Factors associated with interprofessional competencies among healthcare professionals in Japan

ABSTRACT

We aimed to explore factors associated with interprofessional competencies among healthcare professionals in Japan. From June to October 2020, we conducted a cross-sectional survey via a validated self-administered web-based questionnaire using the Japanese version of the Self-assessment Scale of Interprofessional Competency (JASSIC). We recruited participants from an e-mail list. The questionnaire asked about JASSIC, basic demographic information, whether they had undertaken pre- and post-licensure interprofessional education (IPE), and administrative experience; as well as an organizational climate scale, including “Plan, Do, See” factor for management (PDS factor), and the “Do” factor in a leader-centered direction for people who work unwillingly. Factors associated with the total JASSIC score as interprofessional competencies were determined using multiple regression analysis. We analyzed data from 560 participants with an average age of 41.0 years, comprising 132 nurses, 127 doctors, and 120 social workers. The median of the total JASSIC score was 72/90 (range: 66–78). On multiple regression analysis, total JASSIC score was significantly associated with age, PDS factor, administrative experience, pre-licensure IPE, and pos-licensure IPE. These findings emphasize the importance of pre- and post-licensure IPE, and administrative experience for improving interprofessional competencies in Japan.

KEYWORDS:

• Interprofessional competency
• leadership
• surveys
• questionnaire designs
• team climate

Introduction

With the rapid aging of the population and an increase in social disparities, healthcare professionals need to collaborate with each other through the development of interprofessional competencies based on a bio-psycho-social perspective (Bainbridge et al., 2010). Competencies are the ability to perform successfully and efficiently as a professional in a given situation. They require the integration of knowledge and skills as well as a sense of ethics and attitude (Shah et al., 2016; Stevenson, 2010). Competency-based education is the current trend in healthcare professional education, and the acquisition of competencies is incorporated into pre- and post-licensure education and continuous professional development (Frank et al., 2010). Interprofessional competency-based education should also be implemented in the design of IPE activities for healthcare professional (Brashers et al., 2020).

As a first step to this goal, we developed an interprofessional competency framework in Japan, which consists of six domains, namely two core domains of ‘Patient-/Client-/Family-/Community-Centered’ and ‘Interprofessional Communication’ and four peripheral domains of ‘Role Contribution,’ ‘Facilitation of Relationships,’ ‘Reflection,’ and ‘Understanding for Others’ (Haruta et al., 2018). To date, only a few studies have investigated the validity of assessing interprofessional competencies in healthcare settings (Lockeman et al., 2021; Roberts et al., 2019). In fact, while direct observation in assessing interprofessional performance is desirable, observation is hampered by limited opportunities to observe learners/practitioners and a lack of trained observers (Thistlethwaite et al., 2016). In this context, an article reported that 70% of the 37 articles which have assessed interprofessional outcomes to date did so using self-report questionnaires (Della et al., 2002). Another review paper reported that the two tools designed to assess attainment of interprofessional competencies were self-report (Shrader et al., 2017). We therefore speculated that a robust self-assessment form based on interprofessional competencies would certainly be able to provide valuable evidence (Rogers et al., 2017; Spaulding et al., 2019).

We have developed a Japanese version of the Self-assessment Scale of Interprofessional Competency (JASSIC) through a robust statistical process in four steps, expert discussion, cognitive debriefing, feasibility, and statistical analysis (Haruta & Goto, 2021). JASSIC is a validated measurement tool developed based on the interprofessional competency framework in Japan (Haruta & Goto, 2021; Haruta et al., 2018). JASSIC follows the six domains of the interprofessional competency framework. It has a six-factor structure with 18 items consisting of three items per factor. Each item is distributed on a 5-point Likert-type scale (1 = not applicable, 5 = highly applicable), with a possible score range of 18 to 90. Cronbach’s alpha was 0.92 for all items of the JASSIC, and 0.95, 0.88, 0.87, 0.84, 0.90, and 0.81 for each factor, respectively. The correlation between the total JASSIC score and the Assessment of Interprofessional Team Collaboration Scale-II (AITCS-II) was 0.69. However, no studies have reported on what attributes or experiences are associated with total JASSIC scores as interprofessional competencies. We speculated that the clarification of factors related to interprofessional competency across all health professions may allow their application to IPE strategies. We also considered that clarification would allow the seamless assessment of pre-and post-licensure settings both within individuals and across organizations based on competency-based education.

Here, we aimed to explore factors significantly associated with interprofessional competencies in Japan through a survey of healthcare professionals.

Methods

Design and setting

We conducted a cross-sectional survey in Japan from June to October 2020 based on a self-administered web-based questionnaire.

Participants

As participants in this study, we included primary care providers, who routinely engage in interprofessional collaboration with all professions. Links to the survey were distributed to participants via the Japan Primary Care Association (JPCA) e-mail list (Japan Primary Care Association, 2021) or direct e-mail. This professional body was established in 2010 by the merger of three academic societies in primary care and represents primary care in Japan. As of September 2019, 10,470 doctors, 785 pharmacists, and 478 other health professionals were registered as members. As the number of responses from nurses, pharmacists, and rehabilitation therapists was low and participants were recruited in a manner to avoid bias toward one region of Japan, we adopted exponential non-discriminative snowball sampling as purposive sampling through key professional informants (Etikan, 2016), in which we directly asked key professional informants to encourage their own professional peers or local participants to participate.

Survey instrument

We developed the survey using a web-based survey platform. The survey instrument and instructions were provided in Japanese. The survey was designed such that non-consenting participants and those with missing responses could not submit the web questionnaire. The survey instrument included items about the total score of the Japanese version of the Self-assessment Scale of Interprofessional Competency (JASSIC) as the objective variable, as well as basic demographic information, experience of working as a professional, experience of working in the present institution, experience with pre-and post-licensure IPE, administrative experience, and understanding of the “Plan, Do, See” factor for management (PDS factor) and the “Do” factor in a leader-centered direction for people who work in an unwilling manner, in the organizational climate questionnaire as explanatory variables (Peruzzo et al., 2019; Yutaka, 2015).

The explanatory variables were selected by reviewing the literature and considering the effect of interprofessional competencies (Finn et al., 2010; Haruta et al., 2019; Karam et al., 2018; Mulvale et al., 2016). These factors have been associated with implicit bias in healthcare settings (Fitzgerald, 2014; Fitzgerald & Hurst, 2017). We defined experience with pre-and post-licensure IPE as formal or informal courses or additional professional development options, and defined administrative experience as the position of head or leader of a unit, department, or institution. As cultural factors, research into organizational climate has evolved over the years since Lewin’s initial studies of experimentally created social climates (Lewin, 1951). One definition of organizational climate is “people attach to particular features of the work setting, and the growing body of work elucidating the important role that climate plays in understanding organizational functioning, work is still needed in this area” (Schneider et al., 2013). Thus, based on the concept of organizational climate, we adopted an organizational climate questionnaire which has a two-factorial structure, namely the “Plan, Do, See” factor for management (PDS factor) and the “Do” factor in a leader-centered direction (Fukui et al., 2004). The PDS factors implies the organizational climate in which a plan-do-check-act (PDCA) cycle can be easily implemented. The higher the score of the PDS factors, the better the physical and psychological environment, the clearer the planning of activities, the better the attention of managers, and the more autonomous the organizational climate with high participation of organizational members. The Do factor refers to a highly pressured, coercive, and unfair organizational climate in which people work in an unwilling manner. The higher the score of the Do factor, the more manager-centered the organization, the less participation of organizational members, and the more unnecessary tension. In the present study, the questionnaire consisted of a PDS factor (10 items) and a Do factor (10 items) in consideration of the organizational climate that may affect interprofessional competency. Each item consists of a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree), giving a possible score range for each factor of 10 to 50 points.

Statistical analysis

We examined the distribution of each exploratory variable. After determining the descriptive statistics, we investigated the association between the exploratory variables and the objective variable, namely the total JASSIC score.

First, univariate analyses were performed using Pearson’s correlation coefficient to explore the factors associated with the total JASSIC score. With consideration to age, type of professional, years of experience working in the institution, administrative experience, presence of pre-and post-licensure IPE, and 20 items of the organizational climate as potential confounders were considered for multiple regression analysis. Typically, since nurses tend to adopt a more collaborative culture than other professionals, we analyzed healthcare profession data by dividing subjects into nurse and non-nurses (other) professions (Haruta et al., 2019; Karam et al., 2018). To eliminate potential multicollinearity, significant explanatory variables were reviewed based on the correlation coefficients of similar variables to determine which to include in the multiple regression analysis. All statistical analyses were performed using the IBM SPSS v27.0 (IBM Corp., Armonk, New York). All p values were two-sided and considered significant at p < .05.

Sample size

In multiple regression analysis, between 15 and 20 observations for each predictor variable is considered desirable. Accordingly, more than 240 samples were targeted in this study (Siddiqui, 2013).

Ethics approval

The study was approved by the Ethics Committee of the Faculty of Medicine, X University (approval number: 1483).

Results

A total of 560 self-administered web-based questionnaires were analyzed. Among respondents, 292 were women (52.1%). Average age was 41.0 ± 11.1 years and average work experience at the current institution was 9.1 ± 8.3 years. By profession, 132 were nurses (23.6%), 127 were doctors (22.7%), 120 were social workers (21.4%), and 88 were physical therapists (15.7%) and 281 (50.2%) participants had administrative experience. The median of the total JASSIC score was 72/90 (range: 66–78). Two-hundred and twenty-three participants (39.8%) had pre-licensure IPE and 419 (74.8%) had post-licensure IPE. Average scores ± standard deviation (SD) of the PDS and Do factors were 31.5 ± 6.0 and 26.8 ± 6.4, respectively (Table 1).

Table 1. Demographic characteristics of 560 professional healthcare participants in this cross-sectional study about interprofessional education, 2020.

Characteristic	Value	P value	Pearson’s correlations coefficient
Age in years
Mean (SD)	41.0 (11.1)	p < .001	0.174
Median (IQR)	41 (34–48)
Gender, no. (%)
Female	292 (52.1)
Male	268 (47.9)
Years of experience as a professional
Mean (SD)	16.2 (9.6)	p < .001	0.167
Median (IQR)	15 (10–22)
Years of experience working at the current institution
Mean (SD)	9.1 (8.3)	P = .031	0.091
Median (IQR)	6.5 (3–13)
Attendance type, no. (%)
Regular	526 (93.9)
Part-time work	34 (6.1)
Administrative experience, no. (%)
Yes	281 (50.2)
No	279 (49.8)
Profession, no. (%) (including duplicates)
Physician	127 (22.7)
Public health nurses and nurses	132 (23.6)
Pharmacist	27 (4.8)
Rehabilitation therapist	113 (20.2)
Care manager	23 (4.1)
Social worker	120 (21.4)
Psychiatric social worker	22 (3.9)
Care worker	14 (2.5)
Others	35 (6.3)
Facility
University hospital (over 500 beds)	52 (9.3)
Medium hospital (100–499 beds)	225 (40.2)
Small hospital (20–99 beds)	43 (7.7)
Clinic	95 (17.0)
Home-visit nursing station	23 (4.1)
Pharmacy	6 (1.1)
Administrative agency	10 (1.8)
Nursing home	28 (5.0)
Others	74 (13.2)
Pre-licensure IPE
Yes	223 (39.8)
No	337 (60.2)
Post-licensure IPE
Yes	419 (74.8)
No	141 (25.2)
PDS Factor
Mean (SD)	31.5 (6.1)	<0.001	0.388
Median	32.0 (28–36)
Do Factor
Mean (SD)	26.8 (6.4)	<0.001	−0.216
Median	26.0 (22–30)

Abbreviation: SD indicates standard deviation, IQR indicates interquartile range, IPE; interprofessional education, PDS factor; “Plan, Do, See” action for management; Do factor, top-down ordering of work, such as in a leader-centered organization.

* Univariate analysis of the association with the total score of Interprofessional competencies (Pearson’s correlation coefficient).

† Pearson’s correlation coefficient between age, years of experience as a professional, years of experience working at the current institution, PDS factor, Do factor, and total scores of interprofessional competencies.

In univariate analyses of factors associated with the total JASSIC score, explanatory variables with a significance level of <0.05 were relationships with the age, experience working in the current institution, pre-and post-licensure IPE, administrative experience, PDS factor, and Do factor (Table 1).

Multiple regression analysis was performed using an analytical model that included the following explanatory variables: age, gender, profession (nurse or non-nurse), pre-and post-licensure IPE (yes/no), administrative experience (yes/no), PDS factor, and Do factor. Pre-and post-licensure IPE, and administrative experience are coded as 1 = yes. The beta coefficients (β) for age, PDS factor, administrative experience, pre-licensure IPE, and pos-licensure IPE in the total JASSIC score were 0.101 (95% CI 0.018 to 0.179, p = .017), 0.333 (95 CI 0.394 to 0.675, p < .001), 0.108 (95% CI 0.525 to 3.659, p = .009), 0.137 (95% CI 1.166 to 4.270, p = .001), and 0.164 (95% CI 1.871 to 5.453, p < .001), respectively (Table 2).

Table 2. Multiple regression analysis of the association with the total scores of the self-assessment scale of interprofessional competency, by sociodemographic characteristics in this cross-sectional survey of 560 Japanese professional healthcare participants.

Variable	β	P value*	95% CI
Age	0.101	0.017	0.018 to 0.179
Gender (Female:1)	0.018	0.665	−1.239 to 1.941
Profession (nurse:1)	0.007	0.865	−1.719 to 2.046
PDS factor	0.333	<0.001	0.394 to 0.675
Do factor	−0.038	0.398	−0.194 to 0.077
Administrative experience	0.108	0.009	0.525 to 3.659
Pre-licensure IPE	0.137	0.001	1.166 to 4.270
Post-licensure IPE	0.164	<0.001	1.871 to 5.453

r = 0.489, r² = 0.239, adjusted r² = 0.226.

*Multiple regression analysis of the association with total JASSIC scores. Bold text indicates a statistically significant correlation with a p-value less than 0.05.

IPE, interprofessional education; PDS factor, “Plan, Do, See” action for management; Do factor, the top order to do it such as a leader-centered organization

PDS factors includes 10 items of a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree), giving a possible score range for each factor of 10 to 50 points. Higher scores of PDS factors indicate higher self-cognition of organizational climate in which the plan-do-check-act cycle can be easily implemented.

Do factors includes 10 items of a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree), giving a score range for each factor of 10 to 50 points. Higher scores of Do factors indicates higher self-cognition of a more leader-centered organizational climate.

Discussion

This study revealed that factors associated with interprofessional competencies included pre-licensure IPE, administrative experience, post-licensure IPE, age, and organizational climate factors that allow for quality improvement to work together as members of an interprofessional team to continuously improve the system in their healthcare institution. A previous study reported that prior healthcare experience and interprofessional competencies were associated, and age is consistent with this result (Lockeman et al., 2021). Since the mean of total JASSIC score conducted among the staff of another local hospital was 62.8 (Haruta & Goto, 2021), the present participants might be classified as a relatively high-interprofessional competency group. Even taking this into account, the results emphasize the importance of pre- and post-licensure IPE, and administrative experience in improving interprofessional competencies in Japan.

In both pre- and post-licensure IPE, the key factors for acquiring interprofessional competencies are consistent with the concept of competency-based education (Nahrwold, 2005). In pre-licensure IPE, despite some methodological criticism of self-questionnaires, these are frequently used for short-term evaluation (Hamada et al., 2020; Spaulding et al., 2019). In particular, our present finding that pre-licensure IPE is associated with high interprofessional competency is innovative. These findings are not limited to the different institutions, program and teaching methods, but suggest that a pre-licensure IPE program can be a positive evaluation. All health professions students and professionals are required to identify the interprofessional competencies as the “missing part of the jigsaw” which are needed for interprofessional practice (O’Keefe et al., 2017). The pre-and post- licensure IPE that has been implemented to fill this missing piece, such as interactions with health care professionals and students from other professionals, may foster an interprofessional identity (Arndt et al., 2009). As a result, pre-and post- licensure IPE may have improved interprofessional competency although age may have a small effect. Additionally, JASSIC may be a valid tool to evaluate ongoing interprofessional competency seamlessly from pre- and post-licensure settings. To test this hypothesis, it will be necessary in the future to collect longitudinal data from the pre-licensure setting to continuous professional employment using JASSIC.

The fact that administrator experience was associated with the high-competency group may reflect the need for administrators in the healthcare field to acquire collaborative leadership (VanVactor, 2012). Healthcare organizations are changing, and management styles and processes need to be reevaluated from time to time (Autry et al., 2008). Administrator experience can provide an opportunity to gain a cross-professional perspective and improve interprofessional competency. For example, collaborative leadership, which is necessary for adapting to change, involves one or more people in an organization engaging with each other in such a way that leaders and followers raise each other’s motivation and moral level and foster interdependence among multiple parties. A collaborative communication strategy involves an unhindered and continuous cycle of information flowing freely among the members of a team or organization (Bossidy et al., 2002). Thus, our findings might show that administrative experience was associated with factors in the high-competency group, who have gained interprofessional identities in undertaking administrative roles through their experience as the head or leader of their unit, department, or institution (Khalili, 2013).

PDS factors related to an organizational climate in which a plan-do-check-act (PDCA) cycle can be easily implemented were associated with the high competency group. Thus, establishing an organizational climate that encourages quality improvement to continuously improve the system in one’s healthcare institution may improve interprofessional competency. Continuous quality improvement (CQI), such as patient safety, is reflected in the need for an interprofessional perspective (Armstrong et al., 2012). Quality improvement competencies in working together as members of an interprofessional team is considered a core competency of healthcare professionals (Bellack et al., 1997). Similarly, interprofessional collaboration is one factor for the success of CQI (Dobson et al., 2009), and creating an organizational culture that can smoothly implement the PDCA cycle can enhance the interprofessional competency of the group in healthcare institutions (Brown et al., 2018). Additionally, the CQI is valuable in educating students (Ladden et al., 2006) and can be designed seamlessly in pre- and post-licensure interprofessional education.

Several limitations of our study warrant mention. First, a degree of self-selection bias may be present, given that the professionals who completed the survey were self-selected recipients of an e-mail list and non-discriminative snowball sampling. Accordingly, the score of self-assessment of interprofessional competencies of the participants may have been higher than those who in participated in previous study (Haruta & Goto, 2021). The findings may not be generalizable to all primary care settings due to self-selection bias. Second, because the study was conducted under a cross-sectional design, causal associations cannot be assessed. Overcoming this will require longitudinal evaluation from the student to professional period, such as a cohort survey. Third, the analysis by profession focused only on nurses and non-nurses (other). Larger samples are necessary to be representative of the population and to allow the detailed analysis of factors (more professional categories, regional differences, hospital size, etc.).

Furthermore, future studies should also evaluate objective measures such as clinical outcomes associated with interprofessional competencies. Even considering these limitations, given the lack of evidence on the association of interprofessional competency, the value of this study lies in its identification of factors associated with the high-interprofessional competency group. In particular, the finding that the two factors of administrative experience and an organizational climate that allows for quality improvement to improve the system in one’s healthcare institution was associated with high interprofessional competence is internationally meaningful for continuous healthcare professional development, because the findings can be implemented in practical applications aimed at interprofessional collaboration in clinical practice. Additionally, this study has further strengthened the validity and usefulness of the JASSIC as an interprofessional competency-based assessment tool. Although it is unlikely that self-assessment alone will provide a reliable measure of interprofessional collaboration (Schmitz & Brandt, 2015), it is nevertheless a meaningful tool that can be used to identify the impact of usage and educational outcomes by using sub-domain scores. In particular, it might be helpful in assessing interprofessional competencies in Asian countries belonging to the Confucian Asia cultural cluster, which includes Japan (Gupta et al., 2002).

Conclusion

Interprofessional competencies were associated with age, pre- and post-licensure IPE, administrative experience, and organizational climate factors that allow for quality improvement to continuously improve the system in the healthcare institution.

Ethical approval

Ethics Committee of the Faculty of Medicine, University of Tsukuba (No. 1483).

Acknowledgments

The authors thank Ms. Rie Okazaki, Ms. Eriko Totsuka, Dr. Machiko Obara, Dr. Keiko Fukutome participated in the survey as key informants. We are very grateful to the professional healthcare participants in the survey.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings is available on request from the corresponding author (JH), upon reasonable request.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/13561820.2022.2099818

Additional information

Funding

This study was supported by the Interprofessional Collaboration and Community-based Integrated Care Committee of the Japan Primary Care Association;Grant-in-Aid for Scientific Research (B) [22H03320].