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ORIGINAL ARTICLE

Effectiveness of an interprofessional education model based on the transtheoretical model of behaviour change to improve interprofessional collaboration Fatemeh Keshmiria, Mahdi Rezaib, Reza Mosaddeghb, Kamran Moradi c, Peyman Hafezimoghadamd, Mohammad Amin Zaree, Nader Tavakolif, Mohammad Ali Cheraghig, and Mandana Shirazia,h,i

aDepartment of Medical Education, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran; bEmergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran; cEvidence-Based Medicine and Critical Thinking Group, Endocrine and Metabolism Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; dEmergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran; eDepartment of Emergency Medicine, Hazrat-e-Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, Iran; fHazrat-e-Rasoul Akram Medical Center, Iran University of Medical Sciences, Tehran, Iran; gSchool of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran; hEducational Development Center, Tehran University of Medical Sciences, Tehran, Iran; iDepartment of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden

ABSTRACT This study aimed to assess the effectiveness of an interprofessional education model (IPE) based on the transtheoretical model to improve the participants’ interprofessional collaborative practice. The study was conducted in Iran using a controlled before-and-after study design. The participants (n= 91) were the residents of emergency medicine and nurses of the emergency units from two teaching hospitals affiliated to Iran University of Medical Sciences. The participants in the intervention group (n = 40) were 22 residents and 18 nurses. The control group (n = 51) consisted of 20 residents and 31 nurses. The participants were classified based on their stage of readiness to change. The interventions were two-day workshops for each stage (i.e., attitude and intention). We used the Interprofessional Collaborator Assessment Rubric (ICAR) to assess the effectiveness of the developed model. The interprofessional collaboration of the participants in the interven- tion and control groups was assessed at four time points before and after the intervention in the real emergency unit environment. Student’s t-test and repeated measures analysis of variance (RM-ANOVA) were used to analyse the data. We used partial eta-squared (η2) for effect size calculations. The mean values of ICAR scores in the intervention and control groupswere 95.63 ± 19.14 and 89.19 ± 16.11 before the intervention. The mean values of ICAR scores at 3 months after the intervention were 99.82 ± 22.32 and 88.29 ± 16.87 in the intervention and control groups, respectively. After 6 months, the mean values of ICAR scores of the interven- tion and control groups were 98.6 ± 23.40 and 87.98 ± 16.01, respectively. The results showed that the intervention had a medium educational effect size (partial η2 = 0.06) on performance of the participants. Our results showed that an IPE model that is tailored to the learners’ stage of readiness to change improves interprofessional collaboration in the participants. The developed model could be applied for improving interprofessional collaborative performance in other IPE programmes.

ARTICLE HISTORY Received 5 November 2015 Revised 2 December 2016 Accepted 20 December 2016

KEYWORDS Evaluation; interprofessional collaboration; interprofessional education; performance; stages of change; transtheoretical model

Introduction

Interprofessional collaboration has been introduced as a key factor in providing patient-centreed services and improving healthcare outcomes (Vachon et al., 2013). The Canadian Interprofessional Health Collaborative (CIHC) defines interprofessional collabora- tion (IPC) as cooperation of the healthcare personnel and the patients with each other to achieve shared decision making for addressing the healthcare challenges (Canadian Interprofessional HealthCollaborative, 2010). Collaborative competency can consist of two key elements: the concept of a collaborative action to address the patient’s needs, and the concept of a team dynamic to integrate different views and professional capabilities in team- work and to develop respect and trust between themembers of the healthcare team (D’Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005; Zwarenstein, Goldman, & Reeves, 2009). According to Bridges, Davidson, Odegard, Maki, and Tomkowiak (2011), the elements of collaborative practice include

responsibility, accountability, coordination, communication, cooperation, reciprocal trust, and respect. The collaborative prac- tice can effectively improve patient safety and reducemedical error (The Health Professions Network. Nursing and Midwifery Office within the Department of Human Resources for Health, 2010).

Interprofessional collaboration has been regarded as an essential competency in many educational programmes, and interprofessional education (IPE) has been implemented in the educational curricula (Frank & Deborah, 2007; General Medical Council Education Committee, 2009; Swing, 2002). In IPE, individuals from different professions become engaged in learn- ing from, with, and about each other (The Health Professions Network. Nursing and Midwifery Office within the Department of Human Resources for Health, 2010). A collaborative and interprofessional setting prepares the individuals for accepting each other’s roles and understanding the necessity of teamwork for achieving the desired healthcare outcomes. In addition, IPE

CONTACT Mandana Shirazi [email protected]; [email protected] Educational Development Center of Tehran University of Medical Sciences Building, No. 57, Hojatdust Street, Keshavarz Boulevard, Tehran 14197-33171, Iran.

JOURNAL OF INTERPROFESSIONAL CARE 2017, VOL. 31, NO. 3, 307–316 http://dx.doi.org/10.1080/13561820.2016.1276051

© 2017 Taylor & Francis

allows for sharing experiences, skills and ideas, understanding different values, respecting the roles of other professions, and communicating better to improve the healthcare outcomes (Vachon et al., 2013). Therefore, effective planning for imple- mentation of IPE programmes in medical education is very important for improving collaborative capabilities.

Background

During the past decade, the need for developing theory-based IPE programmes has been emphasised by the experts (Clark, 2006, 2009; Reeves &Hean, 2013).Theory is a set of concepts and definitions that play an effective role in explaining the phenom- ena and predicting the outcomes (Glanz, Rimer, & Viswanath, 2008). Applying theory in educational programmes leads to the development of proper goals, directing the educational pro- cesses, and evaluation of programme outcomes (Burns, 2014). In this regard, Mann et al. (2009) introduced the Seamless Care Model, which is a theory-basedmodel based on the constructivist learning theory, situated learning theory, and social cognitive theory, and have shown this model’s effect on educational out- comes. In another study, Leicester Model applied the constructi- vist learning theory, adult learning theory, and reflection and experiential learning theories for promoting patient-centred learning and the teamwork process (Anderson & Lennox, 2009). Clark (2013) has recommended applying transtheoretical model (TTM) in IPE models as a proper tool for guiding beha- vioural change towards interprofessional collaboration in orga- nisations. Applying TTM in IPE programmes leads to an in- depth understanding of various processes that promote change and has a great significance in the process of design, implemen- tation, and continuation of programmes (Clark, 2013). In other words, TTM provides the roadmap for behavioural change in interprofessional collaboration (Burns, 2014).

TTM or stages of change (SOC) was developed by Prochaska and DiClemente as a comprehensive model of behavioural change (Glanz et al., 2008). According to TTM, the process of behavioural change involves five stages of change: pre-contem- plation, contemplation, preparation, action, and maintenance (Glanz et al., 2008). In the field of medical education, the SOC model has been modified by the experts to a three-stage model with three stages of attitude, intention, and action (Buckley, Goering, Parikh, Butterill, & Foo, 2003; Glanz et al., 2008; Parker & Parikh, 2001; Shirazi et al., 2007, 2013; Xiao et al., 2004). In the attitude stage, the individual has no awareness of the problem or no commitment to take action. In the intention stage, he/she has considered behavioural change, while in the action stage, such change has already taken place. The basic assumption of TTM is considering the behavioural change as a staged process where each stage has its specific features. Therefore, it is necessary to design appropriate educational interventions that are tailored to these features (Elder, Ayala, & Harris, 1999). According to TTM, the proper educational approaches should be designed on the basis of an individual’s readiness to change, in order to guide the individual towards the desired behaviour (Glanz et al., 2008). Studies have shown that participation in educational programmes that are based on TTM leads to behavioural change in the participants (Buckley et al., 2003; Shirazi et al., 2007).

According to a systematic review on IPE programmes, most of the studies performed in this field have not been based on theory (Pauze & Reeves, 2010; Reeves et al., 2016). In addition, most of the available studies have evaluated the attitude and readiness of the learners for interprofessional education, and only a few studies have focused on assessing the interprofes- sional performance of the learners (Pauze & Reeves, 2010; Reeves et al., 2016). Therefore, it has been recommended to evaluate the effectiveness of theory-based IPE interventions and the educational outcomes associated with these interven- tions (Reeves et al., 2016; Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). TTM has been previously discussed in the field of IPE (Clark, 2013). It has also been previously implemen- ted in the field of continuing medical education (Parker & Parikh, 2001; Shirazi et al., 2007). In the field of IPE, however, TTM has never been implemented in any study. In the present study, we have evaluated the effectiveness of an IPE model based on TTM to improve interprofessional collaborative performance of the participants. We hypothesised that an educational inter- vention that is tailored the learners’ level of readiness to change for interprofessional collaboration would lead to improvement in their interprofessional collaborative performance.

Methods

We employed a quasi-experimental controlled-before-and-after study design to assess the perceived effectiveness of an IPE experience that used TTM to improve the participants’ views of interprofessional collaborative practice.

Setting

The study was conducted in the emergency units of two teaching hospitals affiliated to Iran University of Medical Sciences (IUMS). The current medical education curricula in the univer- sity and continuing education (CE) settings in the country are discipline based, and the present study was performed as a pioneer IPE programme at IUMS. In addition, it has been shown that there are important challenges in implementation of educational programmes with an IPE approach in the context of our study as a developing country (Irajpour, Alavi, Abdoli, & Saberizafarghandi, 2012; Sunguya, Hinthong, Jimba, & Yasuoka, 2014; Vafadar, Vanaki, & Ebadi, 2015).

Participants

The participants were selected from the emergency units in two teaching hospitals at IUMS. All of the residents of emergency medicine and nurses from these two hospitals (n = 91) agreed to participate in the study. The assignment of teaching hospitals as the intervention and control settings were random. The partici- pants were assigned to either the intervention or control groups based on the teaching hospital in which they were working. The intervention group was consisted of 22 residents of emergency medicine and 18 nurses. The participants in the control group were 20 residents of emergency medicine and 31 nurses. We considered continuing education credits for participation in the intervention in order to encourage the participants to take part in the intervention.

308 F. KESHMIRI ET AL.

The training of the learners was by a team of experts consisting of three medical education experts and two emer- gency medicine specialists. In addition, two faculty members of emergency medicine at each teaching hospital (i.e., four assessors in two hospitals) participated as raters.

The intervention

Preparation phase We implemented an IPE intervention based on the TTM theory (Keshmiri, Moradi, & Shirazi, 2016). According to the TTM, the individuals at different levels of readiness to change (i.e., at different stages of change) would require different education. The IPE model components were developed based on the mod- ified TTM (i.e., three-stage model; attitude, intention, and action), and the educational components were tailored to the characteristics of the ‘stages of change’ and their corresponding ‘processes of change’ (Glanz et al., 2008). In the preparation phase, we delivered the workshops for training of the trainers and assessors and assigned the learners to the TTM subgroups:

Training of the trainers We held a one-day workshop for the trainers (i.e., three medical education experts and two faculty members at the emergency department) about the educational methods and the content of the workshops intended for the learners.

Training of the assessors Training of the assessors was through a one-day workshop which comprised three components: (a) an interactive lecture, (b) small group discussions, and (c) a working group for con- ducting assessment exercises in simulated situations and provid- ing feedbacks. At the beginning of the session, we introduced the project objectives, interprofessional concepts and competencies, the interprofessional collaborator assessment rubric (ICAR), and the guideline for performance assessment (Curran et al., 2010). Then, in the small group discussions, significant aspects of interprofessional collaboration and their examples, which were specific to the emergency department environment, were dis- cussed with the assessors. The education about ICAR items and the scoring method of the instrument were provided to the assessors based on the available guideline (Curran et al., 2010). In the working group, we showed a video related to interprofes- sional collaboration in the emergency ward. The video showed the performance of an emergency team managing a trauma patient, and the assessors were asked to evaluate the perfor- mance of team leader, as an exercise in a simulated situation. Afterwards, the assessment results were discussed with the asses- sors, and individual feedback was provided to them.

Assignment of participants to TTM subgroups A 15-item IPC-TTM questionnaire was developed and vali- dated for the assessment of participants’ readiness to change for interprofessional collaboration (Keshmiri, Moradi, Haeri, Shirazi, & Montazeri, 2016). We used the instrument prior to the intervention for ‘needs assessment’ based on the ‘stages of change’ model (Parker & Parikh, 2001). The questionnaire items were designed based on the key interprofessional colla- boration concepts including role and responsibility, conflict

management, interprofessional communication, sharing of information, and the teamwork. The IPC-TTM questionnaire was designed with three domains representing the attitude (eight questions), intention (four questions), and action (three questions) stages of TTM. The questionnaire was designed as self-reporting with binary items (yes/no). The participant’s answer to each binary item would determine his/her score from that item (No = 0, Yes = 1). These scores are then summed up in each domain and reported as the percentage of the possible maximum score in that domain. The participants are assigned to the attitude, intention, or action stage of readiness to change for interprofessional col- laboration if they obtained their highest percentage score in that domain. The content and face validity of the question- naire was confirmed by an experts’ panel which was consisted of 16 experts from different professions including medical education (n = 5), clinical education and communication skills (n = 5), nursing education (n = 4), and theoretical application (n = 2) experts. The item-level content validity index (I-CVI) for each item of the instrument was in the range of 0.93 and 1.00, and the scale-level content validity index (S-CVI/Ave) for the instrument was calculated as 0.98. The results of confirmatory factor analysis (n = 275) had previously shown an appropriate goodness-of-fit for the 15- item instrument (χ2/df = 2.38, Comparative Fit Index (CFI) = 0.90, Root Mean Square Error of Approximation (RMSEA) = 0.07, Standardised Root Mean Square Residual (SRMR) = 0.07). The internal consistency and reproducibility of the instrument as measured by Cronbach’s alpha and intra- class correlation coefficient were α = 0.80 and ICC = 0.79, respectively.

All of the participants were either at the attitude or the intention stage of readiness to change for interprofessional collaboration based on the scores obtained from the IPC- TTM instrument.

Intervention phase In the attitude group, the emphasis of the educational objectives and material was on understanding the necessity of interprofes- sional teamwork in healthcare and encouraging the learners to participate in interprofessional collaborative practice. Moreover, the emphasis in this group was on the essential sub-skills of interprofessional teamwork in the healthcare team (see below for details). Based on the processes of change in TTM, the educational strategy for the participants who were in the attitude stage was designed with three components consisting of (a) interactive lec- tures about the essential competencies in interprofessional colla- boration, (b) discussions in an interprofessional small group setting followed by videos, and (c) case-based learning inmodified buzz groups. In the modified buzz groups, a case was provided to an interprofessional group of 3–4 residents and nurses, and the participants were asked to find the problem in each case and discuss their reasons and resolution strategies (see Appendix).

In the intention group, the emphasis of the educational objec- tives and material was on improving the participants’ compe- tencies regarding the strategies for implementing effective interprofessional collaboration, the challenges of interprofes- sional collaboration (i.e., personal, cultural, and management challenges), and the approaches to overcoming these challenges.

JOURNAL OF INTERPROFESSIONAL CARE 309

The educational intervention for the participants who were in the intention stage was designed as (a) interactive lectures, (b) discussions in an interprofessional small group setting followed by videos, (c) snowball interprofessional discussions about four cases, and (d) role playing at the end of the workshop. In the snowball discussions, a complex scenario was partially presented to the interprofessional groups of residents and nurses, and they were asked to complete the scenario first individually, then in the paired interprofessional groups of two and four, and finally report back to the larger group (Appendix).

The educational content was developed based on the compe- tency domains of interprofessional collaboration that included teamwork, challenge management, role and responsibility of the team members, interprofessional communication, and collabora- tion skills (Amini, Keshmiri, Soltani Arabshahi, & Shirazi, 2014; Bainbridge, Nasmith, Orchard, & Wood, 2010; Frank, Snell, & Sherbino, 2015; Interprofessional Education Collaborative Expert Panel, 2011; Keshmiri et al., 2016, 2013; Moradi, Najarkolai, & Keshmiri, 2016). The core competencies for interprofessional collaboration that were taught in the intervention group consisted of interprofessional communication (i.e., respectful and struc- tured communication and use of effective communication strate- gies like verbal, non-verbal, written style and competencies of communication with the patients), collaboration capabilities (i.e., establishing collaborative relationships and integrating with and sharing information with other healthcare providers and with the patients), recognising roles and responsibilities (i.e., recognising the individual roles and the responsibilities in the healthcare team), teamwork competencies (i.e., recognition of themselves as part of a team and attempting to follow the principles of team-based care), and leadership and challenge management (i.e., sub-skills of participatory management and conflict manage- ment like active listening, negotiation principles and giving feed- back). The educational objectives and material for each group were designed to be suitable for each stage of TTM and were different for each group. The cases were developed based on the principles of creating good cases at the basic and advanced levels (Herreid, 1997/98; Thistlethwaite et al., 2012).

The control group The residents and nurses in the control group received no educations with regard to the above-mentioned skills (clear control group).

The different aspects of this intervention study are outlined in Figure 1.

Outcome measure

The interprofessional collaborator assessment rubric (ICAR) was first developed by (Curran et al., 2011) as an observational tool for the assessment of interprofessional collaborative perfor- mance. We had previously evaluated and confirmed the validity and reliability of that instrument in Iran (Keshmiri et al., 2016). In 2014, ICAR was modified as a 17-item instrument, and its reliability in a real environment was assessed (Hayward, Curran, Curtis, Schulz, & Murphy, 2014). In the current study, we have reassessed the validity and reliability of the modified ICAR (Hayward et al., 2014). The validity of the instrument was con- firmed by a panel of experts including five medical education

experts and five clinical educators. We assessed the reliability of instrument through the assessment of internal consistency and reproducibility by the test retest approach. We assessed the internal consistency by testing the instrument on 38 residents and nurses. In order to assess the reproducibility, 30 residents and nurses were twice evaluated at Tehran University ofMedical Sciences (TUMS) with a two-week interval. We used trained assessors for the assessment of the participants at this stage. The results showed high levels of internal consistency and repro- ducibility as measured by Cronbach’s alpha (α = .96) and intra- class correlation coefficient (ICC = .89), respectively.

Different domains of interprofessional collaborative perfor- mance that are evaluated by ICAR include communication (four items), collaboration (three item), roles and responsibilities (three items), team functioning (two items), collaborative patient/family centered approach (two items), and challenge resolution/management (three items). Scoring on each item is on a scale of 1–9 for the competency scores where 1 = well below expectations, 5 = meets expectations, and 9 = well above expec- tations. In each assessment, the domains of interprofessional collaboration are individually evaluated, and the sum of all obtained scores from all domains of ICAR instrument is regarded as the overall performance score of each participant.

Data collection

We used interprofessional collaborator assessment rubric (ICAR) to evaluate effectiveness of the developed model (Curran et al., 2011; Hayward et al., 2014; Keshmiri et al., 2016). Assessment of interprofessional collaboration by ICAR was performed at four time points, that is, twice (at 3 and 6 months) before the intervention and twice (at 3 and 6 months) after the educational intervention in the real emergency unit environment. The assessment of each participant at each time point was performed by two faculty members of emergency medicine at each teaching hospital (i.e., four assessors in two hospitals) through the observation of interprofessional perfor- mance of the emergency medicine residents and nurses in the treatment team. Overall, the participants in the intervention (n = 40) and control groups (n = 51) were assessed 320 and 408 times, respectively. The assessment scores obtained at each time point were based on the observation of each participant’s performance in at least four consecutive shifts.

In order to evaluate the inter-rater agreement between the two assessors within each group (i.e., the intervention or control groups), we calculated intra-class correlation coefficient (ICC). Inter-rater agreement between the two raters in the control group as measured by ICC was .78, p < .001. In the intervention group, the inter-rater agreement between the two raters as measured by ICC was .91, p < .001.

Data analysis

The mean of assessment scores obtained at two time points before the intervention was regarded as the pre-intervention score of the participants. We used repeated measures analysis of variance (RM-ANOVA) to compare the pre-intervention ICAR scores of the participants in the intervention and control groups with their ICAR scores over time at 3 months and

310 F. KESHMIRI ET AL.

6 months after the intervention. In this regard, the group mem- bership of the participants (intervention vs. control) was used as the ‘between-subjects’ factor and the time of assessment (pre- intervention, at 3 months, and 6 months after the intervention) as the ‘repeatedmeasures’ variable. In order to evaluate the effect of independent variables such as profession (resident vs. nurse) and learners’ stage of readiness to change (attitude vs. intention) on the ICAR scores of the participants, we used a factorial repeated measures analysis of variance (RM-ANOVA) compar- ing the pre-intervention ICAR scores of the participants in the intervention and control groups with their ICAR scores over time at 3 months and 6 months after the intervention. In this regard, we used a mixed-design ANOVA in which the group membership of the participants (intervention vs. control), their profession (resident vs. nurse), and their stage of readiness to change (attitude vs. intention) were used as ‘between-subjects’ factors, and the time of assessment (pre-intervention, at 3 months, and at 6 months after the intervention) was regarded as the ‘repeated measures’ variable. We used Mauchly’s test to evaluate the assumption of sphericity in the data. Mauchly’s test of sphericity was considered significant if p < 0.05. In cases of

violation in the assumption of sphericity, the degrees of freedom were corrected using the Greenhouse-Geisser estimate of spheri- city (ɛ). Repeated measures contrasts were used to evaluate the effect of independent factors on the ICAR scores of the learners at different time points (i.e., before the intervention vs. 3 months after the intervention vs. 6 months after the intervention).

Comparison of categorical variables was carried out by Pearson’s chi-square test (χ2). Student’s t test was used to com- pare the mean of age and years of work experience between the intervention and control groups. Partial eta-squared (η2) was used for effect size calculations in ANOVA. Based on a general ‘rule of thumb’, the effect sizes are considered small, medium, and large effect sizes if the calculated partial η2 are approximately equal to .01, .06, and .14, respectively (Cohen, 1988). All effects are reported as significant at p < .05.

Ethical considerations

The study was approved by the Ethics Committee at TUMS. The project was registered at Iranian Registry of Clinical Trials (ID: IRCT2015092324056N3).

Trainer and Assessor Training Workshops

Educational workshop for the participants in

the intention stage

Educational workshop for the participants in the

attitude stage

Intervention group (n = 40) (Educational workshops)

R*= 22 N*=18

Control group (n = 51) (Clear control)

R*=20 N*=31

Pre-test:

Assessment of readiness to change (as needs assessment)

Assessment of interprofessional collaborative performance in the intervention and control groups (by two assessors in each group at 3 and 6 months before the intervention)

Teaching hospitals at IUMS were divided into the intervention or control settings

Post-test:

Assessment of interprofessional collaborative performance (by two assessors in each group at 3 and 6 months after the intervention)

Intervention

Received no intervention

Control

Attitude stage (n = 22) (R=12, N=10)

Attitude stage (n = 28) (R=11, N=17)

Intention stage (n = 18) (R=10, N=8)

Intention stage (n = 23) (R=9, N=14)

Figure1. Flow chart of the study steps. *R = resident, *N = nurse.

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Results

Demographics of the participants

Learners In the present study, 40 participants were assigned to the intervention group, and 51 were assigned to the control group. There were 12 men (30%) and 28 women (70%) in the intervention group and 13 men (25.5%) and 38 women (74.5%) in the control group. In the present study, most of the learners in the intervention and control groups were females. However, there was no statistically significant dif- ference in the male to female ratio between the intervention and control groups (p = .632). There was no significant difference between the mean age (31.05 ± 1.4 vs. 30.5 ± 2.1, p = .3) and work experience (3.6 ± 0.5 vs. 4.4 ± 0.2, p = .1) of the participants in the intervention and control groups. In the intervention group, there were 22 participants (55%) in the attitude stage and 18 partici- pants (45%) in the intention stage of TTM. In the control group, we had 28 participants (54.9%) in the attitude stage and 23 participants (45.1%) in the intention stage. The mean of age and work experience in different subgroups of parti- cipants are provided in Table 1.

The trainers and assessors The trainers in our study had a mean age of 46 ± 6 years with 18 ± 2.5 years of work experience. The mean age was 41.3 ± 1.6 for the assessors, and they had a mean of 9.3 ± 2.5 years of work experience. All of the assessors were men.

Effect of intervention on the ICAR scores of the participants over time

The mean of ICAR scores of the participants in the interven- tion and control groups and different subgroups of the study are shown in Table 2.

One-way RM-ANOVA The Greenhouse-Geisser correction factor was required. Comparison of ICAR scores of the participants in the interven- tion and control groups over time by one-way RM-ANOVA showed a significant Group effect on ICAR scores of the lear- ners, F (1, 89) = 6.324, p = .014, partial η2 = .066. Also, there was a significant interaction effect between Group and the Time of assessment, F (1.604, 142.746) = 3.337, p = .04, partial η2 = .036.

Mixed-design ANOVA The Greenhouse-Geisser correction factor was required. The results showed that the main Time effect on the ICAR scores of the learners was not significant, F (1.636, 135.779) = .855, p = .408, partial η2 = .010. There was, however, a significant interaction effect between Group and Time of assessment, F (1.636, 135.779) = 4.562, p = .018, partial η2 = .052, indicating that in comparison to the control group the ICAR scores of the learners in the intervention group had significantly improved after the intervention. Contrasts revealed that the ICAR scores in the intervention group had significantly improved at 3 months after the intervention F (1, 83) = 6.221, p = .015, partial η2 = .070 and the ICAR scores of the learners at the second assessment after the intervention (at 6 months) had not significantly differed with their first assessment (at 3 months) after the intervention, F (1, 83) = 0.541, p = .464, partial η2 = .006.

We found no significant interaction effect between the Time of assessment and the learners’ profession, F (1.636, 135.779) = 1.394, p = .251, partial η2 = .017. There was also no significant interaction effect between the Time of assessment and the learners’ stage of readiness to change at the time of enroll- ment in the study, F (1.636, 135.779) = 2.774, p = .077, partial η2 = .032. These results showed that the learners’ ICAR scores at different time points had not been significantly affected by their profession or stage of readiness to change. Moreover, there was no significant interaction effect between Group, the stage of readiness to change, and Time of assessment, F (1.636, 135.779) = 1.505, p = .227, partial η2 = .018, indicating that the

Table 1. The number of participants and their mean of age and work experience in the subgroups of profession and stage of readiness to change in the inter- vention and control groups.

Groups Profession

Stage of readiness to change N % Age

Work experience

Intervention Resident Attitude 12 30 32.1 ± 4.1 3.2 ± 2.07 Intention 10 25

Nurse Attitude 10 25 30 ± 4.4 4 ± 3 Intention 8 20

Control Resident Attitude 11 21.56 32 ± 4.3 4.6 ± 4.3 Intention 9 17.64

Nurse Attitude 17 33.33 29 ± 4.3 4.2 ± 2.5 Intention 14 27.45

Table 2. ICAR scores of the participants in the intervention and control groups before and after the intervention.

Mean of ICAR scores (SD)

Pre-test Post-test (3 months) Post-test (6 months)

Intervention 95.63 (19.14) 99.82 (22.32) 98.65 (23.40) Control 89.19 (16.11) 88.29 (16.87) 87.98 (16.01) Groups Subgroups Intervention* Profession Residents 92.36 (17.32) 96.07 (23.33) 94.57 (23.01)

Nurses 99.62 (20.95) 104.40 (20.74) 103.63 (23.54) Stage of readiness to change Attitude 96.80 (20.50) 100.71 (24.46) 101.74 (20.00)

Intention 94.20 (17.82) 98.73 (20.04) 94.87 (22.74) Control Profession Residents 84.42 (17.42) 81.15 (18.42) 81.37 (16.76)

Nurses 92.27 (14.69) 92.90 (14.27) 92.24 (14.19) Stage of readiness to change Attitude 80.51 (12.14) 81.89 (13.52) 81.71 (12.24)

Intention 99.76 (14.02) 96.08 (17.53) 95.60 (16.96)

*Intervention in different stages of readiness to change, i.e., the attitude and intention subgroups was participation in the attitude and intention workshops, respectively.

ICAR = Interprofessional Collaborator Assessment Rubric; SD = standard deviation.

312 F. KESHMIRI ET AL.

effect of intervention on the ICAR scores of the participants over time had not been significantly different in the subgroups of TTM. There was also no significant interaction effect between the Group, the learners’ profession, and the Time of assessment, F (1.636, 135.779) = 0.189, p = .784, partial η2 = .002, indicating that the effect of intervention on the ICAR scores of the partici- pants over time had not been significantly different between the professional subgroups (i.e., between the residents vs. nurses).

Discussion

In this study, we have shown that an IPE model based on TTM could significantly improve the interprofessional collaborative performance of the participants. The intervention had a medium effect size in improving the ICAR scores of the participants which, indicates that applying TTM in an IPE model was effec- tive to transfer the learned interprofessional competencies to their interprofessional collaborative practice in a real setting.

Applying the theoretical foundations in the educational pro- grammes, in addition to developing a conceptual map for design- ing interventions, is helpful in guiding the learning processes and assessment of the educational outcomes (Burns, 2014). In the current study, the curriculumplanning that included needs assess- ment and instructional design was based on Prochaska’s stages of change theory or the TTM.

Needs assessment for identifying the differences between the ‘ideal’ and ‘actual’ state of learners is an important factor in designing a tailored educational programme (Kern, Thomas, Howard, & Bass, 1998). In traditional methods of needs assess- ment, the learners’ readiness to change was often neglected. TTM helps the curriculum planners to identify these differences among learners by assessing each learner’s stage of readiness to change so that the educational programme can be tailored to the specific needs of the learner and the behavioural change among learners can thus be facilitated (Parker & Parikh, 2001). Readiness to change is defined as a psychological state of feeling committed to change and being able to change a behaviour towards a desired outcome. Readiness to change as a multi-faceted concept in TTM has been previously used in designing educational interventions (Randhawa, 2012; Weiner, 2009). The importance of designing theory-based educational programmes has been previously emphasised by Parker and Parikh (2001). They used the concept of readiness to change for identifying the needs of learners and designing an intervention based on the learners’ level of readiness to change. Similarly, in this study, we used the concept of ‘readi- ness to change for interprofessional collaboration’ for needs assess- ment and as a guide for designing our educational intervention.

We used cooperative learning and problem-solvingmethods in accordance with the processes of change in TTM. An essential factor in cooperative learning is providing conditions for colla- borative participation and interprofessional learning that includes face-to-face interactions, shared decision making, improving interpersonal skills, and working in small group settings (Thistlethwaite et al., 2012). In addition, the case-based learning method facilitates in-depth learning and integrating the theory to practice in a team situation (Mann et al., 2009; Williams, 2005) and consequently increases the chances of improving perfor- mance among the learners. In this study, we assigned the learners to small groups of residents and nurses in order to enable

interprofessional interactions and small group collaborative prac- tice experiences. Similar to our study, in the Seamless Care model, a combination of problem-solving and small group collaborative practice experience was used for learning knowledge and skills, developing experiential learning, and improving self-efficacy (Mann et al., 2009).

Based on the processes of change in TTM, behavioural change in the attitude stage is facilitated by raising awareness, discussion about relevant events and cases, providing effective models, media campaigns, and group discussion opportunities (Glanz et al., 2008). In the present study, the educational methods for the attitude stage included programmed lectures (for raising aware- ness), educational videos (for presenting role models of interpro- fessional teamwork), small group interprofessional setting, and case-based learning (for providing an interprofessional collabora- tive experience and group discussion opportunities). In the inten- tion stage, the process of change included self-liberation. The aim of this process of change is to develop belief and commitment to change in an individual. Providing opportunities for problem- solving and group decisions (rather than individual decisions) are considered appropriate methods for this stage (Glanz et al., 2008). In the current study, the methods of cooperative learning and case-based learning in an interprofessional small group setting were used at the intention stage. We created a situation for inter- professional interactions and teamwork for solving problems (i.e., clinical vignettes) through case-based learning. Our aim was to provide an opportunity for interprofessional collaboration experi- ences in a condition similar to a real situation. The educational vignettes were designed based on the emergency events that would commonly occur in the studied hospitals. Using the case-based learning method in the process of interprofessional education facilitates applying theory to practice (Thistlethwaite et al., 2012) and has been commonly used in different interprofessional educa- tional models (Anderson & Lennox, 2009; Mann et al., 2009).

Parker and Parikh (2001), in their study based on TTM, used standardised patient cases and provided information about novel treatments in the preparation stage and used a didactic presenta- tion followed by a video of a patient in the contemplation stage. In another study, Shirazi et al. (2013) used a three-stage model of TTM (modified TTM) to develop an educational intervention. The educational methods that they used in the attitude stage includedmodified buzz groups, programmed lectures, and videos, and in the intention stage they used case-based methods, role playing, cooperative learning, and snowball techniques. Their results showed that an educational intervention based on the participants’ level of readiness to change had significantly improved the performance of GPs in the diagnosis and manage- ment of depression. Similarly, in the present study, using educa- tional methods that were tailored to the participants’ stage of readiness to change and their corresponding processes of change directed the learners towards behavioural change.

The University of British Columbia (UBC) model of inter- professional education, which has been designed based on Mezirow’s theory of transformational learning, emphasises on the development of self in interaction with others. According to this model, the best time for learning depends on the develop- mental stage of individuals as ‘professionals’ and their readiness for learning and developing new perspectives on professional interaction (Charles, Bainbridge, & Gilbert, 2010). Similar to our

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model, the UBC model emphasises on the readiness of indivi- duals and interprofessional interactions to develop interprofes- sional collaboration among learners.

Our results showed that applying a theory-based intervention in an interprofessional programme significantly improves inter- professional collaborative performance of the participants. Previous studies in the field of continuing education have shown that the educational interventions that are tailored to the participants’ stages of readiness to change are effective in improving the participants’ performance (Buckley et al., 2003; Johnson, Castle, Van Marter, Roc, & Neubauer, 2015; Shirazi et al., 2013; Shockey & Seiling, 2004).

In relation to study limitations, the quasi-experimental design of the study (i.e., non-random selection of the participants and non-matched selection of the control group) limits the external validity of our results. Also, the small number of participants in our study limits the generalisability of our results to other settings. There might also be a hospital effect as all of the participants in the intervention and control groups were clus- tered in different hospitals. In addition, the number of partici- pants in the TTM subgroups and the duration of the educational course in our study were limited. All of the trainers and assessors in our study hadmedical ormedical education backgrounds, and there were no nurses involved in the training or assessment of the participants. This might also be a possible source of bias in our study. In the present study, we compared the intervention’s effect in comparison to a ‘clear’ control group. This would limit our ability to determine if the observed difference in the pre- and post-intervention scores was a result of applying TTM in our IPE intervention or just the educational intervention itself. Further elucidating studies are recommended to compare the current IPE model, which is based on TTM, with the conventional IPE models to address this.

Concluding comments

This study assessed the effectiveness of an IPE model tailored to the learners’ stage of readiness to change for interprofes- sional collaboration. The study indicated that an IPE model based on TTM effectively improves interprofessional colla- borative performance. Further elucidating studies are recom- mended to evaluate the effect of implementing TTM in other IPE programmes.

Acknowledgements

We would like to express our sincere thanks to Professor Mohammad Farsi, Dr. Marzieh Fathi, and Dr. Saieed Abbasi for their kind contribu- tion in this research and the emergency residents and nurses at IUMS who participated in the study.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Funding

This research has been supported by Tehran University of Medical Sciences.

ORCID

Kamran Moradi http://orcid.org/0000-0001-9839-712X

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Appendix

Buzz groups

The aim of Buzz group method is to increase the participant’s engage- ment and encourage interaction in group activities. The groups are consisted of 2–5 learners working together on a question, problem, or scenario. This method is a useful means of getting and using new

information to solve a problem. At the end of the session, the teacher can check the results of the discussions and give feedback to the learners by asking questions about their answers to the questions or scenarios (Cantillon, 2003; Jaques, 2003).

Snowball groups

In this method, the “pairs” are assigned to the groups of 2, 4, 8, and larger groups in the end. The snowball groups can ensure the participa- tion of learners since the discussions are primarily started in the groups of two and then the participants discuss their ideas in larger groups. In this model, it is necessary to use increasingly sophisticated problems or scenarios as the groups get larger in order to increase participation (Jaques, 2003).

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