Abstract
Objective
This study aimed to explore the value of interprofessional learning in developing interprofessional relationships, as perceived by medical students participating as simulated patients for chiropractic students.
Methods
A cross-sectional study of university medical students, using an online survey and interview sessions, was conducted at the International Medical University, Malaysia, from July 2020 to October 2020. Only students who had previously participated as a simulated patient within a chiropractic examination setting were included; this involved interacting with chiropractic students in observed structured clinical examinations, including history taking, physical examination or motion palpation, and adjustment setups for end-of-semester examinations. Survey responses focused on themes of interprofessional learning, with values of reduction of prejudice, increase in understanding, and improved collaborative attitude. These responses were grouped as positive, neutral, or negative based on Likert scores. Interview responses were analyzed and categorized according to the survey themes.
Results
Fifteen male medical students aged 23 to 26 years completed the questionnaire and interview. Respondents perceived that their experience helped clarify doubts on the scope of chiropractic (66.7%), the role of a chiropractor (80%), and chiropractic professional practices (80%). A majority of respondents (80%) felt that being a simulated patient increased their willingness to learn collaboratively with chiropractic students. Most (93.3%) responded positively to being more willing to work with other health care professionals.
Conclusion
This study showed an overall positive perception among medical students of developing interprofessional relationships with chiropractors and other health care professionals. The results suggest that opportunities for interprofessional learning between chiropractic and other health care programs may assist with the long-term goal of promoting patient-centered care.
Key Indexing Terms: Patient Simulation; Students, Medical; Interprofessional Relations; Chiropractic; Medicine
Introduction
Interprofessional learning (IPL) is an educational process involving 2 professional groups.1 It cultivates in students the knowledge, skill, and attitudinal aspects for health care collaboration that promotes patient-centered care.2 Interprofessional learning not only expands health care undergraduates’ understanding of other professional roles and responsibilities; it also enhances the continuing professional development of postgraduates.3 This growth of interprofessional understanding leads to productive cooperation, which promotes patient-centered care.4 Integrating IPL into a simulation setting allows the individuals involved to experience firsthand the proper handling of replicated real-life cases by students from other professions. This systematic learning strategy evolves the traditional medical education model with innovative opportunities to increase understanding between health care professionals.5
A common issue faced by many working health care professionals is the ambiguous understanding of the roles and responsibilities of other workers from other professions. This, along with prejudice, exists within the community of health care practitioners from different professions.6,7 This issue has been reported to occur not only among professionals but also among students.8 Without proper structuring of IPL into health care education, students’ understanding of other professions may continue to be based on presumptions and possibly misinformed opinions. There is a gap in interprofessional understanding, where their roles could often be misunderstood, which may alter the ideal health care direction toward interprofessional collaboration.
Health care education must take into consideration the value of the strategies implemented in enhancing IPL among students, so that accurate mutual understanding can be encouraged. Students begin their professional courses with stereotypes of other professionals, which can be reinforced during their professional training.9,10 If this bias is not managed in the early stages of student life, long-term effects of disharmonious interprofessional relationships might be promoted. Effective patient care depends on individual practitioners understanding the need to collaborate within and between health care professions.11
In the context of this study, the practice of chiropractic students having medical students act as simulated patients was available only within a chiropractic examination setting; it has not yet been integrated formally into the educational format of the chiropractic program. Because this is the only chiropractic program in Southeast Asia, the value of this collaboration in developing interprofessional relationships has not been explicitly understood and explored. Therefore, this study aimed to identify and explore the perceived value of IPL in developing interprofessional relationships in Malaysian medical students acting as chiropractic simulated patients.
Methods
This was a cross-sectional study involving an online survey and interview sessions. Fifteen medical students at International Medical University who had prior experience as simulated patients in the chiropractic program examination setting were recruited via e-mail to join this study. This involved interacting with chiropractic students in observed structured clinical examinations, including history taking, physical examination or motion palpation, and adjustment setups for end-of-semester examinations.
Ethics approval was obtained from the University Joint Committee for Research and Ethics (BCh I/2020(11)). A study information sheet and explanation of the research protocol were given to participants prior to their inclusion in the study. Upon providing informed consent, participants were given a Google link to access the self-administered survey before the recorded interview session. Interviews on survey responses were held via Zoom meetings and WhatsApp calls, with the audio of the entire interview recorded with a voice recorder and later transcribed for data analysis.
The framework used for this study was designed with Allport's intergroup contact theory12 in mind (Fig 1). Using themes of reduction in prejudice, increase in understanding, and improvement in collaborative attitude in developing interprofessional relationships, it evaluates the understanding and attitudes of medical students toward the chiropractic profession gained through simulation in interprofessional education.
Fig 1.
Overview of study framework.
Survey
The self-administered survey consisted of a set of 9 statements, each focused on a different theme of IPL value based on the themes of reduction of prejudice, increase in understanding, and improved collaborative attitude. Each theme contained 3 statements, scored on a 5-point Likert scale.
Interview
Individual interviews were performed after the survey to further explore survey responses. The entire interview process was recorded digitally to ensure that all details were captured for data analysis.
Treatment of Data
Data were collected from July 2020 to October 2020. All the information acquired from the surveys and interviews was sorted in Microsoft Excel according to the main themes and categories of the survey statements. Respondents’ statements were then further categorized into positive, neutral, and negative statements under each theme. Concise organized explanations of the statements were used to describe the findings.
Results
The characteristics of the respondents are given in Table 1.
Table 1.
Respondent Characteristics
| Characteristic | n (%) |
|---|---|
| Sex | |
| Male | 15 (100) |
| Female | 0 (0) |
| Age range (y) | 23–26 |
| Medical year | |
| 3 | 5 (33.3) |
| Final | 10 (66.6) |
| Experience as simulated chiropractic patient | |
| Once | 9 (60) |
| More than once | 6 (40) |
Survey
Respondents’ perceptions were grouped as either positive, neutral, or negative based on their Likert scores. Scores of 4 and 5 were deemed positive, scores of 3 neutral, and scores of 1 or 2 negative.
For the first statement under the theme of prejudice, 66.7% of the respondents thought that being a simulated chiropractic patient helped them clarify their doubts on the scope of chiropractic. The remaining 33.3% were neutral to this statement. In terms of helping them clarify their doubts on the role of a chiropractor, 80% found the experience of being a simulated patient positive. The rest of the respondents (20%) were neutral. In terms of the professional practices of a chiropractor, again, 80% found being a simulated patient helpful, and the remaining 20% were neutral.
In terms of simulation being helpful in understanding the scope of chiropractic, 80% of respondents found this helpful and 20% were neutral about the idea. With respect to the role of a chiropractor, 86.7% responded positively, with 13.3% neutral and no negative responses. And again, for the professional practices of a chiropractor, 80% and 20% of the respondents, respectively, were positive and neutral.
For the final theme, on improved collaborative attitude, a large proportion of respondents (93.3%) felt that being a simulated patient increased their willingness to learn collaboratively with chiropractic students. The rest of the respondents (6.7%) were neutral to this statement. Many (80%) were positive toward the statement of collaborating with chiropractors, whereas 20% were neutral. More (93.3%) responded positively to the statement of being more willing to work with other health care professionals after being a simulated patient in a chiropractic setting; there were no negative responses to this statement.
Comparison of the overall numerical values of the individual Likert scores for the outlined themes calculated from the respective chiropractic profession categories can be seen in Figure 2. The theme of improvement in collaborative attitude holds the greatest cumulative value, with 190 points. This is followed by the theme of increase in understanding (180) and then reduction of prejudice (175). This shows the overall positive effect of simulation on medical students’ collaborative attitude towards chiropractic students, chiropractors, and other health care professionals.
Fig 2.
Comparative cumulative numerical scores of IPL themes.
Interview Findings
We received no negative feedback comments in the survey responses. The interview findings further described the positive and neutral perceptions with regard to the perceived value of developing interprofessional relationships in the simulated setting. Figures 3 through 6 show the summarized descriptions provided by respondents during the interview process according to the 3 themes.
Fig 4.
Interview responses—theme: reduction of prejudice. OSCE, observed structured clinical examination.
Fig 5.
Interview responses—theme: increase in understanding. OSCE, observed structured clinical examination.
Fig 6.
Interview responses—theme: improvement in collaborative attitude. CT, computed tomography; NMSK, neuromusculoskeletal; SP, simulated patient.
Fig 3.
Survey statements by theme.
The positive description of reduction of prejudice revealed that participants had doubts or misconceptions regarding the chiropractic profession before being simulated chiropractic patients. As for the neutral descriptions, participants shared that the examination setting, poor performance of chiropractic students, and the lack of 2-way communication provided limited exposure to clarify their doubts or misconceptions regarding chiropractic. Participants compared the similarities and differences between both professions in their descriptions. They also had many assumptions about the chiropractic profession, which were clarified by their involvement as simulated chiropractic patients.
For the theme of increase in understanding, positive descriptions explored what the respondents learned. Topics included understanding the thought process of a chiropractor, the scopes manageable by chiropractic, and conservative management that is widely acceptable for many clinical cases, as well as the multidisciplinary approach. As for the neutral descriptions, there were concerns for the subjectivity of chiropractic management, limited exposure to chiropractic from the simulation setting, and a lack of personal awareness related to understanding the chiropractic course. From these descriptions, feedback is mixed, with multiple factors given as reasons, including the skills of the chiropractic students observed, personal opinions, expectations of the academic faculty, and personal ignorance.
The positive responses for the theme of improvement in collaborative attitude included better expertise of chiropractors with regard to the neuromusculoskeletal system, a better personal understanding of chiropractic clinical management, confidence in the profession, and desire for patient-centered care. The neutral descriptions included the perceived contrast between the modules and focus of both courses, a lack of immediate diagnostic means for emergency cases, and a lack of understanding regarding the profession.
Discussion
This is the first study of its kind to explore perceptions of Malaysian medical students about chiropractic through their role as simulated chiropractic patients. From the results, all 3 themes showed positive outcomes in an interprofessional, simulation-based setting. Under the theme of reduction of prejudice, medical students with presumptions about the roles, scopes, and professional practices of a chiropractor found clarity during their time as simulated chiropractic patients. The main reasons they gave in their positive responses included the systematic approach of chiropractic management, professional execution by students, and the justifications given for the chiropractic diagnosis and treatment plan.
The theme of increase in understanding showed positive results from IPL. The highest value was found under the scope of a chiropractor. This could be attributed to respondents’ exposure to chiropractic care in areas apart from the spine, such as the extremities, muscles, or nervous system, and the noninvasive patient management, which differs from some other health care professions.
The greatest value in simulation-based IPL was under the theme of improvement in collaborative attitudes. The results showed that the majority of participants agreed to work alongside chiropractic students, chiropractors, and other health care professionals in the future. The main reasons provided included chiropractic practitioners’ specialized knowledge regarding human anatomy and neuromusculoskeletal systems and the need of certain patients to undergo less invasive, more conservative interventions available through chiropractic care.
Other authors have noted that professionals may have a minimal understanding of interprofessional roles and awareness due to the insufficient incorporation of IPL; this does not aid in providing patient-centered care.5 From the descriptions given by the respondents in this study, a lack of proper understanding and prejudice regarding the chiropractic profession were present.
Interprofessional learning has served as a platform for health care students to develop their professional identities as well as familiarize themselves with the main roles of other professions.13 Shared learning may improve student confidence in clinical aspects that help develop interprofessional collaborative readiness.14 Although the context of this study was not in the setting of shared learning, interprofessional interaction in simulation allowed participants to experience and understand the chiropractic profession. There was still an overall positive perception.15 Interprofessional learning in this context helped familiarize medical students with the chiropractic profession and increased collaborative willingness through simulation.
Following a simulated learning session, students may gain a better understanding of the roles of other professions, which yields a significant improvement in conflict management and the will to work collaboratively.16,17 This can be seen in the positive responses to the themes of IPL regarding the chiropractic profession. The current simulated setting allowed firsthand experience of chiropractic management for the medical students involved.
Hands-on practice in interprofessional collaboration promotes patient care and safety, as well as developing mutual respect and willingness to collaborate.5,18, 19, 20 and reducing stereotyping.21 The results of our study show that simulation may help with reducing prejudice and increasing understanding of the chiropractic profession. This in turn may improve the collaborative attitudes of medical students, described in terms of peer-to-peer learning with chiropractic students, future referrals to chiropractors, and collaboration with other health care professionals. However, this will need further exploration.22
Even the limited IPL in this setting seemed to reduce medical students’ prejudice regarding the chiropractic profession in terms of scope, role, and practices. A proper understanding of the value of IPL through simulation may enable improvement in the learning formats and experiences of health care students.23, 24, 25, 26, 27 Interprofessional learning helped increase our respondents’ understanding and positive view of the chiropractic profession. We found that IPL had a positive influence in this sample of medical students on their collaborative attitude toward the chiropractic profession as well as other health care professions. Our findings show that there may be additional value in IPL, through patient simulation, in developing interprofessional relationships with medical students. The results can act as a guideline in implementing further IPL opportunities between chiropractic and other health care programs in medical universities, with the long-term goal of promoting patient-centered care.
Limitations
Our study results are limited to medical students from the same medical university. We also recognize that one of the more significant limitations of the study is that the IPL setting explored was limited to young male simulated patients in an examination setting, limiting the amount of interaction and communication between medical and chiropractic students. The results from all-male participants may not be generalizable. Further studies should be conducted in settings other than examinations, involving both female and male medical students. As well, future studies should measure whether the perceptions carry on into practice. A follow-up study on the attitudes and behaviors of these medical students once they reach practice would be beneficial to see if there are long-lasting effects of IPL experiences.
Conclusion
This study found an overall positive perception of developing interprofessional relationships in medical students who acted as simulated chiropractic patients. The medical students involved reported positive outcomes in terms of reducing prejudice, enhancing understanding, and improving their collaborative attitude toward the chiropractic profession.
Funding Sources and Conflicts of Interest
This study received financial support by an International Medical University Internal Grant. No conflicts of interest were reported for this study. The views in the study are the findings of the authors and do not reflect the views of the university.
Contributorship Information
Concept development (provided idea for the research): T. G. P., Y.L.
Design (planned the methods to generate the results): T. G. P., Y.L.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): T. G. P.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): Y.L.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): T. G. P., Y.L., K.S.H.
Literature search (performed the literature search): T. G. P., Y.L., K.S.H.
Writing (responsible for writing a substantive part of the manuscript): K.S.H.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): T. G. P.
Practical Applications.
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This study showed an overall positive perception in medical students of developing interprofessional relationships with chiropractors and other health care professionals.
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The results suggest that opportunities for interprofessional learning between chiropractic and other health care programs may assist in the long-term goal of promoting patient-centered care.
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