|Year : 2020 | Volume
| Issue : 2 | Page : 64-71
Knowledge and attitude differences among students at dental-education institutions as a result of interprofessional education
Marta Juslily1, Tri Erri Astoeti1, Adang Bachtiar2
1 Department of Dental Public Health and Preventive Dentistry, Faculty of Dentistry, Trisakti University, West Jakarta, Java, Indonesia
2 Faculty of Public Health, Universitas Indonesia, Indonesia
|Date of Submission||07-Jan-2020|
|Date of Decision||04-Mar-2020|
|Date of Acceptance||07-May-2020|
|Date of Web Publication||8-Jun-2020|
Dr. Marta Juslily
Department of Public Health, Faculty of Dentistry, Trisakti University, West Jakarta, Java
Source of Support: None, Conflict of Interest: None
Background: Interprofessional education (IPE) is an integrated-learning concept designed to improve the collaborative ability of health workers through multi-professional learning. To allow dental graduates to perform collaborative practices with other health practitioners and to support quality services at health-care facilities, IPE must be implemented throughout Indonesian dental-education institutions (DEIs). Objective: The aim of this study is to analyze the differences in knowledge and attitude between students from DEIs that have implemented IPE and those who have not. Method: Descriptive analytic observational research with cross-sectional design. Knowledge is measured via a questionnaire designed by the authors, and attitude is measured using the interprofessional-attitude-scale questionnaire. The total sample consists of 249 students from 3 DEIs: 90 from the Universtas Gadjah Mada (UGM), 76 from Universitas Muhamadiyah Yogyakarta (UMY), and 83 from Universitas Trisakti (Usakti). The subjects were selected purposively using a total sampling method. Result: Statistical testing shows that students from DEIs that have implemented IPE better understand the benefits, competencies, and approach of IPE with a P < 0.05. The Kruskal–Wallis test for attitude also found better results for students from DEIs that had implemented IPE in terms of teamwork, role and responsibility, interprofessional bias, and diversity and ethics with a P < 0.05. Conclusion: There were differences in student knowledge and attitude due to the implementation of IPE at DEIs. Students from universities that have implemented IPE (UGM, UMY) appear to have better knowledge and attitude than students from those that have not (Usakti). However, in several aspects, there were no significant differences between the two groups of students.
Keywords: Collaborative, dental-education institution, healthcare, interprofessional education
|How to cite this article:|
Juslily M, Astoeti TE, Bachtiar A. Knowledge and attitude differences among students at dental-education institutions as a result of interprofessional education. Sci Dent J 2020;4:64-71
|How to cite this URL:|
Juslily M, Astoeti TE, Bachtiar A. Knowledge and attitude differences among students at dental-education institutions as a result of interprofessional education. Sci Dent J [serial online] 2020 [cited 2020 Jul 16];4:64-71. Available from: http://www.scidentj.com/text.asp?2020/4/2/64/286190
| Background|| |
Current health-care trends have experienced a paradigm shift. Health-care providers, including dentists, are increasingly required to work in multidisciplinary teams.,, Moreover, the healthcare-services paradigm has evolved from physician-centered care to patient-centered care; patient-centered care requires collaboration between health-care professionals to achieve patient safety and service quality. Studies have shown that collaborative practice between health-care professionals can improve service quality and patient safety, reduce medical errors, improve patient and health-care-service-provider satisfaction, and reduce health-care costs.,
Efforts to increase collaboration among health-care workers have included the introduction of collaborative practice at an early stage of health-care education through interprofessional education (IPE). IPE is the condition whereby two or more different health-care professionals from different fields learn with, from, and about each other to improve collaboration and the quality of health-care services.,,
IPE is a promising strategy for achieving effective collaboration practices among health-care providers. It helps students to recognize the role of their respective professions, as well as the roles of others. Various studies have shown that the values gained from previous work experience through IPE enhance students' understanding of professional identity and attitudes towards teamwork.,,, However, in the university setting, a survey of 42 countries has shown that only 24.6% of health-care workers had been educated with a curriculum introducing with IPE material. Reeves et al. (2013) reported 15 studies of measured the effectiveness of IPE intervention compared to no education intervention found seven studies indicated that IPE produced positives outcome, four reported mixed outcome (positive and neutral) and four reported no impact.
IPE has not been implemented at all dental-education institutions (DEIs). Although there are 32 DEIs in Indonesia, only six have implemented IPE at the undergraduate level, namely Universitas Indonesia, Universitas Gadjah Mada (UGM), Universitas Muhammadiyah Yogyakarta (UMY), Universitas Padjajaran, Universitas Airlangga, and Universitas Hasanuddin.
Many studies have shown that IPE at university gives students a positive attitude, helps to develop their interest inpatient care, and improves their medical and clinical knowledge.,, Despite this positive outcome, many DEIs are still yet to implement IPE. The objective of this study is to analyze the differences in the knowledge and attitude of students who attend Indonesian DEIs that have implemented IPE and those who attend institutions that have not.
| Materials and Methods|| |
A cross-sectional study was conducted at three DEI from May to July of 2019. Two different scales were used to measure knowledge and attitude. The total sample consisted of 249 students from three DEIs, of which two have implemented IPE (UGM, with 90 students or 36.14%, and UMY, with 76 students or 30.52%) and one has not (Usakti, with 83 students or 33.33%). The minimum sample size required for this study was 70 students from each DEI; however, 90 students from UGM, 76 students from UMY, and 83 students from Usakti completed the survey. The subjects were derived purposively using a total sampling method, and participation was voluntary. Written consent was obtained from the students prior to their receiving the questionnaire. This study protocol was approved by the Ethics Committee of Faculty of Dentistry at Trisakti University with approval number: 246/S2/KEPK/FKG/2/2019.
Questionnaires designed by the authors were used to determine quantitative scales for knowledge and the interprofessional-attitude scale (IPAS) was used for attitude. A purposive-sampling method was employed. The sample was drawn from undergraduate students enrolled in years 3 and 4 of dental programs. The research procedure was implemented via quantitative and qualitative measurements. The procedure consisted of distributing Google Forms-based questionnaires and conducting focus-group discussions (FGDs) to measure knowledge and attitudes towards IPE implementations [Table 1].
|Table 1: Research scale for measuring knowledge and attidues towards interprofessional education|
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All statistical analyses were performed using open source software “Jamovi” (Version 0.9). Frequencies (numbers and percentages) were used to describe the number of undergraduate students from DEI as research participants. The Kruskal–Wallis test was used to discover differences in the knowledge and attitudes of undergraduate DEI students with and without IPE P < 0.05 was set as the level of significance.
| Results|| |
A validity test of the knowledge questionnaire obtained only eight valid questions out of 23. With a significance level of 5% and an r-table value of 0.25, r-arithmetic ranges from − 0.105 to 0.659 were obtained. The reliability of the knowledge questionnaire was obtained through Cronbach's alpha value of 0.671 >0.6 (which is the determined consistency value). The validity test of the IPAS questionnaire with a significance level of 5% and a r-table value of 0.25 resulted in an r count between 0.203 and 0.762. The reliability test of the IPAS questionnaire resulted in a Cronbach's alpha of 0.943 >0.6 and an r-table with 5% significance, showing that the questionnaire was reliable.
The knowledge-testing result showed the average student-knowledge scores and standard deviations for eight questions presented in [Table 2]. Statistical tests performed on the 8 valid knowledge questions returned the total average values of student knowledge for the 3 DEIs, name ly: (1.17), (1.77), (1.50), (1.18), (1.24), (1.18), (1.16), a nd (1.18) on questions 1–8, respectively. From [Table 2], it can be seen that the results from the two DEIs with IPE are lower than the averages on most questions. For UGM, the results for questions 1–8 were: 1.11, 1.79, 1.47, 1.10, 1.18, 1.12, 1.08, and 1.12, respectively, whereas for UMY, these were 1.13, 1.78, 1.33, 1.16, 1.20, 1.21, and 1.21, respectively. Both have good scores compare to Usakti, where IPE was not implemented: 1.28, 1.73, 1.70, 1.25, 1.39, 1.22, 1.22, 1.20 [Table 2]. The Kruskal–Wallis test was also conducted to examine questions for which significant differences (P < 0.05) were found between DEIs, namely questions 1, 3, 4, 5, 7 [Table 3].
|Table 2: Average score for student knowledge from dental-education institutions that have, or have not, implemented interprofessional education|
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|Table 3: Average score, standard deviation, and p-value of knowledge for every dental-education institutions|
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Below, the mean rank values obtained based on the five different aspects of IPE are presented [Table 4]. The first aspect was teamwork, role and responsibility (TRR), for which the highest to the lowest scores were exhibited by UGM (129.11), UMY (128.05), and Usakti (117.75). The second aspect was patient-centeredness (PC), for which the highest to lowest scores were exhibited by UGM (129.11), Usakti (127.98), and UMY (118.00). The scores for interprofessional bias (IPB) were ordered as UMY (142.05), UGM (126.47), and Usakti (107.80); those for diversity and ethics (DE) were ordered as Usakti (129.28), UGM (128.08), and UMY (115.41); and those for community centeredness (CC) were ordered as UMY (129.40), Usakti (126.29), and UGM (124.06) [Table 4]. The average attitude score for all students at all 3 DEIs was 110.63, with a standard deviation 10.844. The lowest score was 78 and the highest score was 130 [Table 5]. The average score of student attitude regarding IPE was found to be higher at UMY (129.47) compare to UGM (124.61) and Usakti (121.33) [Table 4]. All scores were categorized as falling into the good-attitude range.
|Table 4: Mean rank value of 5 aspects of student's attitude for the three dental-education institutions|
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The results of Kruskal–Wallis nonparametric analysis are presented in [Table 6]. The TRR result, which was obtained from nine questions and found to range from 0.152 to 0.887, had a P > 0.05, showing that the attitude of students was not significantly different among the three DEIs. A low significance was also found for differences in terms of PC. However, the P value for IPB was less than 0.05, meaning that this attitude differed significantly between different DEIs. Attitudes toward DE differed little between institutions (P > 0.05), except for the question about communication across culture the P < 0.05. For CC, P was again >0.05, indicating little significant difference between institutions.
|Table 6: P values for 5-aspect interprofessional-attitude-scale questions*|
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Attitudes toward TRR among students at UGM, UMY, and Usakti were 127.58, 126.29, and 121.02, respectively, all of which represent good attitudes (x > 112 = good). However, the ranking obtained does not describe differences in attitudes that are not significant based on the results of the Kruskal–Wallis test. This result is also supported by student's answers in FGD, where their attitudes were gauged from their answers to questions about teamwork.
All UGM's students answered correctly regarding the TRR concept. This is one of the answers from UGM's student:
UGM student: “It is better to create a team with multiple professions to treat patients.” 15 UMY's students out of 18 answered correctly the TRR concept. This is one of the answers from UMY's student: UMY student: “…collaboration of medical professionals will offer comprehensive services to patients. These healthcare professionals have a particular role and responsibility, aiming in the same direction to treat the patient as well as possible…”
Only 4 Usakti's student out of 18 can answered TRR correctly. This is one of the answered from Usakti's student:
Usakti student: “…in my opinion, teamwork is something like surgery, with doctors and their assistants. Each is responsible to and integrated with each other.”
IPB results from FGD comprehensively show differences in the understandings of students from DEIs that have implemented IPE (UMY, UGM) and those from institutions that have not (Usakti). Below are the answers from a student from all 3 DEIs:
UMY student:“ …the common IPB against dentists as a profession is that dentists can only handle tooth and oral-cavity problems.”
UGM student: “. the public sees that dental artisans have the same competence as dentists.”
Usakti student: “Many think dentistry is a specialty of general practitioners.”
| Discussion|| |
IPE was implemented in Indonesian DEIs via a specific program. IPE is obtained from a learning process, which can shape students' beliefs or perceptions about collaborative behavior between professions. The process of IPE learning includes intra-curricular and extracurricular programs, which are provided continuously in all semesters or only in certain semesters. At UGM, IPE has been implemented as an extracurricular program and in topics embedded in the modules of the undergraduate program. The extracurricular program consists of community fieldwork given during the preclinical period before the professional stage. This program is tailor-made with participation from other faculties, including medical, dental, nursing, pharmacy, and other supporting health-care fields. Students are tasked with creating a health project for the community using their own expertise in collaboration and cooperation with students from other faculties. Similarly, IPE at UMY is given as an integrated lecture embedded in the curriculum, involving students from medicine, dentistry and other health-care faculties to learn together as early as the second semester of year 1 and as late as semester seven of year 4. On the other hand, IPE has not been implemented in any particular module at Usakti.
The present study shows that students from the three DEIs exhibited different levels of knowledge on IPE-related subjects and that these differences were statistically significant (P < 0.05). These subjects include IPE benefits (question number 1), IPE competencies (questions number 3 and 4), and IPE approaches (questions number 5 and 7). Students at DEIs with IPE had a better understanding of roles and responsibilities, competencies, and collaboration concepts. Students at Usakti, which has not yet implemented IPE, exhibited lower knowledge. Because UGM and UMY have already implemented IPE in their intra-curricular or extracurricular programs, their students already have a clear picture of what it involves, and students from both of these DEIs have experienced learning together with other faculties and communities. However, even though Usakti has not implemented IPE, its students still have levels of knowledge ranging between medium and good.
Differences in the implementation of IPE also occur between parts of the world such as Europe, America, Australia, and Asia. In America, for example, the 2014 report of the American Dental Education Association showed that IPE was implemented differently at each institution in terms of programs, materials, time of delivery, number of health workers involved, areas of focus, and other aspects. These results indicate that IPE implementation within the curriculum will deliver better attitudes. In addition, knowledge and attitudes in all DEIs is qualitatively found to be positive and to support IPE learning. Another study conducted by Mishoe et al. showed that students who were taught with IPE displayed improved attitudes and behavior.
[Table 7] shows that differences between the three DEIs in terms of attitudes toward IPE had a P = 0.775, meaning that they were not statistically significant. This result may occur because IPE has been implemented (whether structurally or not) in the curricula of UGM and UMY. IPE implementation is ongoing at UMY and has been running comprehensively since the early year student starts learning in DEI. The five topics of IPE (TRR, PC, IPB, DE, CC) fuse in the lecture module and are taught in an interactive way. Meanwhile, IPE at UGM has been applied but not comprehensively; it appears in module topics and extracurricular programs. In these two DEIs, students can better understand IPE concepts. Although IPE has not yet been implemented at Usakti, students' understanding of IPE concepts are vary from moderate to good [Table 3] and [Table 4].
FGD shows that Usakti students' understandings of the concepts of TRR and IP are not as good as those of the students of other DEIs. Usakti students answered questions on the TRR aspect (“…in my opinion, teamwork is something like surgery, with doctors and their assistants. Each is responsible to and integrated with each other.”) and the IB aspect (“Many think dentistry is a specialty of general practitioners”) differently from students at other DEIs, showing that they have a less comprehensive understanding of these concepts. A study conducted by Ilmanita and Rokhman showed that pharmacy students taught with IPE have higher confidence compared to those who were not. Mishoe et al. show that through IPE co-curricular learning students can enhance positive attitude toward teamwork.
In terms of knowledge and attitude testing related to patient care, Usakti students reached the highest value of 127.983, followed by UGM (127.982) and UMY (118.256). Thus, a question arose as to whether the perception and understanding of Usakti students were better than those of the other two universities. Boland et al. conducted a similar study with their measurement to the subscale 2: PC found that attitude of the student with and without IPE intervention are no difference, the score from pre- to post-test was no significant change. Meanwhile, in this study, DEI students show no significant differences between DEIs that have implemented IPE and have not.
The IPB results show that students of UMY exhibited superior knowledge and attitude compared to the other two DEIs. This phenomenon may be because UMY implements IPE beginning in semester 2 in a structured and integrated manner. Knowing their own private identity as well as the identities of others healthcare professionals promoted better teamwork compared to students from other universities. For the students, the ability to understand IPB is very important and useful as a preparatory step to entering the professional world. Such students can collaborate and avoid overlaps of competency and responsibility. A comprehensive understanding of IPB is also apparent from interviews with UMY students.
The statistical results of the DE test showed that students of Usakti had the best results on questions 1–4. This reveals that Usakti students have a good understanding of DE, even though Usakti has not implemented IPE. The author feels that this may be because Usakti's student already possessed strong values and attributes of culture and ethics.
The CC results of the three institutions were all classified as good (x > 112), with no significant differences between them. Thus, the implementation of IPE will not always influence the students' knowledge and attitude towards CC. This can be explained by the fact that in all universities, students are compelled to perform community service every year as part of their extracurricular activities. Positive test results for CC were also found in the study conducted by Fusco for pharmacy students.
Several obstacles were present in this study, which created biased results. The main problem was with data collection through Google Forms. The form-filling procedure was not completed simultaneously by each student. Several students filled in their forms immediately, while others brought their forms home and filled them in several days later. Thus, students could possibly have discussed potential answers amongst themselves. Another factor that may cause side effects is the quantity of samples. Minimal samples give inconclusive statistical views. Other limitation of this study was that the student in each DEIs were not equal in number, which likely to cause bias. To minimize the bias, datas were taken from the entire accessible population and the statistical calculation of quantitative data were based on average values. This condition also occurs in other studies in which a student's attitude before IPE is positive, but improves with IPE.
This study observed knowledge and attitudes related to IPE in the preclinical period only. Better results should be found in professional programs. Ideally, a study should be conducted in both the preclinical and clinical (professional) periods to assess the students' attitudes.
| Conclusion|| |
There were some differences between the knowledge and attitudes expressed by students from universities that had, and had not, implemented IPE. The differences appear to suggest that students of DEIs that have implemented IPE (UGM, UMY) have better knowledge and attitudes than those at universities that have not (Usakti). However, in several aspects, there were no significant differences.
The authors would like to acknowledge the support from the Dean of Faculty of Dentistry Trisakti University, Faculty of Dentistry University of Gajah Mada, and Faculty of Medicine Study Program Dentistry UMY for giving permission to conduct this research. The authors would like to acknowledge the following for their advice and assistance: Dr. drg. Ella Nurlaella Hadi., M. Kes, Prof. Dr. drg. Arlia E. Budiyanti., SU., Sp. KGA, Prof. Dr. drg. Rahmi Amtha., MDS, Sp. PM, PhD, Dr. drg. Yohana Yusra., M. Kes, Prof. Dr. drg. Boedi Oetomo Roeslan, Dr. drg. Ahmad Syaify, Sp. Perio (K), Dr. drg. Tetiana Haniastuti, M. Kes., PhD, DR. drg. Erlina Sih Mahanani, M. Kes, drg. Indri Kurniasih., Med. Ed, drg. Erma Sofiani, Sp. KG, drg. Widijanto Sudana, M. Kes, and drg. Lia Hapsari., M. Epid. The authors would like to thank Dr. Jeffrey Norris and Donald Blumenthal, PhD for their kind permission to use IPAS for this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Friedrichsen S, Martinez TS, Hostetler J, Tang JM. Innovations in interprofessional education: Building collaborative practice skills. J Calif Dent Assoc 2014;42:627-35.
Mishoe SC, Tufts KA, Diggs LA, Blando JD, Claiborne DM, Hoch J, et al
. Health professions students' teamwork before and after an interprofessional education co-curricular experience. J Res Interprofes Pract Educ 2018;8:1-16.
Lawrence D, Bryant TK, Nobel TB, Dolansky MA, Singh MK. A comparative evaluation of patient satisfaction outcomes in an interprofessional student-run free clinic. J Interprof Care 2015;29:445-50.
Khalili H, Hall J, DeLuca S. Historical analysis of professionalism in western societies: Implications for interprofessional education and collaborative practice. J Interprof Care 2014;28:92-7.
Barr H, Helme M, D'Avray L. Developing Interprofessional Education in Health and Social Care Course in United Kingdom: A Progress Report. London: Health Sciences and Practice Subject Centre Higher Education Academy; 2011.
World Health Organization. Framework for Action on Interprofessional Education and Collaborative Practice. Switzerland: World Health Organization; 2012.
Barr H, Koppel I, Reeves S, Hammick M, Freeth D. Effective Interprofessional Education: Argument, Assumption and Evidence. Oxford: Blackwell Publishing; 2005.
Bridges D, Davidson RA, Soule Odegard P, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Medical Educ Online 2011;16:6035.
Maharajan MK, Rajiah K, Khoo SP, Chellappan DK, de Alwis R, Chui HC, et al
. Attitudes and readiness of students of healthcare professions towards interprofessional learning. PLoS One 2017;12:e0168863.
Riva JJ, Lam JM, Stanford EC, Moore AE, Endicott AR, Krawchenko IE. Interprofessional education through shadowing experiences in multi-disciplinary clinical settings. Chiropr Osteopat 2010;18:31.
Sigalet E, Donnon T, Grant V. Undergraduate students' perceptions of and attitudes toward a simulation-based interprofessional curriculum: The KidSIM ATTITUDES questionnaire. Simul Healthc 2012;7:353-8.
Rajiah K, Maharajan MK, Khoo SP, Chellappan DK, De Alwis R, Chui HC, et al
. Suitability of the RIPLS and IEPS for Discriminating Attitude Differences towards Interprofessional Education among Students of Healthcare Profession. Educ Res Int 2016;2016:6. https://doi.org/10.1155/2016/5946154
Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2013;(3):CD002213. DOI: 10.1002/14651858.CD002213.pub3.
Nango E, Tanaka Y. Problem-based learning in a multidisciplinary group enhances clinical decision making by medical students: A randomized controlled trial. J Med Dent Sci 2010;57:109-18.
Cameron A, Rennie S, DiProspero L, Langlois S, Wagner S, Potvin M, et al
. An introduction to teamwork findings from an evaluation of an interprofessional education experience for 1,000 first-year health science students. J Allied Health 2009;38:220-6.
Cameron A, Ignjatovic M, Langlois S, Dematteo D, DiProspero L, Wagner S, et al
. An interprofessional education session for first-year health science students. Am J Pharm Educ 2009;73:62.
Ilmanita D, Rokhman MR. Peran Interprofessional Education Terhadap Persepsi Keterlibatan Apoteker Dalam Kolaborasi Antar Profesi. JURNAL MANAJEMEN DAN PELAYANAN FARMASI (Journal of Management and Pharmacy Practice). 2014;4:166-74.
Boland D, White T, Adams E. Experiences of pharmacy trainees from an interprofessional immersion training. Pharmacy (Basel) 2018;6. pii: E37.
Fusco NM, Maerten-Rivera J, Doloresco F, Ohtake PJ. Improving pharmacy students' attitudes toward collaborative practice through a large-scale interprofessional forum targeting opioid dependence. Am J Pharm Educ 2019;83:7034.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]