, communication, mutual trust and shared decision-making. Despite its crucial role, the IPEC has not gained its anticipated popularity. This study aims to determine the impact of an educational intervention about IPEC on medical, dental and health sciences students in the University of Sharjah. Methods This quasi-experimental research was conducted in three phases; a pre-intervention phase where the Readiness for Interprofessional Learning Scale (RIPLS) inventory was administered online to the medical, dental and health sciences students of the University of Sharjah; an intervention phase where an online workshop was organized via Microsoft Teams®; and a post-intervention phase where RIPLS was used to gather the students’ attitudes towards IPEC. The independent t test was used to compare the responses between genders and junior and senior students. A paired sample t test was used to determine the impact of the intervention on the students’ understandings. A comparison of the pre-post intervention for the subscales of and collaboration, improvement of


Introduction
Interprofessional education (IPE) embraces faculty and students from two or more health professions where they jointly learn in a collaborative environment (1). An overlapping terminology is Interprofessional Learning (IPL) which, as coined by Reeves and Freeth, refers to a learning process that can result from the interaction between members of two or more professions (2). However, IPL is not necessarily an outcome of IPE since it can occur spontaneously in the workplace among members of different disciplines (3,4). From the viewpoint of clinical practice, the best practice model of IPE is the interprofessional education and collaboration (IPEC) where a patient-centered focus is considered in a multi-disciplinary climate healthcare system (5). The primary objective of IPE along with IPEC is to produce healthcare professionals who can work together in an integrated patient-centered care team to improve patient outcomes and satisfaction (6).
The vast expansion of the medical specialties and subspecialties, together with an unprecedented sophistication of skills required in each specialty, have created a genuine need for IPEC in today's clinical practice. In fact, the World Health Organization (WHO) has endorsed a deliberate achievement of IPL to improve patient health and safety (learning together to work together for health) (7). Such emphasis of the WHO on IPE restates its crucial role in healthcare professions. However, a well-structured program for embedding IPE and IPEC in medical education and clinical practice is not available across the globe. In 2011, six professions have joined together as an Interprofessional Education Collaborative Expert Panel to set core competencies for preparing healthcare professionals towards IPEC (8). These professions include six American Associations from Nursing, Osteopathic Medicine, Pharmacy, Dental Education Association, American Medical Colleges, and the Schools of Public Health. Since then, there witnessed a rapid expansion of the IPEC initiatives including the development of several curricula with horizontal and vertical integration of IPE (9,10). The role of IPE is becoming increasingly imperative in today's medical education since it can signi cantly reduce individual resistance towards interprofessional collaboration.
Nevertheless, a remaining challenge for the expected readiness of IPEC is the limited implementation of the concept of multidisciplinary healthcare in most clinical settings worldwide. This factor minimizes the opportunities for effective collaboration among healthcare professions (11). Additionally, there is a lack of a uni ed and validated educational framework that can embed interprofessional collaboration among healthcare professionals from different disciplines. Another crucial hindrance to the smooth inculcation of IPE modules into the existing medical curricula is class scheduling (12). Creating an IPE calendar that can cater to diverse learners' needs is a challenge and sometimes not possible.
Over time, the consistent and wide adoption of IPE can reshape how future clinicians and healthcare systems apply interprofessional collaboration in routine clinical practice. However, during and after the COVID-19 pandemic, little is known about the effectiveness of the online intervention and education of IPE and IPEC that can comprehensively reciprocate the face-to-face educational models. The online courses are shown to be more exible for students and faculty with busy schedules and can be remotely accessed with impactful teaching and learning activities (13). Unfortunately, literature does not provide evidence of the impact of an IPEC intervention via a distance learning model on undergraduate or postgraduate medical and health sciences students.
Accordingly, there is more to investigate for tools and methods to improve the delivery and implementation of IPE in the undergraduate and postgraduate medical training curricula. At the same time, the readiness of the learners from a range of medical and health sciences disciplines should be determined before the inclusion of IPE into the curricula. The present study aims to determine the impact of an online educational intervention of IPE and IPEC on the undergraduate students from different medical and health colleges at the University of Sharjah (UoS), United Arab Emirates (UAE).

Context and participants
We conducted this quasi-experimental study on the currently registered undergraduate students of the College of Medicine (CoM), College of Health Sciences (CHS), and the College of Dental Medicine (CDM) at the UoS, UAE between June and October 2020. Both feasibility and purposive sampling techniques were adopted to recruit the study participants. A pre-and a post-test quasi-experimental design were used for the collection of data. The primary objective was to determine the impact of an online educational intervention of IPEC on the recruited students and to compare the differences of attitudes and understandings between genders and junior and senior students.

Study settings and design
The CoM runs a 6-year MBBS program that adapts a problem-based, community oriented, and studentcentered approach. The students have early clinical exposure and the program gradually enhances the integration of basic and clinical sciences with an emphasis on group work, clinical reasoning and community-based research. The CHS conducts seven undergraduate four-year programs that involve laboratory and clinical training. The programs offer an active learning environment for students, which involves team-based learning, problem-based learning and ipped classrooms. The programs equip students with skills in conducting scienti c research and prepare them to serve the patients and the scienti c community immediately after their graduation. The CDM provides a ve-year program of dental surgery, which provides holistic problem-based expertise through the integration of dental clinical practice and dental health sciences. Students are well trained to manage community-based health problems as well as individual patient care. Currently, there is no formal sturctured IPEC curriculum or training in the participating medical colleges. However, some unstructured educational activities are done by some colleges.
We conducted this research in a pre-intervention, intervention, and a post-intervention phases. An anonymous online survey was used (Google® forms) to collect the participants' responses in each phase. The online workshop was organized using Microsoft Teams® during the interventional phase of our study.

Pre-intervention phase
We used the 19 item-modi ed version of the Readiness for Interprofessional Learning Scale (RIPLS) in our study (Appendix A) (14). A total of 800 students were invited to participate in this phase. The RIPLS scale has three main components: a subscale of teamwork and collaboration (TC) from statements 1-9, a subscale of professional identity (PI) from statements 10-16, and a subscale of professional roles (PR) from statements 17-19. A ve-point Likert's scale including strongly agree, agree, undecided, disagree, and strongly disagree was used for all statements. In addition, the questionnaire included an open-ended qualitative question. Informed consents were obtained from all participants and the questionnaire was administered online two weeks prior to the intervention phase. This served as a benchmark to determine the baseline attitudes and readiness of the students about IPEC.

Interventional phase
During the interventional phase, an online workshop was organized via Microsoft Teams ® where a representative sub-group of 55 students from CoM, CHS, and CDM actively participated. These students were recuirted in the interventional phase as that was primarily based upon their interest and willingness to participate. The layout of the online workshop is illustrated in Figure 1.
The intervention included a 20-minute introduction and orientation of the IPE and IPEC by the principal investigator. The orientation part focused on the understanding, value and impact of IPEC in patient care. Later, the participants were divided into ve groups, each group had 11-12 students with comparable representations from CoM, CHS and CDM. Each group was assigned into a separate breakout room with a facilitator and a team organizer for technical support. The facilitatros had su cient experience in IPEC.
In the breakout session, all ve groups of students were instructed to simultaneously but separately solve a clinical scenario during a 30-min interactive case-based discussion session. One case scenario was used for all groups (Appendix B). The case scenario described a patient with complex clinical conditions that require multidisciplinary care. The facilitators' role was to oversee the discussion and observe interactivity and engagements among students. The facilitators encouraged the participants to engage and create an interprofessional climate by e cient communication and to secure a joint management plan. Finally, all participating students joined back to the main meeting room to share their verbal feedback and re ections in a 15-minute session. Moderators from each group provided ratings of the online intervention.

Post -intervention phase
The RIPLS questionnaire was administered to the students through Google Forms® for their postintervention understanding about IPE.

Statistical analysis
The quantitative data were analysed using the Statistical Package for the Social Sciences (SPSS) Inc., version 20.0. We performed reliability analysis using Cronbach's alpha and descriptive analysis by summary statistics, which includes mean, standard deviation, minimum and maximum values of three factors of RIPLS such as TC, PI and PR. This data was generated as clustered bar charts of frequencies.
We also performed the independent t test to compare the responses of male and female students as well as junior and senior students. Finally, we performed a paired sample t test to determine the impact of the intervention on the students' understanding and readiness about TC, PI and PR in IPE. A p-value of less than or equal to 0.05 was considered statistically signi cant.

Results
During the rst pre-intervention phase, of 800 invitees, we received 530 complete responses (a response rate of 66%). The data included 183 students from CoM, 187 CHS, and 160 from CDM. There were 175 male and 355 female students and 304 junior (1st year to 3rd years) and 226 senior students (4th and 5th year).
The reliability of the RIPLS instrument is shown in Table 1, which con rms that all three RIPLS sub-scales of TC, PI, PR have greater Cronbach's alpha values than the cut point of 0.70. The descriptive analysis of the data showed that the sub-scale TC had the highest mean of 4.15, which indicates that students showed more agreement with the TC as compared to other sub-scales. frequencies of the responses to TC for statements 1-9 are shown in Fig. 2. We have observed that the majority, 335/530 (63%), strongly agreed with the statement 'for small-group learning to work, students or professionals need to respect and trust each other'. This nding indicates that the students showed their readiness for small group learning in IPE. Likewise, the responses to the other eight statements under subscale TC are shown in Fig. 2.
The observed frequencies to the subscale PI of the RIPLS inventory (statements 10-16) are shown in Fig. 3. In this category, a majority, 184/530 (35%), strongly agreed with the statement 'shared learning with other health and social care professionals will help me to communicate better with patients and other professionals. Interestingly, we have observed that the students showed strong disagreement with the statement, 'I don't want to waste time learning with other health and social care students/professionals' with the highest 221/530 (42%) disagreement rate.
The observed frequencies of responses to the subscale PR for statements 17-19 of the RIPLS inventory are shown in Fig. 4. The strongest agreement, 220/530 (42 %), was observed for the statement, 'the function of nurses and therapists is mainly to provide support for doctors. The students showed strong disagreement, 173/530 (33%), to the statement 'I am not sure what my professional role will be/is'.
The results of the independent sample t test for the comparison of the responses between male and female students to the RIPLS inventory is shown in Table 2. First, from the entire cohort, we found signi cant differences in opinions about subscales of TC and PR. Female students' readiness (4.21 ± 0.54) for TC was signi cantly higher than male students' readiness (3.95 ± 0.77). On the other hand, male students' readiness (3.22 ± 0.81) for PR was signi cantly higher than female students' readiness (3.05 ± 0.73). Second, for subgroup analysis of the three colleges, we observed that readiness for TC in female students from the CoM was signi cantly higher than readiness of male students. The readiness for PI was higher in male tahn female students in CHS. We did not nd a signi cant difference between male and female students from CDM. Using the independent sample t test, the comparison of responses to the subscale of TC, PI and PR between junior and senior students from all three colleges is outlined in Table 3. Overall, we found signi cant differences only for PR where senior students' readiness (3.15 ± 0.71) was signi cantly higher than the junior students' readiness (3.95 ± 0.77). For the subgroup analysis of colleges, a pattern was recorded between junior and senior students of the CDM. However, we did not nd any signi cant difference for students from CoM and CHS. A comparison of pre-post workshop responses of students using a paired t test is outlined in Table 4. Using the RIPLS inventory, the readiness of all students for IPE signi cantly improved after intervention for all subscales. However, the acceptance of the subscale PI improved more signi cantly by intervention with a highest mean difference of 0.41 than TC and PR subscales. Finally, the ratings by the facilitators of the intervention workshop are provided in Table 5. For most observations, the facilitators ranked a high median of 4. However, a low median of 3.5 was recorded for the statement, 'there were su cient contributions to patient care from different disciplines. This showed that the facilitators were either undecided or partially agreed with the statement. For the statement, 'the group recognized when the team was not functioning well' the facilitators remained undecided with a median of 3.  In this study, students scored a pre-intervention highest mean of 4.17 for the subscale TC. Literature has argued that IPE leads to IPEC and this phenomenon takes place when different healthcare professionals work collaboratively with patients, relatives, caregivers, and societies to deliver the highest level of care (15). Historically, medical and health sciences students are taught in silos. Once they graduate, they suddenly face a different working environment of clinical practice where they anticipate uncertainties in their new roles, show poor interprofessional communication, less respect for colleagues' roles, and misconception of one another's scope of practice (16). All such challenges endanger patient safety and dissatisfaction towards working in teams. To circumvent this misconception, Hallin et al., evaluated the medical, nursing, physiotherapy and occupational therapy students' attitudes after attending a clinical teamwork training (17). The study has shown that all student groups reported increased perceived knowledge of the other three professions (p = 0.000000). Additionally, the authors have proposed that the intervention had positively contributed to the understanding of communication and teamwork for the improved healthcare outcomes (effect size 1.0; p = 0.00002). Lastly, all groups thoroughly understood the clarity of their roles among teams (p = 0.00003). Such active interventions for IPE courses during the undergraduate training carry great promise in breaking the professional barriers and in harmonizing the collaborative practice.
We have observed that, during the pre-intervention phase, 63% of the respondents strongly agreed with the RIPLS statement 'for small-group learning to work, students or professionals need to respect and trust each other'. This resonates well with our study design where the online educational workshop was structured to adapt small group learning in a case-based discussion format. Our post-intervention analysis has shown a signi cant improvement of the students' attitudes towards IPEC by working in small groups. A plethora of published reports have endorsed the impactful role of small group learning in the medical eld (18) (19) (20,21). From a different perspective, we have observed that 42% of students showed strong disagreement with the statement, 'I don't want to waste time learning with other health and social care students / professionals. Again, this indicates the readiness of the participating cohort of students for further development and implementation of IPEC in their curriculum.
For the PI subscale of the RIPLS inventory, we have noticed a highest agreement of 35% of students about the role of effective communications among the professionals, patients, families, and community stakeholders in IPEC. An overarching concept of compassionate care relies on effective communication, which aims at developing meaningful and purposeful relationships among patients and professionals (20). Nevertheless, a professionally competent physician with poor communication skills can create misunderstanding, judgemental errors, and dissatisfaction among patients resulting in overall substandard clinical care. Therefore, enhancing communication skills of undergraduate medical students within an IPE context is essential (21).
In our study, a pre-intervention analysis of gender differences towards three subscales of the RIPLS inventory has signaled a more understanding of female students for TC (4.21 ± 0.54) than male students (3.95 ± 0.77). In contrast, male students' readiness for PR (3.22 ± 0.81) was signi cantly higher than in female students (3.05 ± 0.73). Similarly, the subgroup analysis of the students' perceptions from three colleges has shown signi cantly more readiness for TC among the CoM female students than males. By and large, we did not nd a signi cant difference in opinions of male and female students from CHS and CDM. In the study by Falk et al., the authors have deduced that male students from different programs were slightly, but signi cantly, less positive than female students during an interprofessional training ward course (22 (23). Furthermore, the investigators have maintained that simulation scenarios were more inspirational by female participants. These ndings of gender differences in attitudes towards IPEC closely articulate with our ndings, which may re ect a stereotype difference in the approach towards IPE and collaborative practice. Literature has not provided a logical justi cation for such gender differences. However, in institutions with a dominant gender representation, such ndings may be of signi cance for the implementation of the IPE curriculum.
Overall, we have found that senior students' readiness to accept PR was signi cantly higher than junior students. This nding is at par with the evolutionary phases and progressive maturity that medical students attain during their educational journey. MacDonald et al., have investigated the degree of knowledge about the role of others in an IPE atmosphere and have introduced a set of behavioural indicators that can facilitate educators in evaluating students in IPE courses (24). These behavioural indicators for the interprofessional competency include recognition of professional territories when the scope of one's profession ends and another's begins, resolving misconceptions, and respecting others' roles during collaborative efforts. Recognition of distinct professional roles and identities among a team of diverse healthcare professionals is also crucial for an ideal environment of IPE as well as for IPEC (25).
The moderators in our educational intervention awarded a high median of 4 to most statements. This reasserts the value of integration, harmony, and collaborative learning among students from different medical disciplines. Finally, a comparative analysis of the responses from pre-post workshop for the subscales of TC, PI and PR has reported a signi cant improvement in understandings and attitudes of students towards IPEC with p values 0.03, 0.00 and 0.00, respectively. Similar studies have shown a long term (26) as well as a short term (27) positive impact of IPE interventions on medical students and healthcare professionals. Regrettably, the positive impact cannot be sustained longitudinally. This is attributed to several obstacles and challenges that educators face during the implementation phase of IPE due to diverse disciplines, overcrowded timetables (28), inadequate resources (29), faculty resistance to the change, (30) and administrative hurdles (31). Some of these barriers can be overcome by regular faculty development programs (32) and by developing a curricular framework including representations from all medical and health sciences faculties (33).

Study limitations
We conducted this study during the peak of the COVID-19 pandemic when all restrictions of social distancing, partial lockdown were enforced in the UAE. This necessitated the use of an online application of Microsoft Teams®, which may have deterred the physical interaction among students and faculty. On the same note, faculty and moderators from different colleges were new to each other and had only virtual introductions during the online interventional workshop.

Conclusion
This study reports a positive impact of an interactive educational intervention on the attitudes and readiness of the medical, dental and health sciences students towards IPE and IPEC. Though the preintervention readiness of the students was encouraging, the post-intervention scores were signi cantly higher. These ndings provide insightful data to educators by indicating the receptiveness and readiness of students for a standard IPEC curriculum in the Gulf region.

Declarations
Ethics approval and consent to participate ). An informed consent was obtained from all participants and the research ethics committee has approved this process of consent. The consent process followed the policies and guidelines of the Declaration of Helsinki.

Consent for publication
All subjects involved in both methods have provided informed consent for participation and publication of this research.

Availability of data and materials
The questionnaire and the workshop case scenario are attached as appendices A and B, respectively. Any ddditional data can be provided on request. The corresponding author, Prof. Salman Yousuf Guraya, will provide additional data, if requested.

Competing interests
Not applicable.

Con ict of interest
Prof. Salman Y. Guraya is an associate editor for BMC Med Education journal. Other author (s) don't have any con ict of interest.

Funding
Not applicable.
Authors' contributions SYG conceived and designed the study, planned, and supervised study tools and interventions, performed analysis of results and revised the manuscript. LD and SH worked on recruitment of the participants and other researchers, data collection and initial and nal write up of the article. NM and SB participated in the interventional phase of the study and in manuscript editing and revisions. AH and MK managed the online workshop and data collection. All authors reviewed and approved the nal draft of the article.