A mixed-method study to determine the readiness of medical and health sciences students for interprofessional education in a Gulf university

Background High ‐ quality patient care is a complex phenomenon that requires collaboration among healthcare professionals. Research has shown that Interprofessional Education (IPE) carries promise to improve collaborative work and patient care. So far, collaboration among various medical disciplines remains a challenge. Several survey-based studies have reported attitudes about IPE, but very few mixed methods studies, particularly in Arabic-speaking countries, have been conducted to determine medical students’ perspectives and readiness. Methods A two-staged sequential mixed methods study was conducted among medical and health sciences students of University of [---],[country]. The perspectives of students toward IPE and collaborative practice were rst gathered by administering a validated instrument; namely Readiness for Interprofessional Learning Scale (RIPLS). This was followed by detailed focused group discussions. Quantitative and qualitative data analysis were performed using SPSS and NVivo, respectively. Results This study cohort included 282 students. All respondents showed readiness to adopt IPE as all statement of RIPLS survey scored high means. Highest mean of 5 was achieved for IPE elements of identifying and resolving patients’ problems and small group work. Three main themes were generated; prior knowledge, need for IPE framework and its implementation. Information workload, lack of clarity and less focused teaching pedagogies of IPE were considered as perceived barriers. Conclusion This study demonstrates substantial agreement of medical and health sciences students towards readiness and perceived effectiveness of IPE. Educators are urged to embed new IPE program into the existing curricular framework that can potentially enhance collaborative learning and improve quality of patient care.

formatively assess IPE and collaborative practice competencies [10]. Educating the learners about salient characteristics of high functioning teams prompted the development of the JTOG®. In Japan, an interesting study investigated the impact of Japanese and Scottish experience of care of diabetes mellitus [11]. The investigators have found that the international standards of IPE set forth for this study were able to raise awareness of diabetes mellitus in terms of patient-centred focused care. In summary, globally there is a trend to inculcate a culture of multi-disciplinary collaboration and team-work.
A modi ed Delphi process will be used in which a panel of Experts, comprising members from across the United Kingdom, with expertise in prescribing and medicines management with regard to the education and practice of healthcare professionals, and antimicrobial prescribing and stewardship, will be invited to take part in two survey rounds. IPE entails certain opportunities where two or more professionals learn with, from and about each other [12]. This integrated approach is in sharp contrast to multi-professional education that encourages health professionals to learn alongside each other in a parallel manner [13]. The outright bene ts of IPE include promotion of interdisciplinary collaborative work [14], overcoming the obstacles and misconceptions among healthcare groups and strengthening professional competencies [15]. Inter-professional practice engaging healthcare professionals from multiple stakeholders such as patients, families and communities improves quality of patient care [16]. Unfortunately, literature shows con icting narratives about a uni ed teaching framework that can be conveniently applied in achieving desired goals of IPE philosophy [17]. Some educators have suggested the delivery of IPE course during pre-quali cation phase [18], while others have argued that IPE would be more effective if taught during both pre-and postquali cation phases [19].
The inter-woven and complex nature of instructional strategies in various healthcare disciplines hinders a smooth incorporation of IPE modules into the existing curricula [20]. Crowded timetables, logistical obligations requiring simultaneous movement of large numbers of students for undertaking similar classes, and lack of resources are some of the main challenges to IPE [21]. Freeth et al. have introduced a 5-point framework of IPE that is based on real-time scenarios, exchange of ideas, simulation, observation, and practice [22]. While such insights seem promising, before designing any program, educators must capture opinions and perceptions of key stakeholders such as students, faculty, administrators and community representatives. Analysis of needs and readiness for IPE curriculum is the rst step in introducing a sustainable and relevant IPE program [23]. Based on a dearth of research in the MENA region about readiness and perspectives of medical students about IPE, this mixed-methods study was conducted. Consequently, educators would be able to effectively solicit and analyze such data for improving learning climate and in drawing students' motivation toward IPE.

Research Design
We chose a mixed method design and conducted the study in two phases: a cross-sectional questionnaire-based phase, followed by a deeper, focus group discussion-based phase. Students from the four colleges (Medicine, Dental Medicine, Pharmacy, and health Sciences) participated in both phases.

Study settings
The College of Medicine (CoM) at University of [---] runs a 6-year problem-based integrated MBBS program including a foundation year. This is a spiral curriculum that boasts on early clinical exposure and supports a student-led learning philosophy. A comprehensive assessment system utilizes a host of evaluation tools such as multiple choice questions (MCQs), Objective Structured Clinical Examination course lecture, attendees were informed about the purpose of this quantitative study and their verbal consent was sought. Students who agreed to participate were asked to ll out an anonymous paperbased questionnaire. The questionnaire was divided into three parts. The rst part inquired about some personal details including gender, age, college of enrollment and previous experience of IPE. The second part of the study questionnaire included a validated scale, Readiness for Interprofessional Learning Scale (RIPLS) [24].. The scale contains 19 close-ended statements about the readiness of medical students for interprofessional education and practice. The participants were instructed to respond on a 5-point-Likert scale in numerical values: 5 (strongly agree), 4 (agree), 3 (neutral), 2 (disagree), and 1 (strongly disagree) for all statements. The responses to RIPLS statements are portrayed in Fig. 1. In the third part of the questionnaire, students were asked to specify whether they are "with" or "against" IPE and whether they would be interested to participate in a focus group discussion to share their opinion about Interprofessional education. Students who agreed were asked to state their names and contact details for further communication. Research was conducted after obtaining ethical approval from Research Ethics Committee.

Statistical analysis
Statistical Package for the Social Sciences (SPSS) version 20.0 was used for statistical analysis.
Descriptive analysis was done by frequency distribution and pictorial representation was shown by clustered bar charts. As all statements were arranged in ordinal scale and inferential statistics were performed by non-parametric tests. The non-parametric Chi-square test was applied for the analysis of 19 statements (variables) that were arranged in categorical form. The Chi-square test was applied to explore the differences between observed frequencies and expected frequencies within each statement. A p value less than or equal to 0.05 was considered signi cant.

Phase 2: Qualitative study
During September 2018, students who, in the quantitative study, expressed an interest to participate in a focus group discussion were identi ed, contacted and invited to take part in the qualitative study.
Students were briefed about IPE and the nature of the study both verbally and using a participant information sheet. In return, they expressed two different attitudes: being (1) with IPE or (2) against IPE.
The perceived behaviors were context based that prompted the researchers to create the focus groups for choosing appropriate group homogeneity. Exogenous homogeneity re ects shared group dynamics such as demographics or profession, while issue homogeneity denotes a shared response towards a particular issue. Consequently, we adopted issue homogeneity; grouping multiprofessional students with similar attitudes together that would encourage and facilitate self-disclosure. We prepared four focus groups, two containing students who were with IPE, and two groups with students against IPE. Consent was obtained verbally during recruitment and upon participation in the focus group discussions.
A set of unbiased and open-ended questions and probes (attached) were devised to elicit the following information from participants: experience with IPE; possible structure and implementation of IPE; and perceived advantages and disadvantages of IPE. Four faculty members with experience in moderating focus groups led the discussions in separate private classrooms. The moderators recorded discussions, and the con dential recordings were handed over to the research team.

Empirical results
Of 300 invitees, we received 282 complete responses (N = 282, response rate of 94%). There were 237 (84.04%) female and 45 (15.96%) male students as shown in Table 1. The data showed that majority 251 (89.01%) of the students were from age group 20-24 years, while 16 (5.67%) students were less than 20 years and only 15 (5.32%) students were older than 24 years. As many as 93 (32.98%) students were from health sciences, 63 ( Don't know 2 (0.71%) Figure 1 shows clustered bar chart of observed frequencies in responses to statements regarding the readiness of medical students for interprofessional education and practice. For S7 'for small-group learning to work, students need to trust and respect each other' 665 (62.32%) students strongly agreed that respect and trust are most effective tools for small-group learning to work (Fig. 1). One hundred and sixty six (58.86%) students agreed with S15 'shared learning will help to clarify the nature of patient problems'. For S18, 'I am not sure what my professional role will be / is' 94 (33.33%) students rated it as neutral.
The results of the Chi-square test showed that the participants' responses to all statements were statistically signi cant (X 2 (4, N = 282) = 143.9 ~ 1440, p < 0.0001) as shown in Table 2. This infers that observed frequencies of student's responses were statistically signi cant from expected frequencies within each category (Table 2). During rst year of foundation of sciences we were studying physics and chemistry and biology with other specialists, such as MDI, MLS, and nutrition, we were studying together, it was so fun we didn't differentiate between others. Another statement we know more about how our friends are, and how we built friendships?

Patients' needs and proactive
Comprehensive and overlapping treatment plans allow us to not only look at patients as one thing but allows us to look at all their needs and prevent future problems from happening, so if we do this with more peers from other majors, it will actually cause us to look and actually help the patient in more than just his chief complaint. IPE will allow us to look at everything and prevent future problems from happening.

Learning
Ph1F: Basically, we share different experiences and different ways of thinking, for example, for me in Pharmacy, we think about medicines, just the drugs used. In Nursing, they think about the patients more regardless of their medical problems. In Medicine, they think about diseases so everyone thinks in different ways so the way we act or react is different, so we are learning.
I believe it should be mostly problem based learning so that when get a piece of information, we do not only look at it from one perspective, but we have Pharmacy, Dentistry and so on. There they have different points of views that we may not consider and won't come to our mind at all.

Multiple things at once
Because we are focusing on multiple things at once but it wastes a lot of time while framing a holistic view, for example, for taking pharmacology of stroke or cardiovascular, if we are taking that at the same time, who would need it more.

Lose depth
You lose depth when you are studying although you would be gaining depth in other people's majors.

Discussion
This study illustrates a strong agreement of the participants about readiness for IPE as well as positive perspectives to implement this insightful educational model into the medical and health sciences curricula. The ndings of our research endorse previous reports that validate the readiness to accept IPE program [25] [26]. The presence of positive attitude towards IPE signi es a clear understanding and mandates the incorporation of IPE initiatives within institutional frameworks. Kapur et al., have deduced that collaborative discussion and sharing of information offer the learners a unique chance for re ection and empower them to take crucial decisions [27]. The educational climate including IPE enlightens learning experience of the students that encourages them to respect and recognize roles and responsibilities amongst team members [28]. This approach certainly enables teamwork and collaboration with positive effect on the quality of patient care.
This study demonstrates a maximum agreement by the respondents for statements 2, 3, and 7 as shown by medians of 5 (Table 1). Statements 2 and 3 illustrate signi cance of IPE in understanding and solving patients' problems. This rea rms signi cance of IPE and practice in that strives to manage a host of medical ailments when professionals from various disciplines join their hands together in medical eld. By practicing multi-disciplinary teamwork, not only responsibilities are shared, but also the changes of medical errors are minimized [29]. Bartaw et al., have argued that a standardized approach by a specialized and multidisciplinary team can substantially reduce the incidence of complications and ends up with better patient outcomes [30]. Our study cohort has also shown a maximum agreement with the positive in uence of IPE in small group learning that helps enhance trust and respect among the learners. Small group learning has been shown to enhance the acquisition of knowledge and professional skills of the students that leads to active life-long learning [31]. Interestingly, Laal and Ghodsi have introduced four major bene ts of small group learning; social (inspirational environment for practicing cooperation), psychological (reduces stress and increases learner's self-esteem), academic (improves academic performance and critical thinking skills), and assessment (applying diverse assessment techniques for holistic assessment) [32]. However, the authors have cautioned that such milestones need expertise and a positive attitude towards implementing IPE program in medical curricula.
Current study has identi ed three broad educational domains of IPE; prior knowledge, framework and implementation of IPE. In their review article, Hall and Zierler have provided a framework for developing and implementing IPE program [33]. To start with, the authors have suggested to secure a commitment by institutional leadership, followed by drafting context-based learning objectives. Then a well-structured faculty development program should be introduced.  [35].
Key themes that emerged from our study included bene ts of IPE such as better communication, elimination of hierarchy, inspiration from others and awareness of patients' needs (Fig. 3). However, lack of role clarity, information overload and less focused teaching strategies have been shown to be disadvantageous in IPE philosophy. In terms of positive perspectives of IPE, our study cohort has agreed on building friendships, patients' needs and proactive and active learning. These ndings reinforce the perception that IPE strengthens professional ties, helps understand and resolve patient's problems and facilitates active learning [36]. In contrast, our cohort has also signaled some negative aspects of IPE; multiple things at once and losing depth. Competing interests from other professions, inclination of learners to learn more from their major topics and multi-tasking have been shown to undermine true essence of IPE practice [37] [38]. From educators' perspectives, embedding a new IPE into the existing curricula and increasing faculty workload also challenge a smooth induction of IPE program. Provision of adequate resources, rescheduling faculty time, institutional support and horizontal and vertical induction of IPE modules into the curriculum can overcome these shortcomings [39].

Study limitations
This study provides a comprehensive account of students' perceptions of IPE with a reasonably high response rate to RIPLS survey as well as focus group discussion. This provides a substantial insight into the opinions and viewpoints of the students. Nevertheless, since the ndings of this study are selfreported perceptions and behaviors, the results cannot be interpreted in a context based situation. Furthermore, since the majority of the recruited population were female students, external validity of this research might have been compromised. Lastly, study on limited medical disciplines may limit validation of results of this study.

Conclusion
This study provides evidence about the readiness of medical students for IPE in a gulf university. A great majority of the students showed positive attitude and their readiness to adopt IPE. The students agreed about the effective role of IPE in collaborative work, in identifying and resolving patients' problems and in minimizing medical errors. However, the students also pointed out some challenges; information overload, lack of clarity and unnecessary competition. Carefully planned faculty development program, engaging institutional leadership, vertical and horizontal integration of new IPE course and institutional support can potentially facilitate its seamless integration.