Journal of Nursing Education

Major Article 

Interprofessional Competence: A Qualitative Exploration of Social Work and Nursing Students’ Experience

Engle Angela Chan, PhD; Winsome Lam, MN; Syrine Kit-Sum Lam Yeung, PhD

Abstract

Being a professional in today’s health care system carries with it an expectation of becoming interprofessional. This study was designed to explore the perceived development of the participants’ interprofessional competence through interprofessional seminars and collaborative community practice. Data were collected from social work and nursing undergraduates through two interprofessional seminar discussions, followed by focus group interviews after the completion of 2 weeks of practice experience. Study findings included: (a) role clarification and enhancement, (b) evolving role emphasis, (c) understanding the importance of and various communications in teamwork, and (d) being more responsive to the meaning of teamwork and the understanding of collaborative interdependence. Through interprofessional collaborative practice, students developed an insight into teamwork, where they witnessed the merits of collaboration and gained an understanding of each other’s lack of holistic approach. In addition, not only the particular practice settings but also the role variations involved revealed various dimensions of interprofessional learning. [J Nurs Educ. 2013;52(9):509–515.]

Dr. Chan is Associate Professor and Associate Head (Undergraduate Studies), Ms. Lam is Clinical Associate Professor, School of Nursing, and Dr. Lam Yeung is Assistant Professor, Department of Applied Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong.

This study was supported by the Faculty-Wide/Cross-Department competitive grant 1.53.37.465J of The Hong Kong Polytechnic University.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank all the student participants, the facilitators involved, and the community partners for their contributions.

Address correspondence to Engle Angela Chan, PhD, Associate Professor and Associate Head (Undergraduate Studies), School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong; e-mail: e.angela.chan@polyu.edu.hk.

Received: January 13, 2013
Accepted: April 17, 2013
Posted Online: August 23, 2013

Abstract

Being a professional in today’s health care system carries with it an expectation of becoming interprofessional. This study was designed to explore the perceived development of the participants’ interprofessional competence through interprofessional seminars and collaborative community practice. Data were collected from social work and nursing undergraduates through two interprofessional seminar discussions, followed by focus group interviews after the completion of 2 weeks of practice experience. Study findings included: (a) role clarification and enhancement, (b) evolving role emphasis, (c) understanding the importance of and various communications in teamwork, and (d) being more responsive to the meaning of teamwork and the understanding of collaborative interdependence. Through interprofessional collaborative practice, students developed an insight into teamwork, where they witnessed the merits of collaboration and gained an understanding of each other’s lack of holistic approach. In addition, not only the particular practice settings but also the role variations involved revealed various dimensions of interprofessional learning. [J Nurs Educ. 2013;52(9):509–515.]

Dr. Chan is Associate Professor and Associate Head (Undergraduate Studies), Ms. Lam is Clinical Associate Professor, School of Nursing, and Dr. Lam Yeung is Assistant Professor, Department of Applied Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong.

This study was supported by the Faculty-Wide/Cross-Department competitive grant 1.53.37.465J of The Hong Kong Polytechnic University.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank all the student participants, the facilitators involved, and the community partners for their contributions.

Address correspondence to Engle Angela Chan, PhD, Associate Professor and Associate Head (Undergraduate Studies), School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong; e-mail: e.angela.chan@polyu.edu.hk.

Received: January 13, 2013
Accepted: April 17, 2013
Posted Online: August 23, 2013

The increased prevalence of chronic illness and a shortage of health workers worldwide (Croker, Trede, & Higgs, 2012) has ushered in the notion of interprofessional education (IPE) since the 1960s. IPE has been defined as occasions “when two or more professions learn with, from, and about each other to improve collaboration and the quality of care” (Centre for the Advancement of Interprofessional Education, 2002, para. 1) and has long been advocated as a means to meet the needs for effective collaboration in health and social care (Craddock, O’Halloran, Borthwick, & McPherson, 2006). Increased recognition and the need for collaborative practice among different health professionals could lead to a better understanding of the patient’s context through shared expertise from each profession (Blickerm & Priyadharshini, 2007). In the current complex health care system, being a professional carries with it an expectation of becoming interprofessional (Meads & Ashcroft, 2005) and collaboratively competent in teamwork (Clark, 2006). A growing body of literature that addresses how and where interprofessional learning can be developed (Zwarenstein, Goldman, & Reeves, 2009), as well as in the context of undergraduate education, is available. Some authors suggest that interprofessional learning is most effective in practice settings (Gordon, Booth, & Bywater, 2010), whereas others report a preference for combining classroom-based with work-based learning (Morison, Boohan, Jenkins, & Moutray, 2003). Hence, clear consensus remains elusive (Gordon et al., 2010). However, if learning is to benefit students’ future collaborative practice, obtaining field experience is essential.

The purpose of this article is to explore and describe students’ perceptions and their performance of interprofessional competence through collaborative practice in community settings. Interprofessional competence, such as understanding one’s own and each other’s roles, values, effective communication, teamwork, and collaboration, was adopted for this study (Sims, 2011).

Method

The selected design of this IPE and IPCP (interprofessional collaborative practice) study was premised on the authors’ previous findings from using seminars with case studies and a problem-based approach for interprofessional learning for both nursing and social work students’ development of their understanding of caring and ethics (Chan, Mok, Ho, & Man-Chun, 2009; Chan, Pang, Ching, & Lam, 2010). The approach to IPCP in the current study involved two phases.

The first was to prepare students from the social work and nursing programs for their interprofessional learning with two interprofessional reflective seminars. In the first seminar, the students shared their reasons for choosing their professions, as well as their professional roles, their understanding of an effective team and its characteristics, and the key enablers for collaboration. They started to share their practice and decision-making process in their uniprofessional field experience, and this aspect was the focus for the second seminar. A debriefing session was conducted for each group to provide general feedback and to share their learning processes at the end of each seminar.

Second, after students’ completion of the two seminars, arrangements were made for them to provide community service of various clients—students from two primary schools and older adults in senior centers—in phase two. These field settings are similar to those unidisciplinary placements required for community nursing experience and social work field work in elderly care. The activities were developed through a joint effort among the practice teachers, the liaison personnel in the placement settings, and the students to identify clients’ needs and the kinds of activities that an interprofessional group of nursing and social care students could provide. For example, health promotion activities for the primary school students were instituted in the theme of caring through growing beans and making sandwiches for their family members. Regarding the elderly individuals, home visits were made for those with chronic illnesses by nursing and social work students together. Two practice teachers from each profession were engaged in joint supervision for each student team during the 2-week placement period.

Ethical Considerations

The study was approved by the university’s ethical committee. Explanation about students’ right to withdraw from the study at any time without penalty was provided before their written consent was obtained. Student participants understood that their data would be kept confidential and would be accessible only by the research team. Although some of the researchers were lecturers (W.L., S.K.-S.L.Y.), none had direct responsibility for the students in the study, thus minimizing the likelihood of conflicts of interest or coercion.

Sampling

Thirty-two social work students and thirty-three nursing students in their senior year were recruited voluntarily. Participants were divided into four groups, with a balanced mix of seven to 10 students from each profession in the seminars. Student ages ranged from 18 to 22 years, with 20% being men and 80% being women. Each group had two facilitators—one from each profession. In phase two, eight social work students and 13 nursing students participated in the community practice, according to students’ availability, their preference, the need for a mixed group, and the number of students allowed for each placement. They formed four interprofessional teams with four to seven students in each team. The demographic spread in the percentage of the gender mix in both seminars and the field work experiences were comparable (Table). Given the difference in the number of students who participated in the seminars and field work, the percentage mix of nursing students and social work students were 51% and 49% versus 62% and 38%, respectively.

Distribution of Nursing and Social Work Students Study Participants (N = 55)

Table: Distribution of Nursing and Social Work Students Study Participants (N = 55)

Data Collection

A qualitative approach was adopted. The two seminar discussions, including the debriefing at the end, were audiotaped and transcribed verbatim for data analysis. Following the community practice, students also participated in a semistructured focus group interview to explore their perceptions and performance of interprofessional competence. Focus group interviews can encourage communication and debate and elicit multiplicity of views from participants (Tuckett & Stewart, 2004), thus helping the researchers to understand students’ various collaborative experiences. Interview questions covered the similarities and differences between the two disciplines, students’ changes in attitude, understanding about each others’ roles, communication, value, teamwork, collaboration, and influencing contextual features. The interviews were conducted by project team members (E.A.C. and the research assistant) who were not involved in the practice experience. The audiotaped interviews lasted from 90 minutes to 2 hours and were transcribed verbatim.

Data Analysis

A qualitative content analysis (Leech & Onweugbuzie, 2008), with the software package ATLAS.ti, was used to analyze data from the seminars and focus group interviews. Careful and repeated readings of the seminar transcripts were performed by the research assistant for a sense of its whole. Then, the text about the students’ experience of their interprofessional learning was extracted and combined into one text, which made up the unit of analysis. The text was divided into meaning units, which were then condensed. The condensed units were abstracted and labeled with a code. Regular meetings were held with the research members from nursing and social work (W.L., S.K.-S.L.Y., and others), during which the codes and the associated quotes from the participants were reviewed. A process of reflection and discussion among the research team resulted in agreement about the codings. Examples of the meaning units, condensed meaning units, and codes are shown in Table A (available in the online version of this article). The various codes were sorted into six categories, with the latent contents of the categories formulated into various themes. It is not a linear process; rather, it is an iterative one, with back-and-forth movement between the whole and the parts of the text.

The text from the focus group was analyzed in the same manner and was compared and contrasted with the text from the seminars. Because the study had varied numbers of student participants for the two seminars and the final collaborative community practice, the research team further examined the data and cross-referenced the findings in the same and in different groups of participants to avoid overreporting participants. The final themes were developed from the data of those students who participated in both the seminars and the field experiences. The team discussed the themes and categories from the analysis until a consensus was derived. Member checking was also conducted at the meetings with the students.

Results

Four main themes were identified: (a) role clarification and enhancement, (b) evolving role emphasis, (c) understanding the importance of and various communications in teamwork, and (d) being more responsive to the meaning of teamwork and the understanding of collaborative interdependence. Examples for each theme and category are shown in Table A.

Role Clarification and Enhancement

Prior to their involvement in this study, the nursing students commented that their knowledge about social workers was only that they handled patients’ financial situations and understanding of their roles was limited. After participating in the study, they understood social workers’ involvement in various aspects of social care and learned much about the community resources that will benefit them in their patient care.

Clarify Misunderstanding. Apart from the nursing students’ understanding of the roles of a social worker, further comprehension of each other’s embraced values altered some social work students’ perception of nurses as uncaring. In IPE, one important assumption is that collaboration can occur only when negative or invalid stereotypes about other professionals are changed (Lidskog, Löfmark, & Ahlström, 2008a). This assumption raised the importance of clarifying misunderstandings. Social work students learned about nursing students’ client-centeredness as an emphasis on physical health and safety; on the other hand, social work students valued self-determination and relationship building for the psychosocial aspects of their clients’ needs. Better comprehension of the core values and nature of work also led to an understanding of each other’s priority setting within field demands and constraints.

Reflective Learning on Critique. Learning about social worker students’ initial negative experience of nurses, many nursing students reflected that they could do better in patient care regarding their projected image of being detached and uncaring. Although they have the patients’ welfare in mind, the interprofessional exchange raised their awareness of thinking from patients’ perspectives, rather than from their own view. After nursing students’ reflection, social work students took one step further to reflect on their own practice after learning about nursing students’ limitations and questioned their critiques on nurses.

Social work students expressed understanding after they learned of nurses’ constraints and role expectations, and reflected that their criticism of nurses as being uncaring might be unfair. Yet, the nursing students believed that some changes should be made. IPE provided a chance for the nursing students to revisit their perceived clinical constraints, such as workload and ward culture. They began to see the need and opportunity to learn how best to manage the issue of constraint with professional values and quality of care in mind. The IPE experience led all the students to think beyond their approach and decision-making process and, as a result, they expressed their wish to change.

Evolving Role Emphasis

In the initial phase of understanding each other, both social work students and nursing students learned about their own and each other’s strengths and limitations and realized their own limitations as strengths of the other discipline. For example, nursing students valued social work students’ skill in communication and learned from them that communication is not only a skill but, more importantly, an attitude in building a relationship with the clients. Nursing students’ understanding of this aspect is more apparent in the data from their visits of older adults when they witnessed the ways of how their social work peers communicated with this population. Both nursing students and social work students expressed their intention to incorporate their learning in the future to improve their roles, resulting in complementary competencies (Sims, 2011).

When the discussion continued, social work students unexpectedly came to recognize their limitations in psychological care, which nursing students respected. Concomitantly, social work students reinforced nursing students’ roles in the psychological care of patients and considered its importance in nursing. Nursing students’ professional identity has been strengthened as a result, and it may help them to build confidence in their nursing role in the future.

Understanding the Importance of and Various Communications in Teamwork

Communication was considered by both professions as important for their collaboration to clarify misunderstandings during the seminars and to help to correct their assumptions in practice so they could better collaborate. Regarding the latter, it is clear that different student teams showed different transitional processes of their understanding about the importance of communication in the seminars to its application in the IPCP.

The four student teams reported different experiences in teamwork as a result of their various communications. To further understand the different communication behaviors, two subthemes related to communication for teamwork and professional role boundary emerged: (a) communication based on assumptions and (b) communication based on observation. Ultimately, students demonstrated an evolving understanding of the importance of communication in effective teamwork.

Communication Based on Assumptions. Students who described unexpectedness and tensions in the placement were mainly from the teams who delivered the health promotion activities at the primary schools. Because the activities included clear physical and psychosocial aspects, the students divided the tasks and worked in parallel, based on their discipline’s knowledge. Their initial communication was also based on the assumption that the other profession shared the same work patterns or habits.

In one team’s practice experience at the primary school, the social work student made an assumption that the nursing student would first create a fun environment for the children before involving them in a bean activity; however, the nursing student was concerned with delivering the content to the children within the designated time. When it was the social work student’s turn to lead her part of the activity, the nursing student expected her to continue with factual information about growing beans, but the social work student instead focused on the fun environment.

The tension experienced through the students’ collaborative learning in practice has translated into an understanding of their communication with each other and how it affected their team-work.

Communication Based on Observation. In the team that provided services for older adults, students reported there was no conflict, but there were some surprises. In this placement, there was a clear professional boundary and the roles of the two professions were well defined. Students knew their unidisciplinary focus, with nurses attending to the physical needs of the clients and their social work counterparts on the psychosocial aspect, and this task division was discussed prior to their joint visit. However, unexpected learning emerged through their actual observation of each other’s task performance, such as the social work students’ concrete suggestions provided to the client through their counseling skills and the nursing students’ teaching of how the spouse should lift the client. They valued each other’s role in the joint visit and appreciated the synergistic impact on the client’s well being, which was unexpected.

Through observation and collaboration, the students not only learned about each other’s strengths but also learned from and with each other about how to work as a team.

In both the primary school and older adult service teams, students shared similar patterns of behavior in terms of division of labor and communication (i.e., in preparation, they talked about a general framework of the activities, but they did not discuss the details). The primary school service teams reported their initial tension in practice, whereas the older adult service teams did not report such tension. The issue seemed to arise from their expectations of each other, which was due to the discrepancy in their ways of doing things; in one school service team, the social work students focused on context, whereas the nursing students emphasized task completion. This was an identified conflict that rested on the process of delivery when the social work students and the nursing students had to deliver the activities together. On the other hand, although there were similar expectations of a uniprofessional approach in the older adult service team, the different content knowledge and skills were perceived to be invaluable learning for their complementary competence. This experience also seems to have been facilitated by the nature of the older adult service, as it caused one group of students to stand aside to observe while the other provided services to the clients. Notwithstanding the students’ learning about content and process, the importance of communication in teamwork to develop collaborative competencies is acquired through social experiences, where interaction and reflection are central conditions for learning (Lidskog et al., 2008b).

Being More Responsive to the Meaning of Teamwork and the Understanding of Collaborative Interdependence

As the students learned about communication and team-work in the planning of clients’ activities based on their common knowledge or profession-specific learning, it became clear that IPE needs to be experiential in the practice setting (Clark, 2006). For both sets of students, their perceived collaboration after the seminars was captured by their comments of “saw the opportunity of collaboration” and “complement each other” but with no further elaboration. It was only after their experience in practice and their witness of each other in action that they were able to identify ways for their collaboration. Thus, the provision of practice opportunities for students’ transfer of their learning about teamwork from seminars is crucial for their collaborative learning. The possible reason is two-fold. First, students may require time and opportunity to facilitate their internalization of the meaning of teamwork (Mann, Sargeant, & Hill, 2009). Second, students were able to appreciate more concrete details in their collaborative effort through practice. During the seminars, students were enthused about their collaborations and complementary competence, although their comments were more general, such as “I have learned.” Some of the more concrete ideas about how to collaborate with each other to deliver better services after their practice also enabled students to make comments such as “I have learned and will try to practice it” and “I wish to learn more.” Their desire to learn more from each other to integrate the new learning into their own work reflected an altered view on the interrelationship of physical and psychosocial care. It is also clear that social work students reflected only on the comprehensiveness of their care (holistic care) after they witnessed the difference between interprofessional and uniprofessional care in their field experience.

This sense of interdependence arose when various expertise was merged as the nursing students and social work students created the integrated care for the elderly clients together, which neither group would have been able to create independently (Bronstein, 2003). They also witnessed how best to work as a service team for older adults and developed a positive and shared identity through wishing to learn more from each other, rather than seeing themselves primarily as nurses or social workers on a service team for older adults.

Although the students reported having experienced the importance of collaboration between health and social care, services for older adults in Hong Kong continued to be fragmented. The assessment of older adults is done by each of the different health and service organizations. Similar to the global aging population, such collaboration in Hong Kong between medical and social services is urgently needed in the care of the aged (Woo, Mak, Cheng, & Choy, 2011). Lee (2001) asserted that more effective collaboration is required between health workers and social workers in the promotion of residents’ adjustment. In her study working with older adults in a residence home in Hong Kong, Lee found that social workers were more interested in the elderly individuals’ lives, whereas nurses mainly attended to their physical needs.

Discussion

Role Clarifications

In the context of change and systems of distributed expertise (Edwards, Apostolov, Dooher, & Popova, 2008), there is a need for conventional health care teams to work closely with social sectors (Thistlethwaite, 2012). Busy work schedules and the lack of close proximity for social workers and nurses working as co-location team members in Hong Kong’s acute hospital settings create a barrier to their relationship building and team cohesion (Oandasan et al., 2009). Nurses make patient referrals to social work services but have limited contact in person. Notwithstanding a connection between health and social care, this study provided the nursing students with an opportunity to go beyond the stereotypical view of the social worker as an outsider, which is held by health professionals (Lidskog et al., 2008a). The negative stereotyping of nurses by some social work students was also overcome in this study.

Understanding the Importance of Communication in Teamwork

Teamwork is not only a concept but rather a learned experience with an awareness of one’s assumptions, preferences, and interpersonal skills and an understanding of shared practice (Angelini, 2011). Mezirow’s (2009) theory of transformative learning points to this critical self-reflection on assumptions and students’ assessments of the sources, nature, and consequences of habits of mind. Because social work students are expected to have learned more about the group process and are often described as being socialized into maintaining effective team member relationships (Russell & Hymans, 1999), it was surprising to see how the social work students’ habitual independence may have hindered their initial teamwork with the nursing students, albeit the latter also relied on their knowledge in working as a team. Understanding the meaning of teamwork in their communication, assumptions, and observation was a valuable learning tool in terms of both the social work students’ and the nursing students’ readiness to work together (Baggs & Schmitt, 1997). Being interprofessional involves unlearning traditional patterns of interacting and relating—a process that applies to both professional groups in this study.

In addition, it was easy for the two groups of professionals to work in their familiar silos. This finding reflects the current tenuous collaborative endeavor between nursing and social work in school health activities (Sulkowski, Wingfield, Jones, & Coulter, 2011) in Hong Kong. Bourdieu’s (1998) concept of habitus, as the partly unconscious adoption of rules, values, and dispositions from each profession’s cultural practice, refers to a pattern of acquired learning from their profession and culture, whereby specific expertise, unique roles, and corresponding values are developed that mark professional boundaries. Some may safeguard their expert areas, which makes sharing roles and expertise for collaborative practice a challenge.

The availability of more interprofessional opportunities that require changes to students’ habitus is fundamental to their clear disposition toward collaborative work (Sims, 2011). For this to occur, as with the social work students and nursing students, the students will have to focus beyond their ways of acting and thinking based on physical health and relationship building, respectively. Students continued their interactions with openness and respect, which enabled their further questions about reasons for their differences and how these differences affect common values and goals in their client-centered teamwork (Clark, 1997). It is their openness and respect that is the value and ethical dimension of interprofessional competence, which seems to have motivated the progress in their shared learning. The student participants could communicate and interact openly and with respect in the seminar discussions and community practice, which related largely to the creation of a nonthreatening atmosphere during this study. Despite a tight schedule for the caring activities, the students were supported by supervisors from both professions. Both the safe environment and their claim of equal status and similar ages contributed to mitigating the conflicts caused by organizational structure, hierarchy, and unequal power.

Experiential Understanding of Collaborative Interdependence as a New Generation

The literature suggests that engaging students in educational interventions to reflect on and identify how they intend to change their practice as a result of the intervention can promote such changes in practice (Mann et al., 2009). The students in this study made specific mention of how they perceived their collaboration during the home visits of the older adults. The concomitant need for treatment and management of long-term conditions requires a shift from acute service delivery to a chronic care model that emphases primary health care (Thistlethwaite, 2012).

Students’ discussions and the continuous understanding of their uniprofessional and interprofessional practice have reconsolidated their commitment as a new generation to their client care, rising above the current challenges of collaborative practice and the constraints of professional boundaries, and striving for a different culture of practice. This continued reflective learning is significant for the new generations working with limited human resources and a general fragmented collaborative structure between nursing and social care, while needing to reconstruct their own identity beyond that of a single profession in Hong Kong. Hence, notwithstanding our positive findings of students’ learning about interprofessional competence, there exists a strong indicator that to be a member of an interprofessional health care team, one needs to develop continuously (Kilgore & Langford, 2009). The sustainability of students’ interprofessional competence will also require continuous opportunities and support from organizations, as individual novices’ efforts in the complex work environment are faced with busy work responsibilities; thus, it is difficult for novices to implement and maintain changes on their own (Mann et al., 2009). Concomitantly, a commitment from policy makers to bridge the gaps between medical and social services is essential, and learning outcomes that emphasize the expectations and details of interprofessional teamwork from key accreditation bodies are needed (Interprofessional Education Collaborative Expert Panel, 2011). This will provide more guidance for interprofessional programs and, importantly, their continuous evaluation and development.

Conclusion

The study findings showed an initial superficial perception of the nurse’s role as one of tasks performed and a perceived negative image of nurses by social work students to more complex conceptions of the knowledge, responsibility, and values of both professions that are also influenced by clinical constraints. Their appreciation of each other’s strengths, such as nursing students’ knowledge of physical health and patient safety and social work students’ communication skills and psychosocial emphasis, led to their recognizing the importance of the interrelationship of both the psychosocial and physical aspects, not only in theory but also in action. In the practice-based IPE, more concrete details of collaboration were apparent, with students suggesting ways to collaborate in home care visits of older adults. Lidskog et al. (2007) asserted that it is not enough to know the specific tasks performed by a professional to understand his or her role in the team. Rather, more important in collaboration is to have a common understanding of the focus and purpose of the work of the team through a shared identity (Wee et al., 2001). Their continuous learning about teamwork and communication elicited different patterns of communication, which reflected the nursing students’ and social work students’ uniprofessional expectations situated in their perceived role boundaries for their collaborative planning of clients’ activities. It was not only the particular settings but also the tasks involved that would bring out various dimensions of interprofessional learning. Students’ continued self-reflection on their own professional values and competence, as well as their interprofessional exchanges, raised their hopes with regard to the challenges of their clinical reality for the new generations.

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Table A: Distribution of Nursing and Social Work Students Study Participants (N = 55)

10.3928/01484834-20130823-01

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