Identification of barriers and facilitators of successful interprofessional education (IPE) – a scoping umbrella review / Identifizierung der Einflussfaktoren für die interprofessionelle Ausbildung (IPE) – ein Umbrella Scoping Review

The study is an umbrella scoping review. Combining an umbrella review and a scoping review is the most effective approach to achieve the objective of this study, which is to identify the influencing factors for IPE. Conducting an umbrella review is appropriate to this project, as there are already several systematic reviews available on the topic (Hammick et al., 2007; Reeves et al., 2017). This approach avoids redundant searches, screening individual studies, and synthesizing existing studies, and provides a good overview of the current state of the research field (Aromataris et al., 2015). It can also help uncover potential discrepancies or conflicting results (Aromataris et al., 2020).

The methodology of the scoping review also allows for the identification of influencing factors for IPE. The included reviews are not limited to systematic reviews (Munn et al., 2018). This is particularly important for a concept like IPE, as there are many qualitative studies available. The study followed the methodology for scoping reviews proposed by the Joanna Briggs Institute, with the specific inclusion criterion of including only reviews in the search process (Peters et al., 2020).

A research protocol has been developed, which can be accessed at the following address https://1drv.ms/w/s!AiVcI8peCpyUidBIiUg2_uBhMoARPQ?e=Y36QDK. In addition, the PRISMA checklist was used to assess the quality of scoping reviews.

For the research and selection of studies, the inclusion and exclusion criteria were defined following the PIOSC format (Population, Intervention, Outcome, Study Design, Context) (see Table 1). The study only included published reviews from 2014 onwards, written in German, English, or Dutch.

The selected literature had to include study participants who were involved in healthcare, either as students/trainees of a healthcare profession, or as qualified healthcare professionals. The included reviews had to encompass at least two different healthcare professions, and the participants had to have been involved in some form of IPE activity or workshop. Reviews that focused on investigating influencing factors, such as barriers and/or facilitators of IPE, were included. Various review formats that conducted a systematic literature search, such as systematic reviews and scoping reviews, were included in the search. All the different contexts in which IPE can take place were included in the research and study selection.

Reviews that only included one healthcare profession, or reviews with participants from healthcare professions that did not involve the treatment of humans (i.e., veterinarians), were excluded. Reviews that focused on individuals before the start of their education or training, such as those in pre-practicum, were also excluded. Reviews that did not specifically focus on the concept of IPE, but rather on the concept of IPP (interprofessional practice) or interventions that assessed readiness for IPE/IPP by using the Readiness for Interprofessional Learning Scale (RIPLS), were also excluded. The latter was excluded because Mahler et al. (2014) found no internal consistency for RIPLS in the German context and does not recommend its use for investigating the readiness for IPE.

Reviews that examined the concept of IPE and additionally addressed IPP and/or readiness for IPE/IPP (without RIPLS) were included, but only the results related to IPE were evaluated. Furthermore, reviews that focused on the effectiveness of IPE programs and/or knowledge gained from the IPE program were excluded. Reviews without a systematic literature search and empirical studies were excluded. All the different settings in which IPE can potentially take place were considered in the research and study selection.

A three-step search strategy was performed (Peters et al., 2020). At first, an initial search was conducted in the MEDLINE (PubMed) and Cochrane Library databases. The titles, abstracts, and keywords of the articles found in this search were examined for synonymous search terms. Second, search strings were created for the databases to be searched, including MEDLINE (PubMed), CINAHL (Ebsco Host), PsycINFO (Ebsco Host), Embase (Elsevier), and Cochrane Library. To document the process, the template from RefHunter was used (Hirt & Nordhausen, 2020). A librarian reviewed the search string, and optimization of the search string was carried out according to their recommendations. This involved specifying the keywords used in each database. The final search string used for MEDLINE is provided in (Appendix 1). The literature search was conducted on November 16, 2022. There was no hand search carried out in specific journals, or any other form of grey literature search. Finally, the reference lists in the included reviews were also searched for additional studies.

The study selection was conducted using the web tool CADIMA (Julius Kühn-Institut (JKI), 2023). After identifying and removing duplicates, the title-abstract screening was performed by two reviewers (JW and MH). Both reviewers reviewed the titles and abstracts of the identified studies independently. They classified the studies into one of three categories, labelled as inclusion, exclusion, or uncertain, based on the predetermined inclusion and exclusion criteria. The assignments were compared, and in cases where both reviewers classified a study as uncertain or provided conflicting categorizations, there was a discussion between the researchers to reach a consensus. The same approach was applied during the full-text screening, with a justification provided for the exclusion of studies.

For data extraction, an Excel table was created following the JBI template for scoping reviews (Peters et al., 2020). The extracted data from each included review encompassed author(s), title, publication year and country, objective/research question, participants, context, review type, search strategy, inclusion and exclusion criteria, number of included studies, data extraction and analysis, results related to the influencing factors of IPE, limitations, and conclusion or key findings.

Following data extraction, the influencing factors were synthesised using a qualitative narrative synthesis approach based on the research questions (Booth et al., 2016; Rumrill & Fitzgerald, 2001). This approach allows for the examination of studies that differ in their research questions, samples, and methods, and characterizes the results into multiple categories using textual data (Popay et al., 2006).

The development of categories was an iterative process. Initially, the analysis levels of micro, meso, and macro levels were used. We choose this frame of reference in order to be able to analyze the influencing factors from a holistic perspective that included individual, organizational and societal perspectives. Both reviewers assigned the extracted influencing factors to a specific level. If appropriate, they independently developed subcategories to further summarize the results. The level assignments were compared, additional subcategories were developed, existing ones were summarized or modified, and main categories were formed. These main categories departed from the original analysis levels of micro, meso, and macro levels, focusing instead on the main dimensions of learners, educators, and institutions. Overall, this process was highly dynamic and based on both the extracted influencing factors (inductive approach) and existing theoretical constructs (deductive approach).

The included reviews originate from eight different countries. Two reviews each were from the United States and the United Kingdom, and Australia, New Zealand, Indonesia, Japan, South Africa, and the Netherlands each contributed one review. The reviews were published between 2014 and 2022. Most of the studies (n = 4) were published in 2016.

In total, the reviews included between 12 and 65 studies, with a total number of 336 studies included. These included studies were published between 1995 and 2022. The most common type of included review was the systematic review (n = 4), followed by the scoping review (n = 2). The participants in the reviews consisted of students, educators, and healthcare professionals, with some additional participants from the social sector. The context in which IPE was conducted encompassed various settings, including both educational and clinical settings within the scope of training.

In summary, there was wide variability and heterogeneity among the included reviews. Most reviews focused on a specific aspect, whether it was population, intervention, context, or study design. For example, one study looked at the basis for IPE and considered the effectiveness of different types of IPE activities (Reeves, Fletcher, et al., 2016). This study analyzed the key aspects of the context (presage), related mechanisms (process), and associated outcomes (product) based on the 3P model (presage, process, product by Freeth & Reeves, 2004). Another study specifically focused on the teaching method of simulation-based training with at least two different health professions (Palaganas et al., 2016). Another study only addressed IPE in the clinical setting and focused instead on learners’ perceptions in medical and nursing education (Visser et al., 2017). Another study solely focused on faculty development in IPE (Watkins, 2016). One study encompassed IPE in the context of midwifery (Madisa et al., 2022), and another study included only qualitative studies in the review (Reeves, Pelone, et al., 2016).

The study of Reeves, Pelone et al. (2016) focused on teacher, in this context a facilitator who conducted IPE with learners from health and social care backgrounds. One study aimed to identify challenges or barriers, and initiatives to overcome them, from developed countries in order to anticipate how to solve those challenges in developing countries. The authors followed the World Health Organization (WHO) approach of implementing IPE in all countries (Sunguya et al., 2014).

The results of the qualitative narrative synthesis are summarized in figure 2. The figure illustrates all the identified influencing factors of IPE into three main dimensions, displayed as Learners, Educators, and Institutions. The overlapping rectangles represent the interdependence of all the influencing factors (see Figure 2).

Figure 2:

The influencing factors related to the dimension of learners were identified at both the individual and team levels. At the individual level, factors were categorized into personal characteristics and attitudes of the learners (see Table 2). Following the definition of attitudes from the Online Dictionary of Psychology and Pedagogy, the “attitude category” was subdivided into cognitive, affective, and behavioral components (Stangl, 2023). At the team level, distinctions were made between team characteristics and collaboration (see table 3). The identified influencing factors were weighted as barriers, facilitators, or general influencing factors. The attribution of certain influencing factors could depend on the perspective taken. For example, IPE goals had a facilitating effect when clearly defined goals were set, but conversely functioned as barriers when these goals lacked clarity. Furthermore, in some cases the reviews have presented diverse and occasionally contradictory outcomes concerning these factors, such as those concerning the role of previous practical experiences.

Factors influencing educators in IPE were divided into three categories: attitudes of educators, general approaches and those specific to IPE teaching and learning methods. Broader considerations regarding instructional techniques also had an impact. Predictably, methodologies that centred around teamwork, collaborative activities, and supportive tools played an important role in IPE. Additionally, facilitators and obstacles related to specialized IPE learning approaches are outlined in Table 4.

In this main dimension, all influencing factors related to institutional conditions were summarized. A primary focus was set on the structures and the organization of interprofessional education (IPE). Three categories were identified: resources, organizational structures, and implementation (see Table 5).

In the dimension of learners, Reeves, Fletcher, et al. (2016) noted a lack of clarity regarding how demographic factors contextually influence IPE programs. Overall, the literature pays little attention to the composition of groups in IPE, especially when learners collaborate in small groups or what happens when different demographic characteristics converge. Discrepancies in age structures were found to have a negative impact on collaboration, as well as clinical experiences that were associated with negative experiences related to hierarchies or status (Reeves, Fletcher, et al., 2016; Sunguya et al., 2014). One possible explanation for why younger students tend to assess their interprofessional relationships more positively is that, due to their shorter biographies, they have less experience compared to older learners. Consequently, the opportunity for them to accumulate negative experiences has been relatively limited (Reeves, Fletcher, et al., 2016). Appelbaum et al. (2019) found that successful team cohesion and a sense of psychological safety (i.e., the belief that one can voice their opinion without fearing negative consequences) significantly influence team effectiveness. Future studies should therefore further investigate demographic factors such as age, gender, and cultural aspects (e.g., profession, status) as they affect group composition in IPE, as well as their impact on team cohesion.

IPE is significantly shaped by diversity. According to Gilbert (2005), interprofessional education teams in healthcare should not be defined by the nature or diversity of their professional composition, rather by the quality of their communication and the degree of collaboration, but this very diversity poses a challenge in IPE (Mitchell et al., 2011).

Diversity in interprofessional teams arises primarily from how the interprofessional groups are composed. It emerges from the variety of professions coming together, resulting in differences in learning levels, knowledge bases, learning needs, learning experiences, learning styles, and professional jargon. All these aspects have been identified as challenges, but they are precisely what characterize interprofessional teams later on. Various research groups emphasize that when a highly diverse interprofessional group collaborates effectively, they reach better decision-making, as well as more innovative and creative approaches to problem-solving (Dunn et al., 2018; Mitchell et al., 2011; Reinders & Krijnen, 2023). The diversity within interprofessional teams and learning groups, along with the associated differences in opinion, are central to the added value of interprofessionalism (Mitchell, 2021). In this context, diversity in its various dimensions should be considered as a variable that can have a positive or negative impact on the functioning of groups. Mitchell et al. (2011) found that diversity and team efficiency are related, and that these aspects influence the dimension of “team belongingness.” Therefore, in IPE teaching, the construct of diversity should be addressed, team efficiency should be emphasized as a steering factor, and learners’ sense of “team belongingness” should be strengthened. The relationships between these factors should be further explored in depth.

Another aspect of how diversity influences team efficiency can be found in the constructs of social identity theory and social categorization (Mitchell et al., 2011; Reinders & Krijnen, 2023). Social groups categorize themselves based on perceived similarities and differences among their members and define their affiliations as belonging to either the in-group or the out-group (Hean & Dickinson, 2005). This process of self-categorization forms the basis for bias, differentiation and the formation of prejudices (Burford, 2012; Willetts & Garvey, 2020). In the practice of interprofessional collaboration, this professional stereotyping plays a negative role and hinders the ideals of IPE (Reeves, Fletcher, et al., 2016; Sunguya et al., 2014; Visser et al., 2017). Processes and mechanisms that mitigate these stereotypes should be integrated into education to promote a sense of belonging to the interprofessional team as the favored group and can thereby strengthen interprofessional identity. There should be sufficient space and time for team-building activities in the teaching-learning concepts (Madisa et al., 2022; Riskiyana et al., 2018). The process of self-categorization should be focused on commonalities and their benefits within the interprofessional learning group. With adequate time resources dedicated to it, it strengthens relationships and interactions among group members. Recognizing the values, skills, and personality traits within the group has a profound influence on how teams operate (Bell et al., 2018). The promoting factor of sufficient time should be intentionally incorporated into interpersonal relationships, allowing learners to become familiar with each other and providing ample time for informal learning. All this supports the importance of belongingness to the interprofessional team and contributes to the dismantling of hierarchies and differences in status (Madisa et al., 2022; Reeves, Fletcher, et al., 2016; Sunguya et al., 2014; Visser et al., 2017). Perhaps the integration of interprofessional competencies in the more recent curricula of health professions is partly responsible for the more positive ratings of interprofessional relations in younger people. In summary, for learners, interacting demographic factors such as age, gender, and cultural differences in the context of group composition and diversity need to be further investigated. New insights from these variables should be deliberately applied as promoting factors in IPE. Also, a sense of belonging in interprofessional teams is identified as an important positive influencing factor. Further research is needed to understand the related factors that strengthen interprofessional identity in IPE.

The competence of educators was identified as a significant component by practically all the included reviews (Lawlis et al., 2014; Madisa et al., 2022; McNaughton, 2018; Palaganas et al., 2016; Reeves, Fletcher et al., 2016; Reeves, Pelone et al., 2016; Sunguya et al., 2014; Visser et al., 2017; Watkins et al., 2016). The profile of requirements for IPE educators, as derived from the reviews, was complex. Educators should serve as role models, possess a non-frontal teaching style that invites enthusiasm and empathy, and consider diversity appreciatively. They should promote group processes, accompany learners, and facilitate meaningful reflections. They should also possess multiple teaching methodologies, and be able to combine them and collaborate with colleagues from other professions to develop effective interprofessional teaching and learning materials. The World Health Organization (WHO, 2010) has also previously set similar requirements for IPE educators.

However, according to current research, only a minority of educators meet such a profile. Watkins (2016) focused extensively on the development of training programs for IPE educators. Interestingly, many similarities emerged between the influencing factors that were identified for learners and the factors influencing educators’ learning. Educators had to recognize their roles as professional participants in IPE faculty development, but also their changing roles in collaborative teams. Competent moderators who employed teaching methods such as reflection and self-experience facilitated knowledge acquisition. In summary, Watkins (2016) concluded that educators became competent IPE educators when they were taught in the same way they would later teach IPE. The ideal composition of the teaching staff should also reflect the diversity of the learners. In this way the teaching team can serve as a model for successful IPE.

The identified overarching approaches of IPE teaching and learning methods embody three important aspects of interprofessional collaboration. First, there is a patient-centered approach (Madisa et al., 2022; McNaughton, 2018; Sunguya et al., 2014). Such an approach is also recognized as an important domain in international interprofessional competency frameworks (IPEC, 2016; Canadian Interprofessional Health Collaborative, 2010). Accordingly, here the client and their concerns and wishes are at the center of the collaboration. The main aim is always to collectively achieve the client’s individual goals to the best of each individual’s ability.

Secondly, there is a team-based approach, focusing on collaboration and promoting team-building activities (Madisa et al., 2022; McNaughton, 2018; Riskiyana et al., 2018; Sunguya et al., 2014; Visser et al., 2017). The recommendations of the international competency frameworks for this approach align with the promoting factors that we identified (IPEC, 2016; Canadian Interprofessional Health Collaborative, 2010).

Thirdly, there is experiential and practice-based learning (Madisa et al., 2022; McNaughton, 2018; Riskiyana et al., 2018; Visser et al., 2017). There are still barriers, however, to implementing interprofessional activities in the clinical context (Schot et al., 2020). The significant benefits of practical experience for learners may fade if the concept of interprofessional collaboration is not firmly embedded in real-world practice. Without an interprofessional orientation in practice, practical experiences can impart negative effects. Although practice-based learning through clinical placements holds a high value, there is still research that needs to be done about the successful implementation of IPE in a practical setting (Schot et al., 2020).

The aspects identified as supportive tools are not really specific to IPE and generally apply to promoting learning, such as reflection or creating a safe and positive learning environment (Robertson et al., 2022). Despite the advancing digitization, e-learning was rarely mentioned as a teaching design for IPE in the reviews, or was even described by learners as unnecessary when face-to-face options were available, as seen in Visser’s study (2017). One possible explanation is that later collaboration also takes place face-to-face. It is important to consider that most studies were conducted before the COVID-19 pandemic. At that time, e-learning was still a relatively innovative and unfamiliar medium. One consequence of COVID-19 is that the use of and familiarity with e-learning formats has increased (Kaap-Fröhlich et al., 2022).

Different types of e-learning methods were reported, such as online/web-based programs, tele-education, mobile app, and massive open online courses (MOOC). Successful e-learning provided interactive and authentic learning experiences that promoted direct clinical applications (Zhang et al. 2023). Potential benefits of integrating e-learning in IPE are particularly seen in the implementation of IPE in rural areas or outpatient settings (Kaap-Fröhlich et al., 2022).

Another option is a blended learning format that combines elements of online-based self-study and project work with face-to-face learning (Kerres & Witt, 2003). This format could reduce organizational and planning effort, as well as the resulting difficulties in scheduling IPE learning groups. It should be emphasized that the studies identified practical experience and direct contact through face-to-face phases as irreplaceable. However, e-learning formats should be considered in evaluation studies of IPE programs, and their potential for teaching and practice should be further investigated.

Furthermore, combining various teaching and learning approaches supports interprofessional interaction and helps maximize interprofessional collaborative learning (Madisa et al., 2022; Riskiyana et al., 2018). Applying diverse teaching strategies, such as simulation-based learning, small- group learning, reflective learning, and practical experiences with clinical situations, as well as different combinations of all of these, leads to greater development of interprofessional competencies (Madisa et al., 2022). Lectures should be avoided in IPE teaching (Visser et al., 2017). In summary, the more practice-oriented the interprofessional teaching becomes, the more potential for advancement it receives, as it serves as a true catalyst for interprofessional collaboration (Jones et al., 2022; Sottas et al., 2016).

The mechanisms described in the WHO Framework for Action on Interprofessional Education and Collaborative Practice (2010) should support the implementation of IPE. On one hand, there are mechanisms for educators to consider, such as institutional support and training. On the other hand, curricular mechanisms like principles of adult education, logistics and planning, as well as the content of the IPE programs, should be taken into account. These mechanisms continued to find their relevance as influencing factors in the dimension of institutions in the included reviews. A major challenge lies in traditional mono-professional educational structures, where content-heavy curricula and complex planning logistics hinder the integration of IPE. Overcoming these difficulties largely depends on the provision of institutional resources.

In order to establish sustainable IPE programs, faculty development, supported by all stakeholders, is crucial. Notably, the endorsements of management and leadership play a significant facilitating role (Madisa et al., 2022; Reeves, Fletcher, et al., 2016). According to the position paper formulated by the GMA committee for German-speaking countries, faculty development is seen as one of the specific core requisites for IPE, alongside legal frameworks and networks (Kaap-Fröhlich et al., 2022). Interprofessional executive leadership should create flexible structures and allocate time for implementation, and educators should be prepared for their roles through training (Kaap-Fröhlich et al., 2022). An institutional interprofessional vision should be developed and pursued. Educational programs should be aligned with existing interprofessional competency standards and curricular integration should be supported by a longitudinal, structured IPE curriculum that aligns with interprofessional practice. Also, from an international perspective, as outlined in the CAIPE strategy for 2022–2027, faculty development plays a pivotal role in providing essential support to institutions in departmental, curricular, and assessment-related matters [https://www.caipe.org/strategy].

The need for change in systems (in education and healthcare) has been emphasized since the Lancet Report (2010). As a key component in transforming the educational system, generating funding and resources for faculty development, organizational processes, and personnel training at the institutional level are crucial. Concerning IPE, initial regulations should establish interprofessionalism through the inclusion of education and examination regulations – for example, in nursing professions (Bundesministerium der Jusitz, 2018). or in the national competency-based learning objective catalogue for medicine (NKLM 2.0). Legislative and political initiatives should support the integration of interprofessional education, and training programs for IPE educators should be established. In summary, management and leadership need to create structures and processes that allow for the sustainable implementation of IPE and have a positive impact on educators and learners.

One significant strength of the present umbrella scoping review lies in the literature search and data analysis. The creation of a search protocol allows for comprehensive transparency and traceability of the search process. Two reviewers conducted the screening procedure and subsequent qualitative narrative synthesis. As is common in qualitative analyses, a certain level of subjectivity in category formation cannot entirely be eliminated. To mitigate this, the heterogeneity of the reviewers in terms of age, profession, and teaching/practice experiences was considered.

Nevertheless, our methodological approach of inclusion and exclusion criteria can be discussed. During the search process, studies evaluating the effectiveness of IPE programs and/or knowledge gain through the IPE program were intentionally excluded. These effectiveness studies measured outcomes in terms of enhancements in students’ knowledge, skills, attitudes, or the learning outcomes resulting from IPE. In this umbrella review, the emphasis was placed on understanding the contributing factors to IPE, which is why these studies were excluded. Thus, it is possible that studies relevant to our research objective were excluded by our methodological approach. However, it is not entirely ruled out that other reviewers may arrive at slightly different results following the data analysis. Additionally, the search was limited by excluding grey literature and including only English, German, and Dutch-language articles published between 2014 and 2022. Consequently, further potential IPE studies may have been overlooked, while others of relevance were not integrated due to the chosen methodological procedure.

The qualitative narrative synthesis of the ten included reviews revealed three main dimensions: learners, educators, and institutions. The resulting model illustrates the mutual dependency of the influencing factors in IPE to health professions in general. The tables that have been created for each main dimension, along with their identified influencing factors, can be used as indicators to identify areas for improvement and potential changes in IPE. However, influencing factors for IPE should always be considered in their interdependence and not as individual independent factors. In particular, expanding support from management and leadership, along with the implementation of effective faculty development concepts, is crucial. Further research is needed to gain a deeper understanding of the constructs and their relationships between diversity, team efficiency, and the development of interprofessional identity in the context of IPE.