Health Professions as Distinct Cultures in Interprofessional, Intercultural Clinical Placements: A Pilot Study Exploring Implications for Interprofessional Supervision

Diann S. Eley*

University of Queensland, Australia

Lindy McAllister                                                                                    

University of Sydney, Australia

Lucy Chipchase

University of Western Sydney, Australia

Jenny Strong

University of Queensland, Australia

Shelley Allen

University of Queensland, Australia

Bronwyn Davidson

The University of Melbourne, Melbourne Medical School, Australia

Abstract

This paper reports on a pilot study that incorporated discipline specific clinical skill development with intercultural and interprofessional education (IPE) experiences for eight health professions students on clinical placement in a Disability Program in Vietnam. The aim of this study was to examine students’ experiences of interprofessional work while in an intercultural learning environment.

A mixed methods design explored student perceptions of their experiences and learning in an interprofessional and intercultural context using semi-structured interviews, the Readiness for Interprofessional Learning Scale (RIPLS) and the Cross-Cultural Adaptability Inventory (CCAI) pre- and post-placement. The quantitative measures were used as a means of individual feedback to student and to assist in the interpretation of the qualitative data. Interviews indicated that students agree on the importance of working interprofessionally but perceived adjustment to interprofessional supervision was more challenging than adjustment to the Vietnamese clinical culture. Students scored lowest on Professional Identity (RIPLS) and Personal Autonomy (CCAI).

This study provides an adjunct approach to gaining insight into final year students’ perception of interprofessional work while in an intercultural learning environment. Our small sample size cannot imply student’s definitive attitudes toward IP and IP supervision. However it may suggest that more research combining interprofessional and intercultural learning may contribute to a better understanding of the notion of professions as distinct cultures and students’ perceptions of IPE ‘interculturally’. This may further develop best practice in interprofessional supervision that empowers student learning and reinforces their professional identity.

Keywords: health professions students; intercultural learning; interprofessional learning; interprofessional supervision

Background

Intercultural competence (ICC), including intercultural communication skills, are key graduate attributes for health professionals, and graduates who are able to work confidently across differing cultural contexts and are most likely to succeed in demanding contemporary workplaces (Lewis 2003). Increasingly in health professional education, universities embed into the formal curriculum intercultural educational experiences for their students in the form of international placements (Cushner and Karim 2003). This trend also aligns with increasing emphasis on internationalisation of the curriculum in Australian universities (Leask 2009).

Overseas electives in medicine (Hanson 2010) and intercultural placements in allied health (Murdoch-Eaton, Redmond and Bax 2011, Simonelis and Njelesani 2011) are examples of student mobility, which has increased significantly in recent years to address both the need to develop intercultural competence and internationalise curricula. However, there is little data to demonstrate the learning outcomes of such educational experiences.

Interprofessional practice

Likewise, the capacity for interprofessional practice is increasingly demanded in workplaces. Employers and clients require health professionals who respect each other’s roles and contributions, are able to work collaboratively to achieve quality outcomes and communicate effectively with each other and with clients. As a result, interprofessional educational (IPE) is now considered a fundamental part of health profession education programs (Thistlethwaite 2011). Ideally, IPE during their programs will expose students to attitudes and roles of other professions, considered essential to coping with the future demands of health care. Together, intercultural and interprofessional educational experiences are becoming increasingly important as health professionals are required to work interprofessionally in intercultural contexts (Dunston et al. 2009). Therefore, clinical learning opportunities that target the development of ICC and IPE are high impact educational activities that aim to prepare graduates for contemporary workplaces.

Increasingly, the literature (see, for example, Ho et al. 2008, Scarvall and Stone 2010, and Thistlethwaite 2011), is establishing the importance and benefits of IPE. Learning is maximised through exposure to perspectives from various professions and there is increased opportunity to gain generic skills such as communication, teamwork and planning. As proposed by Thistlethwaite (2008), this means accepting other professions and including them in our education by offering a varied set of learning experiences including team based assessment as an important measure of clinical development.

Intercultural training

Providing intercultural training is recognised as a vital part of health science education.Health professional educators have found it challenging to address students’ learning needs and develop effective tools to measure the development of intercultural competence (Hamilton 2009).  While medicine has tended to use intercultural training solely within its own profession, additional benefits have been shown by combining this with an interprofessional approach (Cushner et al. 2003, McCabe 2001).

Combined IC and IPE

However, in health professional education, few studies have evaluated the effect of a combined IPE and IC placement. With allied health students, McAllister and colleagues (McAllister et al. 2006, McAllister and Whiteford 2008) reported powerful learning outcomes for students engaged in interprofessional intercultural placements in Vietnam and Indonesia. They describe a continuum of development of intercultural competence in the students involving: awareness of aspirations and expectations of the intercultural experience, experiencing culture shock, becoming aware of and overcoming stereotypes, intercultural communication issues and strategies for managing these, and developing personal coping strategies.

An extension to intercultural practice with clients is the notion that individual health care professions have their own cultures as each has its own language, values and beliefs (Hall 2006, Horsburgh et al. 2006). Hall (2006) described professional cultures as barriers to interprofessional teamwork because specialised training can reinforce immersion into the knowledge of one’s own professional group and create blindness to the knowledge of other groups. As such, effective IPE in the health sciences requires communication ‘interculturally’ across health professions. The provision of interprofessional intercultural experience was then a major rationale for the placement described in this paper.

The placement described in this paper was located within a theoretical framework of situated learning where learning is a function of the activity and culture in context (Lave and Wenger 1991). The educational experience emphasised interaction, collaboration and participation in a community of practice. Within this overarching theoretical positioning, our project incorporated theories of intercultural competence, adult learning (Merriam 1993), and lifelong learning skills (Wetzel et al. 2010), including the use of peer learning (Baldry, Currens and Bithell 2003, Daniels 2010) and reflection (Kinsella 2010). These have all been shown to be useful to facilitate students’ intercultural learning and competency (McAllister et al. 2006; 2008). 

Previous studies on IPE and ICC and student learning have tended to be qualitative in nature, relying on student reflective journals and interviews to understand the intercultural interprofessional learning experience and its outcomes (Copley et al. 2007, Cushner and Karim 2003, McAllister et al. 2006, 2008, and McCabe 2001). Using the notion of professions as distinct cultures, this pilot study aimed to assess health professions students’ capacities for interprofessional learning in an intercultural environment using a mixed methods approach. This pilot contributed to a larger qualitative study which examined interprofessional education in an intercultural context (Chipchase et al. 2012, Strong et al. 2014) and aimed to provide an additional approach to gaining insight into final year students’ perception of interprofessional work while in an intercultural learning environment. We provide an overview of the main study and highlight the implications of the quantitative findings, using extracts from the qualitative data to illustrate key points.

Methods

Ethical approval was received from the Behavioural & Social Sciences Ethical Review Committee of The University of Queensland.

Setting and participants

The following is a brief overview of the setting and participants. Further description is detailed in Strong et al. (2014). Eight final year student participants, two each from medicine, physiotherapy, occupational therapy and speech pathology were recruited purposively through their expressed interest in the project and the opportunity to undertake an international clinical placement.  Having two students from each discipline was determined to be most beneficial in terms of maximising peer support and learning during the placement. Students were provided with formative assessment from the clinical educators on generic skills such as team work, communication and reasoning, using a specially developed feedback template. Students received summative assessment in their specific discipline on their return based on the tool used within their disciplines to assess clinical competence. The five week disability placements were located in orphanages and a school for children with disabilities in Hue, Vietnam. Interpreters for the students and staff throughout their placement were arranged through an existing partnership with the Office of Genetic Counselling and Disabled Children, Hue College of Medicine and Pharmacy.

All participants were female with a mean age of 22.5 years (range = 20-30). All had previously travelled overseas at least twice, primarily for holidays with family. All had previous part time and casual employment and two students had worked professionally for up to five years. All students had previously undertaken some form of volunteer work. Study components included activities pre-placement (orientation, workshops), on-placement (health checks, reflective journals), and post-placement (group debriefing).

Four clinical educators from occupational therapy, speech pathology and physiotherapy accompanied the students on their placements for 2-3 week periods. They were chosen based on their experience in paediatrics and working with children with a disability, supervising and assessing students, and supervising allied health teams. Two had prior experience of working in Vietnam. Their presence was staggered over the five weeks to ensure there were at least two educators working with the students at all times. This meant that four students at any one time were without a supervisor from their own discipline. Hence all students received interprofessional supervision during some portion of their placement.

Design

A mixed methods design (Creswell and Plano Clark 2007) used qualitative interviews and two quantitative measures. All details of the qualitative data collection and analysis are available in Chipchase et al. (2012). The quantitative measures were the Cross-Cultural Adaptability Inventory [CCAI] (Kelley and Meyers 1987), and the Readiness for Interprofessional Learning Scale [RIPLS] (McFadyen et al. 2005, Parsell and Bligh 1999). Students completed both in a group setting six weeks prior to travelling and two weeks after their return. Both inventories were chosen because their components were relevant to the learning demands of the placement.

The CCAI (Kelley and Meyers 1987) is a self-report training instrument that consists of 50 items that assess four key components of cross-cultural adaptability: emotional resilience, flexibility and openness, perceptual acuity and personal autonomy.  Each item has six response options on a Likert scale (1=Definitely Not True to 6=Definitely True).  The overall internal consistency (Cronbach’s Alpha) is .90 ranging from .68 (perceptual acuity) to .82 (emotional resilience). The CCAI was a focal point of the first pre-placement workshop because its administration facilitates the development of self-understanding in cross-cultural adaptability and provides a platform for further awareness and adaptability training. The scale shows high consistency and validity required for credible research (Majumdar, Keystone, and Cuttress 1999).

The RIPLS is a self-report tool to assess attitudes towards IPE. We used the updated RIPLS designed to assess four key dimensions that are conducive to positive outcomes in interprofessional learning. These are described as: teamwork and collaboration, negative professional identity, positive professional identity and roles and responsibilities (McFayden et al. 2005). This version of the RIPLS is scored on a five point Likert scale (1=strongly disagree to 5=strongly agree). The small participant sample meant that analysis of the RIPLS and the CCAI data was descriptive only.  No quantitative data are presented but instead the trends we found across the students’ scores on each subscale are discussed in conjunction with representative quotes by each student. The purpose of these quantitative measures was to provide feedback to students on their personal strengths and weaknesses regarding their cross-cultural adaptability and interprofessional perceptions.  As a pilot study, and given the small sample size, the CCAI and the RIPLS data were used to assist in the interpretation of the qualitative data. 

Results

Detailed presentation of the study’s qualitative data can be found in Chipchase et al. (2012). This paper briefly describes a snap shot of the interview findings as they relate to the discussion of scores on the CCAI and the RIPLS. The three overarching interview themes were: the ‘placement context’ which describes the clinical and cultural environment that the students lived and worked in for five weeks; ‘intercultural practice’ which refers to cultural differences in clinical practice, and ‘interprofessional teamwork and supervision’ which reflected the greatest challenge to students because they did not have continuous supervision from their discipline.

Overall student perceptions strongly indicated that adjusting to non-discipline specific supervision in a complex team learning environment was perceived as more challenging than the Vietnamese clinical culture. This interpretation was represented in the individual student scores on the RIPLs and CCAI where all students scored lowest on levels of ‘professional identity’ and ‘personal autonomy’. Table 1 presents pertinent quotes from the student interviews which illustrate the main points from the CCAI and the RIPLS. The primary issues were due to difficulties associated with the fact that students did not have continuous supervision from their particular discipline at all times during their placement. This was noted as the most challenging aspect of the placement. 

Table 1. Pertinent quotes from the student interviews illustrate the main findings from the CCAI and the RPLS. Pseudonyms are placed before the quotes.

Student perceptions of intercultural awareness were assessed by the Cross-Cultural Adaptability Inventory (CCAI) which provides a general indicator of an overall cross-cultural adaptability.  Quotes below highlight the components of flexibility and openness, emotional resilience and personal autonomy.
Trends in on the CCAI scores	Representative quote
All students had high to very high levels of ‘Flexibility/Openness’ pre-placement.	[Emily] “[I want] to really learn how to work and collaborate with other people, not only in our team, but in other cultures as well”.
	[Elizabeth] “I’m very interested to see what the therapists are like over there, what knowledge they have from working with the other physios who have been there before, what they’ve learned from them.  Then how we can kind of work with them to further both of our knowledge in the area and learn from each other”.
High 'Emotional Resilience' was revealed during debrief sessions and reflection post-placement experiences.	[Erin] “I guess …  [incident] really - it was sort of a bit shocking but at the same time, it just sort of prompted me into being more, just having to be really professional and maintain a professional attitude with the nun or the staff member and everyone else there and not making judgements because that wasn’t my place to do that. Also just the cultural differences, it was really highlighted there I guess. It was already very apparent just with everyday living, that sort of thing. But that was also a big eye opener, yeah”.
‘Personal Autonomy’ is strongly associated with a sense of identity and self-efficacy. However the students’ scores on ‘Personal Autonomy’ ranked very low to low both pre- and post-placement.	[Maree] “I just think in reality it will be hard because I'm not sure what will be expected of me in terms of occupational therapy, physiotherapy or speech therapy skills and whether people are expecting me to display them as a part of this project or to learn them as a part of this project. On a flipside of that, what are the other [OT, PT, SP] students expecting in terms of medical skills?  Are they expecting to demonstrate crossing over into the medical role as well as the allied health role and vice versa”?
Student perceptions on readiness for interprofessional learning was assessed by the Readiness for Interprofessional Learning Scale (RIPLS) through ‘teamwork and collaboration’, ‘ negative professional identity’, ‘positive professional identity’ and ‘roles and responsibilities’.
Trends in on the RIPLS scores	Representative quote
All students were in high agreement about the value of ‘working interprofessionally’ with respect, trust and team-work skills important for group learning to be effective.	[Kate] “increasing my confidence in working in an inter-professional team would be ... [an aim], because I sometimes feel that I don't necessarily have all the knowledge and tools to contribute to a team. So just working close in a team environment will help me feel more confident than I actually do”.
Pre-placement all students’ aims showed their desire to learn how to work more ‘collaboratively’ and to contribute to an interprofessional ‘team’.	[Clare] “… working in an interprofessional team is also a big [aim].  I’ve had a little interprofessional experience before but it’s only been with a professional from one other discipline. Whereas this time we’ll be working with quite a few different disciplines, so I think it will be really interesting to see the dynamics and also overcome some of the obstacles that we might face as a team”.
There were low scores and less agreement regarding ‘Positive Professional Identity’ and ‘Roles and Responsibilities’. Post-placement students were unsure of their professional role.	[Erin] “Yeah, I just think that the cross-disciplinary work would be more effective with people who are initially comfortable and confident in their own roles before trying to branch into other people's areas and to do that with prowess or to do that with meaning, in a sense, rather than just to do it inadvertently”.
Likewise post-placement there was an underlying uncertainty of their various ‘Professional Roles’.	[Kate] “But I think in terms of being in an inter-professional context, I think that none of us were confident enough or knowledgeable enough or secure enough in what the actual role of our profession was”.
This quote suggests uncertainty around ‘Professional Identity’ and attitudes toward relationships with other professionals.	[Clare] “I guess that’s the feedback definitely for the next few years that every discipline needs an educator the entire time. It’s just too difficult”.
Concerns around confidence in their ‘Professional Role’ are in line with their uncertainty about their ‘Professional Identify’.	[Emily] “On reflection, I don’t know whether it would alleviate the problem but to have a supervisor from each discipline might be the way around that (lack of confidence) because they would have a more confident or a more definitive idea about the specific roles.  Because we weren’t confident in our own definitive specific roles, it was then also a bit challenging to be cross-disciplinary - we ended up doing that by accident in a sense”.

The total CCAI score is an indicator of general cross-cultural adaptability.  All students scored moderate to high in their self-perception of cross-cultural adaptability and their scores fall within the normal range for females of this age group and education level (Kelley and Meyers 1987). All scores increased slightly post-placement. All students scored lowest on the subscale ‘personal autonomy’ which was within the low range. Overall RIPLS scores indicated that students were in high agreement about the importance of IPE and teamwork in increasing the effectiveness of group learning. All students’ scores were lowest on ‘professional identity’.

Discussion

This paper has reported on a pilot project involving intercultural, interprofessional clinical placements for students from four health professions. Our main findings suggest that students felt they managed better with the intercultural aspects of the clinical placements than they did with the interprofessional aspects. This was apparent from the interview data stating their perception that they needed supervisors from their own discipline throughout the placement, but may also be associated with uncertainty about their professional role and responsibility within an interprofessional team. These qualitative findings lend preliminary support for the latter because the lowest scores from all students were recorded on positive professional identity, measured by the RIPLS and personal autonomy as part of the CCAI. It may further suggest a perception that their discipline supervisors will help them clarify their professional role and build their identity. 

These implications may be highlighting the distinct cultures inherent in health professions and suggest that preparing students to manage the (hidden) cultures encountered within interprofessional work may present the greatest challenge to educators engaged in IPE placements. Hall (2005) has equated health professions as cultures with their own specific knowledge, language and territory. Although vital to performing their professional role, this culture may be at odds with the ethos of interprofessionalism. Our findings may be indicative of a potential area of conflict between developing confidence in one’s professional identity and professional knowledge and skills, and a readiness to share learning with and accept expertise of other professions intrinsic in IP supervision.

Intercultural experiences are increasingly acknowledged as important to develop awareness and skills to communicate with people from a range of cultures and contexts. This intercultural work may occur in the 'at-home' context, given the increasing cultural diversity around the world, or in overseas work, as professionals work for short or long periods overseas in established health services or through aid and development work (Jackson 2009).

Research on intercultural programs can be informed by Bennett’s (1993) ‘Developmental Model of Intercultural Sensitivity’, a theoretical framework which focuses on an individual’s awareness and response to cultural differences. Central to this theory is ethnocentrism in which one’s own culture is central to all reality, and ethnorelativism in which one is comfortable with many different customs and standards and can adapt to unfamiliar environments (McAllister et al. 2006). Reduction of ethnocentrism, awareness of other cultures and one’s own, intercultural communication skills, enhanced clinical reasoning capacity, interprofessional teamwork skills, and increased discipline specific competence are all essential to intercultural education.

Our pilot findings suggest that students felt uncomfortable in accepting guidance and supervision from another discipline when their goal was to develop the skills of their chosen discipline. If one considers the skills necessary to successfully function in a different culture (i.e. openness, flexibility, communication, resilience), it follows that these skills also need to be practiced to successfully function across ‘professional cultures’. It would make sense to include these skills in interprofessional training. However it may be that learning certain skills such as communication is more nuanced in interprofessional contexts than in intercultural contexts. This notion also emphasizes the need to prepare students for IP supervision by presenting them with its challenges and benefits, and models for how it could be implemented and best utilised to support their learning. IP supervision can enhance student learning through enriched perspectives from other professions and a more holistic view of patient care, plus the opportunity to gain generic skills in communication, teamwork, clinical reasoning, critical thinking, functional assessment of clients, planning skills and community education.

Some of the difficulties associated with the acceptance of interprofessional supervision are in line with the acknowledged shortcomings of IPE. These include the timing of IPE experiences. For example, final year students are more likely to prefer less supervision compared to first year students (Anderson 1988). Our students reported pre-placement that supervision was paramount to their learning. However post-placement there were a variety of what might be termed attitudinal factors expressed in interviews toward interprofessional supervision that caused the most difficulty, including their reluctance in accepting supervision from another discipline (Chipchase et al. 2012). Pollard, Miers, and Gilchrist (2005) found similar discrepancies between scores on interprofessional measures before a personal experience that were less positive afterwards. As noted by Parsell and Bligh (1999), changing attitudes is most difficult to overcome but is necessary to develop a true sense of teamwork and collaborative skills.

The overall measure of our students’ awareness and inclination toward interprofessional learning was very high. However when one combines this favourable awareness on a survey to actual quotes by the same students’ post-placement we found that there is individual uncertainty around professional identity and personal autonomy roles (Table 1).  However student uncertainty could also stem from several confounding variables such as lack of experience with people with disabilities, and/or with interprofessional teams, and/or with roles involving educating others (peers, teachers, carers). Role blurring, overlapping of competencies and uncertainty around responsibilities as noted by a few students in our sample could also be complicated by their multiple roles as a visitor and guest, student and clinician combined with achieving learning goals and also supporting local staff. Clearly the question around the development of professional identities and how it may influence interprofessional learning is largely unresolved (Adams et al. 2006).

Limitations

The small sample size was the major limitation for the quantitative data (CCAI and RIPLS ) but helped provide insight into the interview data. The sample was adequate for the qualitative in-depth exploration of student perceptions of their experiences.

Conclusions

Our findings have highlighted a need to better prepare students for working ‘interculturally’ between health professions and to accept IP supervision as an enhancement to their learning experience. Students know the rhetoric and agree with the dominant stance on interprofessionalism in health care. They know it is important because we as educators tell them it is important, they have seen it in practice and it is the exemplar that all health professions strive for. Therefore on paper students score highly regarding their attitudes toward IP and IP supervision. However their attitudes expressed in interviews after their placement experience suggest reluctance toward sharing supervision when faced with uncertainty around their discipline specific role. This suggests that while students may agree with the premise of IPE, their expectations need to be managed. We should not assume that what they accept in the classroom will be automatic in practice.

More research is needed on developing good practice in interprofessional supervision to ensure that clinical educators are themselves comfortable with interprofesssional collaboration and know how to supervise students in an interprofessional way that empowers student learning. Essential to pre-departure preparation should be ensuring supervisors are able to deliver good interprofessional supervision, and help students feel ready and able to use it to maximise their learning (Scarvell and Stone 2010). For example, pre-departure role playing and scenarios that introduce the challenges of interprofessional supervision, and post-departure debriefing activities to help students reflect on experiences and distil what can be transferred to the workplace. Considering IPE through an intercultural lens and fostering the development of openness, resilience, communication and flexibility, which are vital to successful intercultural practice, may be a productive way of instilling a true interprofessional approach to student learning.  

Acknowledgments

This study was supported by a Learning Enhancement Grant from The University of Queensland, Faculty of Health Sciences.

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