The experiences of pre-licensure or pre-registration health professional students and their educators in working with intra-professional teams: a systematic review of qualitative evidence protocol

Abstract

Centers conducting the review University of Victoria and the Queen's Joanna Briggs Collaboration for Patient Safety: a Collaborating Center of the Joanna Briggs Institute Review question/objective The aim of this review is to identify the experiences of pre-licensure or pre-registration health professional students and their educators of intra-professional teams. The objectives of this review are: To identify the experiences of pre-licensure or pre-registration health professional students about learning how to work in intra-professional teams. To identify the experiences of health professional educators about teaching intra-professional collaboration across categorical and/or regulatory boundaries of professional groups. The specific question for this review is: What are the experiences of health professional students and educators learning to work in intra-professional teams? Background Nursing education and practice are influenced by the complexities inherent in the need to provide professional care to patients, families and communities in varying contexts across the globe. While numerous initiatives under the umbrella of health care reform (such as interprofessional practice and collaborative practice) are addressed in nursing literature, there has been less attention paid to exploring relationships between categories of nurses (such as registered nurses and licensed practical nurses) who are expected (through regulation and discourses of intra/interprofessional practice) to effectively engage in collaborative practice.1,2,3 While other health care professionals are also encouraged to engage in collaborative, interprofessional practice4,5,6 There is little literature available which discusses intra-professional experiences of professionals within various health care programs. Thus, questions are raised as to how interprofessional, intra-professional, and collaborative practice are conceptualized in literature, but also how students and educators experience intra-professional relationships while in pre-licensure health care education programs. Intra-professional practice is not consistently defined in the literature. Some authors refer to intra-professional practice as students from differing years of a particular program (such as a baccalaureate nursing program) engaging in learning together, whether in classroom, clinical or community contexts.7,8,9 Leaders from the Center for the Advancement of Interprofessional Education10 describe interprofessional education as two or more professions learning with, from and about each other but do not address intra-professional learning. While it is expected that interprofessional education will indeed result in improved outcomes for not only patients but health care professionals and the health care system, Martin Saarinen11 suggests that the predominating movements towards adoption of interprofessionalism have overlooked the significance of exploring intra-professional education, such as collaborative nursing programs, with registered nursing (RN) students and practical nursing (PN) students learning together. Thus, for purposes of this review, intra-professional education will be defined as various categories of students under one disciplinary umbrella, such as nursing, (which would include RNs, licensed practical or vocational nurses [LPNs/LVNs], and registered psychiatric nurses) engaged in learning processes together in various educational contexts (classroom, clinical, community or simulation laboratory). While there are initiatives, guidelines and regulatory documents which support interprofessional practice,12,13,14,15 less attention is given to research regarding intra-professional practice in both practicing (post-licensure) and educational contexts. DeMarco,16 in discussions regarding intra-professional alliances, suggests that intra-professional relationships (which involve a relational contract based on respect and commitment) need to be promoted in nursing curricula. Further, DeMarco suggests that there is a need to “broaden understandings of patient outcomes by exploring them as part of a context of work relationships with each other”.16(p. 177) The National League for Nursing acknowledges the significance of interprofessional relationships in health care but also recommends that nurse leaders focus on inclusivity of nurses (LPN/LVNs and RNs) by developing intra-professional learning experiences where students of various nursing-related educational programs learn side-by-side. New models of academic progression are called for, where “nurse educators and clinical practice partners work together to create new models of academic progression”.3(para. 3) While there is a significant focus throughout the literature on interprofessional collaboration, Wackerhausen17 suggests that interprofessional collaboration is impeded by barriers created by ineffective intra-professional relationships. The development of intra-professional relationships has been linked to how professional identity is created and maintained within individual professions. Professional identity development based on first-order reflection involves self-affirming activities which maintain the status quo, whereas second-order reflection is achieved through utilizing expanding conceptual resources which increases the perspectives from which one can reflect. It is only within second-order reflection, Wackerhausen argues, that intra-professionalism can be effectively developed through which interprofessional relationships can evolve. Similarly, Powell and Davies,18 in a study exploring experiences of acute pain service team members, found that “intra-professional boundaries (within the medical and nursing professions) hindered collaborative working among doctors and limited the influence that the acute pain service nurses could have on improving the practice of other nurses”.18(p. 807) Thus, there are discussions regarding a need to explore relationships between and among various categories of health care providers in order to support effective working relationships which ultimately can impact on patient outcomes. In Canada, changing care delivery models in various acute care contexts (with the introduction of increasing numbers of LPNs and health care aides) impact intra-professional working relationships. While it is important to explore these relationships among working nurses, it is also significant to explore how they experience these relationships as students, and how their educators experience these relationships. Questions arise as to if, and how, these relationships are appropriately supported in educational contexts,19,20,21 and the conduct of this review can provide important insights into how intra-professional collaboration is experienced by both students and educators. Currently, there is little research that addresses intra-professional relationships among categories of pre-licensure nursing students. There are currently no systematic reviews available on this topic. However, our preliminary searches have found several qualitative studies within social work, occupational therapy and dentistry that provide qualitative findings related to experiences of intra-professional collaboration, as well as a literature review exploring inter- and intra-professional relationships. Therefore the focus of this systematic review is to explore how all health professional students and their educators experience intra-professional practice before students graduate, become licensed/ registered as a health care professional, and enter the workforce. In July 2014, a preliminary search of the literature was undertaken with the guidance of a research librarian. The CINAHL and Medline databases were searched in order to ensure that relevant literature with qualitative findings could be found for this review. The search was intentionally kept broad due to the various ways that inter/intra-professional, inter/intra-disciplinary and collaboration are conceptualized in the literature. The reviewers decided to err on the side of caution by searching more broadly and reviewing a larger number of abstracts for inclusion in the study. In this way pertinent literature would not be erroneously excluded from the search. Upon review of the abstracts and search terms for results from the above search, it became evident that large numbers of articles pertaining to inter-professional education or practice were found but they did not include findings on intra-professional experiences of students or educators. Thus, a revised search was performed with the assistance of a research librarian in February, 2015, removing the terms related to “interprofessional” from the search, and adding “intraprofessional collaboration”. In consultation with the research librarian, the search strategy was further refined, discussed in detail below. The search below will be re-run and refined as necessary as part of the three-step search strategy process. A search of the Cochrane Library of Systematic Reviews, the PROSPERO database, and the JBI Database of Systematic Reviews and Implementation Reports has been conducted. No systematic reviews of qualitative studies exploring pre-licensure health professional students' experiences learning intra-professional practice are evident in the literature. Currently, little is known about students' experiences in learning how to engage intra-professionally with other entry-to-practice students within a particular discipline. Our proposed systematic review therefore fulfils all requirements for the PROSPERO database. Inclusion criteria Types of participants This review will consider studies that investigate pre-licensure health professional students' and educators' experiences of intra-professional teams. We will define pre-licensure health professional students as those students enrolled in a health-related diploma or degree program leading to the writing of a licensure or registration exam prior to engaging in practice (i.e. regulated health care provider programs). Health related programs that will be included are those that have multiple points of entry-to-practice under one disciplinary domain. This could include (but will not be limited to) disciplines such as dentistry, nursing, medicine, occupational therapy, pharmacy, physiotherapy or social work. Thus, we will consider studies that include experiences of students and educators working in various disciplinary domains (such as dentistry, medicine, nursing, occupational therapy pharmacy or physiotherapy) focusing on regulated health professions which have more than one point of entry into practice for their students (e.g. baccalaureate degree or diploma). This review will not include studies which describe students of a particular disciplinary domain (i.e. nursing) engaging in collaborative learning with students from varying years of a particular or single baccalaureate or diploma program. We will exclude literature that pertains to any health care student who is already licensed but engaged in post-licensure continuing education or higher degree programs. Our intent is to focus on students' experiences in an initial diploma or degree program in order to become a health care professional, as well as educators who teach in these contexts. Phenomena of interest This review will consider studies which explore how pre-licensure students and educators experience intra-professional collaboration among various entry-to-practice categories of a particular discipline. As expectations continue for various healthcare professionals to collaborate effectively in their workplaces, this review will focus on instances where intra-professional collaboration or teamwork is experienced in pre-licensure educational contexts and how this collaboration or teamwork is experienced. This review can provide important insight for educators regarding how best to prepare health professional students for practice in various shifting health care contexts. Context The purpose of this review is to consider how this body of knowledge can inform how nursing students (baccalaureate and diploma) and their educators experience intra-professional teamwork in Canadian educational contexts. We are interested in studies conducted in contexts that are similar to those in Canada, and studies will be limited to the following countries: Canada, United States of America (USA), Australia, Great Britain, New Zealand and Nordic countries: Denmark, Finland, Sweden, Iceland and Norway. Types of studies This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Qualitative findings from evaluation research (including mixed methods studies) and peer-reviewed case reports will be included when they report on the relevant learning experiences of students or educators. Studies published in English will be included in this review. Studies published in other languages will be tallied (but not translated) to provide an indication of the availability of international literature available on students' and educators' experiences related to intra-professional practices. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of Medline and CINAHL (see strategy outlined below) will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published in other languages will be tallied (but not translated) to provide an indication of the range of international literature available on this topic. Studies published after 2000 will be considered for inclusion in this review as these studies are more likely to be relevant for current health education contexts. The databases to be searched include: CINAHL, Health Source: Nursing/Academic Edition, ERIC, Medline (Pubmed), TRIP, Web of Science, PsycInfo The search for unpublished studies will include: Grey literature sources such as government websites, OCLC PapersFirst for conference papers, OCLC Proceedings First for conference proceedings, Proquest Dissertations and Theses, the New York Academy of Medicine Grey Literature Collection, nursing education websites (such as the Canadian Association of Schools of Nursing), MedNar, and Google Scholar. Initial keywords will include controlled vocabulary and keyword terms related to intra-professional teaching and learning and pre-licensure or pre-registration health professional students. These terms will be identified, refined, and combined according to the conventions of each database searched. Initial keywords to be used will be: intraprofessional relations*; intraprofessional collaboration; intraprofessional or intra-professional*; student*; faculty or instructor*; education. If a large volume of studies are identified without limiters, qualitative research terms will be used to focus the search. The following search strategy will be used: S1: (MH “Intraprofessional relations)” or (MH “intraprofessional collaboration*”) S2: MH intraprofessional* S3: MH intraprofessional* or intra-professional* S4: MH “Students, Nursing, Diploma Programs”) or (MH “Students, Nursing, Baccalaureate+”) or (MH “Students, Pre-Nursing”) or (MH “Students, Nursing+”) S5: student* S6: (MH “Faculty, Nursing”) S7: (faculty or instructor*) S8: (MH “Curriculum+”) or (MH “Course Content”) S9: (MH “Education, Nursing+”) or (MH “Education, Nursing, Baccalaureate+”) or (MH “Education, Diploma Programs+”) S10: education S11: S1 or S2 or S3 S12: S4 or S5 or S6 or S7 S13: S8 or S9 or S10 S14: S11 and S12 and S13 S15: S11 and S12 and S13 with limiters: published ≥January 1, 2000 Bibliographic information and abstracts will initially be reviewed for relevance to the review question by two independent reviewers. If either reviewer feels that the study may be relevant, the full paper will be retrieved for assessment. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of primary studies will be contacted as needed to clarify findings. Data extraction Qualitative findings will be extracted by two independent reviewers from papers included in the review. Data will be extracted from papers using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and specific objectives. Data synthesis Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Unusual or refutational cases will be described in narrative form. Conflicts of interest The authors have no conflicts of interest to declare. Acknowledgements We would like to acknowledge funding received from the School of Nursing, University of Victoria, to support JBI comprehensive systematic review training for the primary reviewer. We would also like to acknowledge the assistance and training provided by the University of California San Francisco (UCSF) Center for Evidence-Based Patient and Family Care: an Affiliate Center of the Joanna Briggs Institute in preparing the first draft of this protocol.