Behavioural outcomes of interprofessional education within clinical settings for health professional students: A systematic literature review

ABSTRACT

Interprofessional education facilitates collaborative practice, which promotes high-quality patient care and patient safety. Interprofessional education (IPE) experiences within clinical settings provide an opportunity for the development of interprofessional collaborative practice competence. The aim of this systematic review was to review the literature evaluating interprofessional education for health professional students within clinical settings and summarize the behavioral outcomes. Databases searched were PubMed, Embase, Scopus, Web of Science, Taylor & Francis Online, ERIC and PsycINFO. Full-text articles were independently screened by two reviewers and included if agreed. Outcomes were analyzed using Kirkpatrick’s model modified for IPE. Studies with behavioral change outcomes were analyzed and synthesized using narrative methods. Included studies provided evidence that IPE experiences in clinical settings can enable students to develop and integrate interprofessional collaborative practice competencies, across diverse types of settings. Key tasks enabling students to achieve these learning outcomes included synchronous patient consultations, collaborative development of integrative health-care plans outside of patient consultations, and participation in socialization with health-care teams. There were limitations in the methodological design of the included studies, with limited use of comparator groups and validated tools, high usage of self-report data and serious risk of bias identified across all quantitative included studies. In conclusion, high-quality research designed to measure the construct of behavioral change is lacking. Such research could further investigate the key tasks in IPE experiences in clinical settings that are necessary for students to develop the range of required collaborative practice competencies and integrate these. This could provide clarification regarding if and how this could be achieved across different types of clinical placements.

KEYWORDS:

• Behavioural outcomes
• clinical placements
• interprofessional education
• literature review
• students

Introduction

Interprofessional education (IPE) in clinical settings provides benefits to patients, health service organizations, universities, and students (Brewer et al., 2014; Nagelkerk et al., 2021; Schussel et al., 2019; Smith, 2012). Such programs have been found to improve patient clinical outcomes, promote positive patient experiences in health care, and advance health service organizational collaborative practices (Nagelkerk et al., 2021; Schussel et al., 2019). IPE in clinical settings provides the opportunity for universities to support students to develop the skills and abilities needed to meet industry demand (Brewer et al., 2014; Smith, 2012; World Health Organisation, 2010). IPE clinical programs also enable universities to contribute to societal needs through the benefits of interprofessional practice (Barnett et al., 2001; Nagelkerk et al., 2021; Schussel et al., 2019; Smith, 2012). Interprofessional education in clinical settings in which students can translate theory into practice, benefit students by facilitating the development of employment capabilities (Brewer et al., 2014; Smith, 2012).

Embedding IPE into health professional qualifying tertiary courses is seen as essential to enable students to enter the workforce with the skills and ability to engage in effective collaborative practice (Frenk et al., 2010; Spaulding et al., 2019; World Health Organisation, 2010). Collaborative practice promotes health workforce reform and improves patient safety and quality of health care (Lemieux-Charles & McGuire, 2006; Brewer & Jones, 2013; Schmutz et al., 2019). Globally, IPE curriculum programs and experiences are being developed to varying degrees in higher education institutions to enable graduates to meet health professional body recommendations and qualifying requirements (Herath et al., 2017; Khan et al., 2016).

IPE in clinical settings, considered in this systematic review as an experience during which learners from two or more professions collaboratively provide healthcare to real patients, provides ideal opportunities for the development of interprofessional collaborative practice competence. Educational theory suggests that to enable learners to work effectively in complex situations, individuals need to develop appropriate competencies and be able to integrate and apply them in different contexts (Canadian Interprofessional Health Collaborative, 2010; D’eon, 2005; Peyser et al., 2006; Roegiers, 2016). Such development requires learning activities in authentic settings, beyond the classroom alone (Frenk et al., 2010; Thompson et al., 2016). IPE in clinical settings has been shown to develop knowledge and self-efficacy in some aspects of interprofessional collaborative practice including teamwork skills (Jones et al., 2020), understanding of roles of other professionals and the patient’s perspective (Kent et al., 2017), and increased relationships and communication between and amongst health providers (Thompson et al., 2016).

Background

There are a number of literature reviews that have considered the evidence for IPE in clinical settings (Boshoff et al., 2020; Brack & Shields, 2019; Davidson et al., 2008; Kent & Keating, 2015; Kent et al., 2017; Lim & Noble-Jones, 2018; Oosterom et al., 2019; Stetten et al., 2019; Walker et al., 2018); however, a limited number of these have specifically discussed student behavioral change outcomes. Two systematic reviews reported a broad range of student outcomes, which included student behavioral change (Davidson et al., 2008; Stetten et al., 2019). Davidson et al. (2008) undertook a systematic review of interprofessional pre-qualification clinical education in health professional students. Overall, positive findings were reported in the majority of studies included in their review, although quality issues were identified across the studies (Davidson et al., 2008). However, whilst the review identified behavioral change outcomes, the number of studies classified as having behavioral change outcomes, what the outcomes were and how these were measured, were not detailed. Stetten et al. (2019) conducted a systematic review of learning outcomes of health professional students in interprofessional service-learning experiences. Overall, across all types of interprofessional outcomes, they concluded there was insufficient evidence to demonstrate the efficacy of service-learning experiences (Stetten et al., 2019). A relatively low number of their included studies described behavioral change outcomes (eight out of 49 of their included studies) (Stetten et al., 2019). Some of these eight behavioral change studies were clinical, in which students provided health care to real patients, however there was no detailed analysis of the behavioral outcomes and assessment methods applied.

Two other literature reviews specifically focusing on interprofessional training wards (Oosterom et al., 2019) and pre-registration nursing students (Lim & Noble-Jones, 2018) also reported a broad range of student outcomes, including student behavioral change, from IPE in clinical settings. These found a lack of evidence of behavioral change as a result of student IPE in clinical settings. In the latter study, this may have been a result of the limited time frame of their database search (2011–2016) and their inclusion of qualitative studies only (Lim & Noble-Jones, 2018).

There has been variability in how data from tools that could be considered to measure behavioral change has been interpreted. For example, the Interdisciplinary Education Perception Scale (IEPS) has been described as measuring behavioral change in some literature reviews (Spaulding et al., 2019; Walker et al., 2018). However, other literature reviews have described this tool as measuring attitude change (Canadian Interprofessional Health Collaborative, 2012; Davidson et al., 2008). In our work, we have interpreted this tool as measuring attitude change, to align with the classification of IPE assessment tools by the Canadian Interprofessional Health Collaborative (2012). We have used their classification system consistently across our included studies to categorize types of outcomes measured.

In summary, there have been a limited number of literature reviews that have specifically considered behavioral change outcomes as a result of IPE in clinical settings. In those that have, there has been little detail on the methods of assessment of the behavior change, and there has been a lack of consensus in how the behavioral change is evaluated. Given this gap in the literature we conducted a systematic review to appraise the literature evaluating health professional student interprofessional education in clinical settings and consider the evidence for behavioral outcomes in these settings.

Method

This systematic review followed the PRISMA guidelines for reporting (Moher et al., 2009). The protocol for this systematic review was written a priori and was registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/URXJT).

Search strategy

This review searched the following databases (March, 2020): PubMed, Embase, Scopus, Web of Science, Taylor & Francis Online, ERIC and PsycINFO. There were no date restrictions. Database searches were re-run prior to final analysis (June, 2021). The search strategy was peer reviewed by all members of the review team. The strategy used to search PubMed is available in Supplemental Material 1. This search strategy was translated for use with all other databases.

Screening

Titles and abstracts generated from these searches were screened by the main reviewer and excluded if they did not meet the inclusion criteria. Full-text articles were independently screened by two reviewers and included if both reviewers agreed the article met the inclusion criteria. Discrepancies were resolved through screening by a third reviewer from the team until at least two reviewers were in agreement.

Inclusion criteria

Eligibility criteria for inclusion were structured according to PICO (participants, intervention, comparator, and outcome) (Higgins et al., 2020). All types of research and evaluation study designs were included. Studies that were not peer reviewed original research articles and studies not in the English language were excluded.

Types of participants

Studies were included if the interventions were conducted with undergraduate and postgraduate health professional students undertaking pre-registration programs.

Types of interventions

Studies had to involve Interprofessional Education (IPE) in clinical settings, where an IPE intervention was defined as:

When members of more than one health or social care (or both) profession learn interactively together, for the explicit purpose of improving interprofessional collaboration or the health/wellbeing (or both) of patients/clients. Interactive learning requires active learner participation, and active exchange between learners from different professions. (Reeves et al., 2013, p. 4).

Clinical tasks were defined as: “relating to the observation and treatment of actual patients rather than theoretical or laboratory studies” (Stevenson, 2010, p. 326). These intervention studies included, however, were not limited to, hospital, private practice, community, student-led clinic, training ward, aged care residential and rural community and other community service settings where actual patients were assessed and treated. Studies which did not involve patients such as clinical simulation and classroom theoretical case studies were excluded.

Types of comparators

Studies were not excluded based on a comparator criterion.

Types of outcomes

Following full-text screening, outcomes were classified by the main reviewer according to Kirkpatrick’s categories modified for IPE outcomes (Barr et al., 2005). These categories are illustrated in Table 1. Studies classified as having Level 3 (behavioral change) outcomes were included in this study. In occasions of uncertainty, studies were independently reviewed by a second reviewer and included if agreed through team discussion. The categorization of studies was aligned with the classification of IPE assessment tools by the Canadian Interprofessional Health Collaborative (2012).

Table 1. Kirkpatrick’s categories modified for interprofessional education outcomes (Barr et al., 2005).

Level 1	Learner reaction
Level 2a	Changes in attitudes/perceptions
Level 2b	Acquisition of knowledge/skills
Level 3	Behavioral change – transfer of learning to practice setting and changes professional practice
Level 4a	Organizational change
Level 4b	Benefits to patients/clients

Data extraction

The data from the included studies that were extracted included general information such as study location and setting, study design and methodology, participant demographics, intervention details and description, and the outcomes of the interventions. Data were also extracted according to the presage-process-product (3P) model adapted for IPE (Biggs, 1993; Reeves & Freeth, 2006): learning and teaching context, teacher and learner characteristics (presage); approaches to learning and teaching (process); and collaborative outcomes (product) data. This model has been used in previous systematic reviews of IPE to extract and analyze data (Reeves et al., 2016). Information on whether interventions had been linked to an educational theory and/or a competency framework and whether behavioral change outcomes had been mapped to a competency framework were also extracted. The main reviewer completed data extraction, which was documented in an Excel spreadsheet and was confirmed through team review. Identified missing data was documented in the Excel spreadsheet.

Risk of bias assessment

Risk of bias of the included studies was assessed using the ROBINS-1 tool (McGuinness & Higgins, 2020; Sterne, Hernán, et al., 2016) for non-randomized intervention studies as recommended by Sterne et al. (2020). The Critical Appraisal Skills Programme (CASP) Qualitative Checklist (Critical Skills Appraisal Programme, 2020) was used for assessment of methodological strengths and limitations of included qualitative studies, as recommended by Noyes et al. (2020). Two reviewers independently assessed each included study, and consensus was reached through team discussion.

Analysis and synthesis

As a result of the heterogeneity in interventions and outcomes in the included studies, statistical meta-analysis was not carried out. Included studies were analyzed and synthesized using narrative methods, similarly to a previous broad IPE systematic review (Reeves et al., 2016). These have been recommended for analysis and synthesis of heterogeneous data in systematic reviews investigating the effects of interventions (Popay et al., 2006; Snilstveit et al., 2012). The extracted data was analyzed by the main reviewer using Bigg’s presage-process-product (3P) Model of Learning adapted for IPE (Biggs, 1993; Reeves & Freeth, 2006). Use of theoretical approaches in research evaluating IPE has been recommended to consider influencing contextual factors and educational mechanisms (Reeves et al., 2015; Suter et al., 2013; Thistlethwaite, 2012). The 3P theoretical model provided a means through which the complex and dynamic health-care environment and learning processes could be included when considering the IPE outcomes, as suggested by prior research (Olson & Bialocerkowski, 2014; Thistlethwaite, 2012). Qualitative data extracted from included studies using the 3P model was further analyzed using content analysis. The data was then synthesized using conceptual mapping (Popay et al., 2006) to develop a textual narrative, which was reviewed and refined by team discussion. The conceptual mapping technique links heterogenous findings from included studies in a systematic review by using visual flow diagrams to create a model illustrating relationships relating to the review question (Mulrow et al., 1997; Popay et al., 2006). Textual narratives discuss “study characteristics, context, quality and findings” and use “differences and similarities among studies” (Lucas et al., 2007, p. 2) to elucidate key findings (Lucas et al., 2007).

Results

Results of the database searching and the screening process are illustrated in Figure 1. Thirty-eight studies had Level 3 (behavioral change) outcomes.

Figure 1. Screening flowchart (Moher et al., 2009).

Overview of level 3 (behavioral change) included studies

The characteristics of the 38 included studies are detailed in Supplemental Material 2. Twelve studies used pre-post analysis, 11 studies used mixed methods, 11 used qualitative design, and four studies used other types of design (observer assessment during and post, observer assessment during, project evaluation with descriptive outcome data and longitudinal study design with post assessment). Twenty-two studies (58%) had self-reported behavioral outcomes, 15 studies (39%) out of the 38 included observational methodology to measure the behavioral outcomes, and one study (3%) had unclear methodology.

Out of the 28 studies using quantitative assessment for behavioral outcomes, 16 (57%) used validated tools, eight (29%) did not use validated tools, two (7%) used one tool which was validated and one which was not validated, and two (7%) did not provide details of the assessment method. There were 15 different types of quantitative tools used to measure behavioral outcomes across these studies, as listed in Table 2. There were a range of qualitative assessment methods as summarized in Table 2. These included semi-structured interviews (Fallsberg & Hammar, 2000; Hulen et al., 2019; Brewer & Flavell, 2020; Ng et al., 2020), focus groups (Morphet et al., 2014) and analyses of ethnographic data including textual analysis of student learning journals, participant observations, focus groups, interviews, informal conversations, fieldwork, and review of anonymous health record documents (Gudmundsen et al., 2019, 2020; Jentoft, 2021; Suiter et al., 2015). Qualitative assessment methods also included analysis of student written reflections (Bzowyckyj et al., 2017; Gordon et al., 2020), data from open-ended questions from surveys of student self-assessment of competencies (Leathers et al., 2018), documented clinical recommendations (Schussel et al., 2019), student written episodes of integrational activities (Fallsberg & Hammar, 2000), and transcriptions of audiotaped team meetings (Montemuro et al., 1999). Further details of the outcome assessment methodologies of the included studies are provided in Supplemental Material 2.

Table 2. Types of level 3 outcome measures used in included studies.

Outcome Measures
Quantitative Studies Team Development Measure (Beebe et al., 2018) Assessment of Interprofessional Team Collaborative Scale (AITCS) (Giuliante et al., 2018; Marcussen et al., 2019; Mink et al., 2020) Team Observation Protocol (Montemuro et al., 1999) Performance Assessment of Communication and Teamwork (PACT) Tool (Rotz et al., 2016) Interprofessional Collaborative Competencies Attainment Survey (ICCAS) (Caratelli et al., 2020; Coan et al., 2019; Giesler et al., 2020; Hartnett et al., 2019; Hatfield et al., 2020; Luebbers et al., 2017; Mette et al., 2021; Mulvaney et al., 2020) Curtin University’s Interprofessional Capability Assessment Tool (Brewer & Stewart-Wynne, 2013) Interprofessional Collaborative Competency Survey (Fell et al., 2019; Sevin et al., 2016; Timm & Schnepper, 2020) Survey corresponding to the goals and objectives of the course and aligning with the IPEC competencies (Leathers et al., 2018) Interprofessional Collaborator Assessment Rubric (Pawłowska et al., 2020) Parent surveys (Pawłowska et al., 2020; Straub & Bode, 2019) Evaluation of students’ interprofessional behavior through their clinical recommendations (Schussel et al., 2019) Standardized Pharmacy Student Assessment Rubric (Theodorou et al., 2018) Interprofessional Teaching Objective Structured Clinical Examination (iTOSCE) (Zaudke et al., 2016) Team observed structured clinical encounters (TOSCE) (O’Connell et al., 2021) Direct observation and assessment during a home visit using an 8 item assessment with 6 item Likert scale (Ploylearmsang et al., 2021) Descriptive data (project evaluation) (Haber et al., 2015)
Qualitative Studies Semi-structured interviews (Fallsberg & Hammar, 2000; Hulen et al., 2019; Brewer & Flavell, 2020; Ng et al., 2020) Reflective journaling/student reflections (Bzowyckyj et al., 2017; Gordon et al., 2020) Qualitative analysis of data from written episodes (Fallsberg & Hammar, 2000) Ethnographic qualitative data (including methods such as interviews, observations, informal conversations, textual analysis of student learning journals, clinic staff focus groups, reflexive focus group interviews, review of anonymous health record documents (Gudmundsen et al., 2019, 2020; Jentoft, 2021; Suiter et al., 2015) Student focus groups (Morphet et al., 2014)

Only two studies (5%) used a comparator group (Marcussen et al., 2019; Mette et al., 2021). The outcomes of these two studies using comparator groups were both based on self-reported data. Both used validated tools however only the Interprofessional Collaborative Competency Attainment Survey (ICCAS) has been validated in health professional students (Archibald et al., 2014; Mette et al., 2021), with the Assessment of Interprofessional Team Collaboration Scale (AITCS), only validated in health-care workers (Hellman et al., 2016; Marcussen et al., 2019; Orchard et al., 2012).

Risk of bias of level 3 (behavioral change) included studies

The risk of bias was assessed using the ROBINS-I tool (Sterne, Hernán, et al., 2016). The results are illustrated in Figures 2 and 3. There was a serious overall risk of bias in all of 28 included non-randomized intervention studies, with risk of bias due to confounding and measurement of outcomes being the main areas of potential risk. Serious risk of bias due to confounding was identified in a number of studies as a result of participation in the IPE experience being voluntary. Students with more positive attitudes toward IPE may have been more likely to volunteer and this may have biased results in these studies. Further, serious risk of bias in measurement of outcomes was identified in all included studies. As all of the included studies reported subjective measurement of behavioral outcomes using non-blinded assessors, this inferred serious risk in measurement of outcomes according to the ROBINS-I protocol (Sterne, Higgins, et al., 2016). Subjective outcome measures in risk of bias assessment have been considered to be those which could be influenced by an individual’s judgment (Savović et al., 2012; Wood et al., 2008).

Figure 2. Overal risk of bias (McGuinness & Higgins, 2020).

Figure 3. Risk of bias domains (McGuinness & Higgins, 2020).

Assessment of the methodological strengths and limitations of the included qualitative studies using the CASP Qualitative Checklist (Critical Skills Appraisal Programme, 2020) found that the majority of studies had overall moderate strength, as illustrated in Figure 4. In the qualitative studies, the most common risk of bias was the lack of critical examination of researcher roles, with risk of bias due to the relationship between researchers and participants in some studies.

Figure 4. *CASP criteria for qualitative research appraisal: 1. Was there a clear statement of the aims of the research? 2. Is a qualitative methodology appropriate? 3. Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between researchers and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of findings? 10. How valuable is the research? (+ = Yes, - = No,? = Unclear) (Critical Skills Appraisal Programme, 2020).

Presage, process and product synthesis and qualitative analysis of level 3 (behavioral change) studies

Presage

The presage factors included were intervention settings, student professions and prior student IPE experience, drivers, funding, organizational support, similar to previous IPE studies using the 3P model (Reeves & Freeth, 2006; Reeves et al., 2016), and whether interventions were linked to a competency framework.

There were at least 16 different types of settings (Supplemental Material 2). Seven studies used more than one type of setting. The most common settings were interprofessional training wards (seven), student-led clinics (seven), community health centers/clinics (six, including two rural), and hospitals (six, including one rural). Other types of settings included home visiting services (four), other clinics (outpatient (two), pediatric dental (two)), primary care clinics/centers (three), service learning (three), screening programs/clinics (three), a community event (one), a medication management center (one), a rural nursing home short-term stay center (one) and an aged care facility (one). Participants consisted of student cohorts ranging from 2 to 11 different types of professions.

Drivers for the IPE intervention studies included patient safety and quality of care (15), along with accrediting health professional body requirements (eight). Many studies had external project funding from grants (17), universities (four), joint funding from universities and government agencies (two), hospitals (one), and joint funding from universities and health services (one). Funding was not explicitly specified in 14 studies.

Organizational support was described in 20 studies, and not specified in the remaining studies (18). Lack of organizational support and resources were identified as barriers to transferring IPE to post-graduate practice (Hulen et al., 2019). Positive collaborative relationships developed between staff from different professions were seen as powerful facilitators for success which assisted in overcoming institutional logistical barriers (Luebbers et al., 2017). Support and inclusion of students by staff enabled the students to feel valued, take risks, and develop confidence (Montemuro et al., 1999; Morphet et al., 2014). Shared space facilitated interprofessional communication (Mette et al., 2021) and regular team discussions enabled collaborative patient care (Ng et al., 2020). IPE implementation was facilitated by allowing time for faculty relationship development and collaborative decision-making (Luebbers et al., 2017). Intentional modification of traditional hierarchies, faculty role modeling, and cultural change were identified as strategies to overcome barriers relating to power dynamics and leadership issues (Hulen et al., 2019).

Interprofessional education in clinical settings were explicitly linked to a competency framework in 24 studies, and there were no links to competency frameworks in 14 studies. The most common framework discussed was the Interprofessional Education Collaborative (IPEC) competency framework (17) (Interprofessional Education Collaborative, 2016). The other frameworks were Brewer’s interprofessional capability framework (two studies) (Brewer & Flavell, 2020; Brewer & Stewart-Wynne, 2013), the CIHC competency framework (three studies) (Canadian Interprofessional Health Collaborative, 2010; Mink et al., 2020), the Interprofessional Learning Competencies (IPLCs) (one study) (Gordon et al., 2020; O’Keefe et al., 2017), and the Interprofessional Oral Health Competencies (one study) (Haber et al., 2015).

Twenty-one studies identified that student participants had experienced IPE prior to or experienced non-clinical IPE as part of the study intervention, and two studies indicated students had not. Fifteen studies did not specify if students had experienced IPE prior to the study intervention. The effect of prior IPE on intervention outcomes was analyzed in two studies, which both found it made no significant difference to the outcomes (Giesler et al., 2020; Sevin et al., 2016).

Process

The process factors included the structure and duration of the IPE intervention, whether interventions were linked to educational theories, whether IPE interventions were compulsory, similar to previous IPE studies using the 3P model (Reeves & Freeth, 2006; Reeves et al., 2016), and whether teaching and learning activities were aligned with intended learning outcomes and assessment. Nine studies linked their intervention to educational theories. The theories included adult learning, community of practice and constructivist theories (Brewer & Flavell, 2020), learning-by-doing and learning-is-doing theories (Fallsberg & Hammar, 2000), the sociocultural theory of learning (Gudmundsen et al., 2019), transformational boundary learning (Jentoft, 2021), transformative learning theory (Ng et al., 2020) and contact learning theory (Brewer & Flavell, 2020; Schussel et al., 2019). The clinical IPE intervention was compulsory for students in 14 of the studies, in three studies it depended on the program students were enrolled in, it was voluntary in 14 studies, and this was unspecified in seven studies. In 36 studies (95%), teaching and learning activities were aligned with intended learning outcomes and assessment.

There was significant diversity in the structure of the clinical IPE interventions with respect to duration and facilitation. The duration of the clinical IPE interventions varied widely from a few hours to one year. Nine studies used facilitators trained in IPE, one study described facilitators as being trained but not specifically in IPE, and 28 studies did not specify whether supervisors were trained in IPE facilitation. Students were facilitated to reflect in groups or in journals on their clinical experiences in 10 studies. Twenty-three studies described including regular collaborative practice workshops and team meetings as part of the student IPE experience. These were alongside their clinical experience in 11 studies, prior to the clinical experience in seven studies and both prior to and alongside the clinical experience in five studies.

Product

The products were the types of outcomes (positive, mixed results or no change) as in a previous IPE systematic review using the 3P model (Reeves et al., 2016). The majority of results had positive (33 out of 38 studies, 87%) outcomes, with four studies showing mixed results and one study showing no change.

Included studies using quantitative tools reported a range of student collaborative behavioral outcomes as a result of IPE experiences in clinical settings. The heterogenous range of skills and abilities measured within quantitative tools aligned with competencies described in published IPE competency frameworks (Canadian Interprofessional Health Collaborative, 2010; Interprofessional Education Collaborative, 2016). A statistically significant increase in scores across all collaborative practice competencies from pre to post was found in seven self-report studies (Caratelli et al., 2020; Hartnett et al., 2019; Leathers et al., 2018; Luebbers et al., 2017; Marcussen et al., 2019; Mette et al., 2021; Sevin et al., 2016). Two of the seven quantitative self-report studies used comparator groups, with both finding the intervention groups had significantly higher post scores than the comparator group (Marcussen et al., 2019; Mette et al., 2021). In one of these studies, the increase in competency levels over the time of the intervention was also reported to be significantly higher in the intervention group than the comparator group (Marcussen et al., 2019). Five observational studies (Brewer & Stewart-Wynne, 2013; O’connell et al., 2021; Ploylearmsang et al., 2021; Theodorou et al., 2018; Zaudke et al., 2016) reported evidence of demonstration of all competencies. Two self-report (Giesler et al., 2020; Timm & Schnepper, 2020) and five observational studies reported evidence for only some competencies (Montemuro et al., 1999; Pawłowska et al., 2020; Rotz et al., 2016; Schussel et al., 2019; Straub & Bode, 2019). Three self-report studies found no changes in collaborative practice competency scores from pre to post (Beebe et al., 2018; Fell et al., 2019; Giuliante et al., 2018). In the studies in which only some competencies were demonstrated as a result of the student IPE in clinical settings, the domains these were most commonly seen in were teamwork (Montemuro et al., 1999; Pawłowska et al., 2020; Rotz et al., 2016; Schussel et al., 2019; Straub & Bode, 2019; Timm & Schnepper, 2020), communication (Montemuro et al., 1999; Pawłowska et al., 2020; Rotz et al., 2016; Timm & Schnepper, 2020), patient-centered care (Montemuro et al., 1999; Pawłowska et al., 2020; Schussel et al., 2019) and roles and responsibilities (Giesler et al., 2020; Pawłowska et al., 2020). Evidence of conflict resolution was reported in one study (Pawłowska et al., 2020).

Both self-reported and observational qualitative outcomes in the included studies provided evidence of collaborative practice competency development from student IPE experiences in clinical settings. All assessed interprofessional collaborative competencies were reported to be attained by students in four self-report studies (Bzowyckyj et al., 2017; Caratelli et al., 2020; Fell et al., 2019; Gordon et al., 2020) and one observational study (Brewer & Stewart-Wynne, 2013). Integration of a range of interprofessional skills and abilities by student participants to provide collaborative, patient centered care was described in six self-report studies (Bzowyckyj et al., 2017; Caratelli et al., 2020; Fallsberg & Hammar, 2000; Giuliante et al., 2018; Brewer & Flavell, 2020; Morphet et al., 2014) and two observational studies (Jentoft, 2021; Montemuro et al., 1999).

Other qualitative studies included in this review found evidence of some interprofessional collaborative practice competencies from student IPE experiences in clinical settings. Demonstration of roles and responsibilities, interprofessional communication and teamwork competencies was reported in four self-report studies and three observational studies (Gudmundsen et al., 2020; Hulen et al., 2019; Leathers et al., 2018; Luebbers et al., 2017; Ng et al., 2020; Schussel et al., 2019; Straub & Bode, 2019). Evidence of other interprofessional competencies including patient-centered care (Gudmundsen et al., 2020; Ng et al., 2020) and collaborative leadership (Luebbers et al., 2017) were reported in three studies.

There were a range of experiences reported in the included studies which facilitated students to develop interprofessional collaborative practice competencies. These included students having the opportunity to provide health-care services to a patient during a consultation synchronously (Bzowyckyj et al., 2017; Giuliante et al., 2018; Leathers et al., 2018; Luebbers et al., 2017; Brewer & Flavell, 2020; Montemuro et al., 1999; Morphet et al., 2014), socialization of the health-care team (Bzowyckyj et al., 2017; Morphet et al., 2014), and talking with students and supervisors from other professions (Gordon et al., 2020; Morphet et al., 2014). Other experiences were observing students or clinicians from other professions or participating in their activities (Gordon et al., 2020; Brewer & Stewart-Wynne, 2013; Morphet et al., 2014), working in collaborative teams to provide patient care outside patient consultations, including case conferences and patient assessments (Bzowyckyj et al., 2017; Gordon et al., 2020) and receiving and sharing information in group discussions about health management (Caratelli et al., 2020; Fallsberg & Hammar, 2000; Montemuro et al., 1999; Morphet et al., 2014; Ng et al., 2020). Writing and reviewing health-care team notes and records were reported to facilitate intersection of student practice and to enable students to participate in interprofessional, patient centered care (Gudmundsen et al., 2020; Jentoft, 2021). Seeing patients in their own home and participating in the health care of patients with other professions resulted in students developing insight into client perspective and adopting a more patient centered approach (Giuliante et al., 2018; Jentoft, 2021; Ng et al., 2020). This range of IPE experiences in clinical settings reported in the included studies enabled students to develop interprofessional collaborative practice competence, through strategies and processes such as delegation, dividing tasks into parts, developing team plans together before seeing patients (Fallsberg & Hammar, 2000), and crossing boundaries to establish roles (Jentoft, 2021).

Discussion

The aim of this systematic review was to review the literature evaluating health professional student IPE interventions in clinical settings and synthesize the evidence for behavioral change. Our study provides evidence that IPE in clinical settings can enable students to develop interprofessional collaborative practice competencies. Analysis of the quality of the evidence indicated limitations in methodological design.

Behavioral outcomes

The analysis of the Level 3 (behavioral change) outcome data from our systematic review of IPE interventions in health professional student clinical training identified key clinical IPE experiences which enabled students to develop interprofessional collaborative practice competencies. Given the variability in health professional work and context, distinguishing processes, which enable competency development facilitates transferability of findings (Kent et al., 2017; Olson & Bialocerkowski, 2014). Key processes identified were opportunities for students to provide health-care services to a patient synchronously, participate in socialization with health-care teams, talk with students and supervisors from other professions, observe students or clinicians from other professions or participate in their activities, work in collaborative teams to develop integrated care plans outside of the patient consultation, receive and share information in group discussions about health management, write in and review health-care team notes and records, and see patients in their own home. These findings are consistent with previous work on learning mechanisms of IPE in clinical settings (Kent et al., 2016, 2017).

The constructive alignment of teaching and learning activities with learning outcomes and assessment that was demonstrated in the majority of included studies has enabled students to develop interprofessional capabilities required for health professional graduates through social constructivist learning (Biggs, 1996; Frenk et al., 2010; Thistlethwaite, 2012). Experiences enabling such outcomes are possible in IPE in clinical settings, where students are immersed in the complex sociocultural environments of authentic health-care settings and are directly involved in team processes to provide care for real patients, providing vital authenticity to learning experiences (Jessee, 2016; Kennedy et al., 2019; Smith, 2012; Thistlethwaite, 2012). These results were consistent across included studies despite heterogeneity of setting and intervention types.

These findings are consistent with previous research on influences of the clinical learning environment on student learning, which found behavioral interventions in such environments can develop relationship building capacity in health professional students (Jessee, 2016). Overall interprofessional collaborative practice competence requires integration of the range of collaborative practice competencies in a practice situation (Canadian Interprofessional Health Collaborative, 2010). The range of competencies, which can be grouped into the domains of roles and responsibilities, team functioning, collaborative leadership, conflict resolution, interprofessional communication, and patient-centered care, could also be described as skills and abilities, or capabilities (Canadian Interprofessional Health Collaborative, 2010). The importance of student interprofessional education in a clinical learning environment that has been confirmed in this review is the opportunity for students to develop and integrate these competencies in the authentic sociocultural context of health-care settings in which graduates will be required to operate in the future. Of note, the evidence for the demonstration of overall competence through integration was provided by included qualitative studies which used a range of research methodologies including ethnography, reflective journaling, focus groups and semi-structured interviews, and analysis of team meetings. This highlights the value and importance of use of a range of epistemological approaches and modes of inquiry which incorporate qualitative research methods in evaluation of IPE (Olson & Bialocerkowski, 2014).

The importance of organizational context identified from the results of this systematic review is consistent with the suggestion by Ginsburg and Tregunno (2005) of the significance of supportive organizational contexts and resource allocation in facilitating interprofessional collaborative practice. The presence of organizational support, funding, adequate time and space for collaborative practice, staff collaboration and role modeling, support and inclusion of students, and flattening of hierarchies were identified from the included studies as strategies to facilitate student interprofessional collaborative functioning behavior (Hulen et al., 2019; Luebbers et al., 2017; Mette et al., 2021; Montemuro et al., 1999; Morphet et al., 2014; Ng et al., 2020).

Quality of the evidence

There were methodological limitations identified in the included studies. There were no randomized controlled trials, and limited use of comparator groups and appropriately validated tools. More than half of the included studies were based on self-reported data, which can be influenced by social desirability bias (Arnold & Feldman, 1981; Davidson et al., 2008), and response-shift bias in pre-post testing (Howard & Dailey, 1979; Howard, 1980; Schmitz et al., 2017). Three included studies (Coan et al., 2019; Luebbers et al., 2017; Sevin et al., 2016) used retrospective pre-post testing which addresses response-shift bias, however, this method may infer recall bias (Archibald et al., 2014). Self-reported results could be considered to be student perceptions of behavioral change rather than actual behavior change, and consequently Kirkpatrick’s Level 2a (attitudes and perceptions) rather than Level 3. However, the self-reported results have been included as Level 3 in this review to be consistent with the inclusion of studies with self-reported perceptions of behavior change data in the Level 3 outcome category in previous systematic reviews (Hammick et al., 2007; Reeves et al., 2016), and the original classification of IPE outcomes using Kirkpatrick’s model (Barr et al., 2005).

There was an overall serious risk of bias in the non-randomized intervention included studies. The possible direction of the effect of the bias is toward overestimation of the positive outcomes. For a number of studies, student participation was voluntary, and this may have resulted in the inclusion of students with more positive attitudes participating, resulting in potential bias of outcomes in a positive direction. Lack of blinding of outcome assessors has been shown to increase bias in studies using subjectively assessed outcome measures (Savović et al., 2012; Wood et al., 2008). In these studies, subjective outcome measures were considered to be those which could be influenced by an individual’s judgment, for example, participant reported, and clinician assessed outcomes (Savović et al., 2012; Wood et al., 2008). All behavioral outcomes of the included studies in this review, according to this definition, were therefore subjectively assessed, and there was no assessor blinding reported, inferring serious risk of bias.

The majority of the qualitative studies were assessed as having moderate strength. However, most of their outcomes were based on self-reported data, which may have also contributed to bias toward more positive outcomes. The risk of bias identified from lack of adequate consideration of the relationship between researchers and participants in the qualitative studies may have further contributed to the overestimation of positive results. This may have occurred as a result of lack of adjustment for bias from potentially optimistic attitudes of researchers toward IPE.

In addition to the methodological limitations, it is also important to consider the construct of behavioral change that is being measured. Behavior can be defined as how an individual acts in response to a specific set of circumstances (Stevenson, 2010). The term competency has been considered to encompass knowledge, skills, attitudes and judgments which confer an individual the potential ability to practice collaboratively (Canadian Interprofessional Health Collaborative, 2010). The ICCAS tool, which is used in a number of the included studies, was designed with the intent to assess changes in attitudes and behaviors and is based on collaborative competencies (MacDonald et al., 2010). The ICCAS tool asks students to self-assess their ability to practice collaboratively (Archibald et al., 2014). Ability can be interpreted to mean that an individual has the means to do something (Stevenson, 2010), rather than that an individual has done something. The IPECC tool (Dow et al., 2014) uses similar wording to the ICCAS tool and is also used in a number of the included studies in this review. Data measured using tools such as these may predict behavioral change in the future rather than providing evidence of actual behavioral change that has occurred. Such data could be considered as perceptional rather than behavioral. The latter could be captured through documented observations of behavior using quantitative tools such as the ICAR (Curran et al., 2011), or through use of qualitative data collection methods such as ethnographic observation, student focus groups, semi structured interviews, reflections, or written episodes in which examples of changed behavior are provided (Bzowyckyj et al., 2017; Fallsberg & Hammar, 2000; Gordon et al., 2020; Gudmundsen et al., 2019; Hulen et al., 2019; Jentoft, 2021; Morphet et al., 2014; Ng et al., 2020; Suiter et al., 2015).

Limitations

Limitations of this research are that gray literature was excluded in the database search, snowballing and hand searching were not carried out, and studies not in the English language were excluded. The inclusion criteria and data analysis necessitated subjective judgment. As a result, it is possible that some potential studies may have been missed or excluded, and some misinterpretation in included study results may have occurred.

Conclusion

This review found student IPE interventions in clinical settings can enable students to develop interprofessional collaborative practice competencies and integrate these in authentic settings. Key tasks enabling students to achieve these learning outcomes have been identified from analysis of the included studies. There were methodological limitations with the behavioral outcome data, in particular in the included quantitative studies, and inconsistency in behavioral construct measurement. Future research such as quantitative studies using validated tools designed to measure the construct of behavior, with high-quality methodological approaches such as the use of comparator groups would be beneficial. It is recommended that such research be undertaken in combination with appropriate theory-based qualitative research. This could further investigate the key tasks in IPE experiences in clinical settings that are necessary for students to develop the range of required collaborative practice competencies and integrate these, and clarify if and how this can be achieved across different types of clinical placements. This could assist with curriculum planning and potentially provide transferable high-quality evidence for other types of work integrated learning.

Acknowledgments

The authors thank Tracy Bruce, Health and Behavioural Science Librarian from the University of Queensland for assistance in developing the search strategy.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/13561820.2023.2170994.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The work was supported by  The University of Queensland and the Research Training Program, Australian Government.

Notes on contributors

Sonya Mattiazzi

Sonya Mattiazzi is a PhD Candidate at The University of Queensland. Her doctoral research project is focused on the impact of student clinical interprofessional education.

Neil Cottrell

Neil Cottrell is an Associate Professor in the School of Pharmacy and the Director of Interprofessional Education at The University of Queensland.

Norman Ng

Dr Norman Ng is a Lecturer in the Faculty of Health and Behavioural Sciences and School of Human Movement and Nutrition Sciences at The University of Queensland.

Emma Beckman

Associate Professor Emma Beckman is a Teaching and Research Academic in the School of Human Movement and Nutrition Sciences at The University of Queensland.