The Challenges Teachers in Interprofessional Teaching Face When Developing a Shared Assumption of Responsibility: A Mixed-Methods Study

Abstract

Background: Interprofessional education in the healthcare sector is becoming increasingly recognized in Germany; it is increasingly being included in the curriculum. The learners are usually the focus of the research. This study focusses on the teachers, as they are the ones who carry out the teaching and thus prepare the learners for practice. The aim of this study is to find out what skills interprofessional teachers should have for joint teaching and how the joint assumption of responsibility can be achieved in an interprofessional setting. Methods: Using a mixed-methods design, interprofessional courses were first identified across Germany in relation to the three professions of medicine, nursing and physiotherapy. Based on 76 fully completed quantitative questionnaires, the respondents’ views were surveyed with regard to the competences of the teachers, among other things. In 15 interviews based on these results, experts were asked more in-depth questions about competence limits and the assumption of responsibility, and the resulting data material was analyzed using Kuckartz’s structuring qualitative content analysis. Results: The quantitative results show that 70% of respondents (n = 53) consider it important to recognize profession-specific boundaries, while only 46% (n = 35) consider it important to assume joint responsibility. The qualitative part of the study shows that a basic understanding of the other professions is seen as conducive to dialog and collaboration. Furthermore, a shared assumption of responsibility is seen as an essential component of interprofessional teaching. Conclusions: In order to develop a shared assumption of responsibility, (self-)reflection is required; this also requires a conscious negotiation and development process on the part of the teachers. Teachers must align their joint actions with the needs of the learners so that they can later think and act across professions in patient care. As the process of (self-)reflection rarely takes place in mono-professional training programmes, opportunities to learn it are needed.

1. Introduction, Theoretical Background and Research Questions

Interprofessional education (IPE), i.e., students from different healthcare professions learning with, from and about each other [1], has been discussed and researched since the 1960s [2] to ensure that working together works well. In Germany, IPE has gained considerable momentum as a result of the Robert Bosch Stiftung’s call for proposals; this has led to interprofessional education projects being initiated at 24 out of 40 university locations with medical faculties since the end of the project [3]. In addition to medical students, this primarily involves students of the newly academicized healthcare degree programmes (e.g., nursing, physiotherapy and midwifery). Most interprofessional projects in Germany relate to the practical setting, such as interprofessional training wards. Preparation for collaboration in the context of training, on the other hand, takes place much less frequently. This applies to learners as well as teachers. In addition, most studies focus on learners, while the role of teachers is rarely examined [4].

However, teachers have a special role to play in interprofessional education, as they must demonstrate specific interprofessional competences in addition to the generally required didactic competences. In a previous study [5], the following IPE competences were defined: (a) interprofessional communication, (b) respect for other professions, (c) the recognition of profession-specific boundaries, (d) clarity of one’s own role, (e) teamwork, (f) interprofessional reflection, (g) interprofessional conflict resolution and h) the joint assumption of responsibility. National and international studies show that shared responsibility can lead to problems in practical settings [6,7]. If areas of activity overlap, the person with the greatest expertise in this area and therefore the greatest possible competence should take on the task. This person is not necessarily the person who has the highest degree or is at the higher level in the hierarchy. Sharing responsibility can therefore be a logical step towards reducing these problems.

The aforementioned IPE competences are also needed in teaching in order to convey the positive effects of IPE to learners. For interprofessional collaboration, these must be negotiated responsibly in dialog [8]. Since there are no comprehensive training programs for teachers in Germany that prepare them for joint teaching, the question arises as to how teachers (should) deal with the joint assumption of responsibility in the context of IPE.

Previous studies have identified the needs of IPE teachers and what is needed to prepare them well for collaborative teaching, such as the structure and content of further training, specific knowledge regarding concrete teacher actions, etc. These studies can be seen as a cornerstone on which the current study is based [5,9].

The aim of this study is to investigate which competences are necessary for IPE, how teachers assess the joint assumption of responsibility in teaching and to what extent knowledge of the other profession’s field of activity is required for this. Teachers from the fields of human medicine, nursing and physiotherapy in Germany who have experience in IPE were surveyed. The following research questions were explicitly analyzed:

• What skills should teachers who belong to the three professions of human medicine, nursing and physiotherapy have in the context of joint teaching?
• To what extent is it necessary to have knowledge of the content of the other profession in the context of joint teaching?
• How can a joint assumption of responsibility in interprofessional teaching succeed?

2. Materials and Methods

A mixed-methods design was chosen for this study. First, an online questionnaire was used to gain an initial impression. Building on this, guided interviews were conducted to gain a deeper understanding. The insights gained through the qualitative phase are intended to fill gaps in the explanations that could not be adequately answered by the quantitative survey [10].

This study received a favorable ethics vote (application no. 214/2018). It is compliant with the ethical guidelines of the Declaration of Helsinki of 1964 and its latest revision of 2018. Written informed consent was obtained from all of the included study participants.

2.1. Quantitative Design

2.1.1. Quantitative Questionnaire

This study addresses interprofessional education at the teacher level. As no standardized questionnaires were available at the time of the survey, a questionnaire was developed on the basis of theory-based literature. Publications were included that explain teaching at universities [11,12,13,14], deal with the competence development of teachers [15,16] and address participation in didactic–pedagogical and interprofessional further training [17,18,19].

The online questionnaire contained a total of 28 questions and was divided into five areas: 1. socio-demographic information; 2. scope and experience in teaching; 3. professional and interprofessional competences; 4. self-organized IPE events; and 5. qualification of IP teachers. The question formats were: open and closed questions, single and multiple choice and free text. In the preliminary field, the questionnaire was carried out with five test subjects and adapted following feedback. There was no further validation. The questionnaire is provided as Supplementary Materials.

2.1.2. Preliminary Research

An extensive online search was conducted to identify training institutions throughout Germany in the professions of human medicine, physiotherapy and nursing. In the period from September to December 2019, we addressed the question of whether cross-professional teaching events are offered in the respective institutions and whether cooperation as such is addressed. In the event of a positive response, the respondent’s willingness to participate in an online survey was ascertained, whereupon a link to the questionnaire was sent. This could be completed up to December 2019. After the deadline, the data from the completed questionnaires were analyzed descriptively in IBM SPSS Statistics 27.

2.2. Qualitative Design

2.2.1. Qualitative Guideline

Based on initial descriptive analyses of the online questionnaire, a guideline (

Table 1. Presentation of the guide with seven main questions.

Main Question
What do you personally understand by interprofessionalism?
2. What do the interprofessional courses that you teach/are involved in look like?
3. How do you envisage optimal interprofessional education at universities of applied sciences, vocational colleges or universities, or what should it look like?
4. Many people believe that the first step in interprofessional education should be to familiarize oneself with the other profession. Do you agree and, if so, why do you think it is important to have basic knowledge of the other profession?
5. In your opinion, do monoprofessional competences differ from interprofessional competences?
6. In the online questionnaire that you were kind enough to complete, three quarters of respondents cited interprofessional communication as an important competence, but less than half cited the shared assumption of responsibility. How can you explain this? Why does the aspect of taking joint responsibility seem to play a subordinate role?
7. What expectations do you have of an interprofessional qualification course? What should it look like so that you feel well prepared for joint teaching?

) was developed for conducting qualitative interviews. Seven topic areas were identified: 1. definition of IPE, 2. own IPE events, 3. optimal IPE events, 4. basic knowledge of other professions, 5. IPE competences, 6. communication and shared responsibility, and 7. IPE qualification course. Each of the areas contained one main question and further detailed questions.

2.2.2. Sample

In the online survey, participants were able to declare their willingness to take part in an interview in a separate form and provide their e-mail address. The aim was to achieve the greatest possible heterogeneity in terms of age, gender, teaching qualifications and the duration and scope of interprofessional teaching. A total of 15 interview partners were selected, five from each profession—human medicine, nursing and physiotherapy. When they were contacted, the subjects received a detailed letter of information and a declaration of consent upon confirmation of the appointment. All interviewees took part voluntarily and authorized the anonymous publication of their data.

2.2.3. Interviews

The interviews were conducted between the end of January 2020 and mid-February 2021, with the first eight interviews taking place in person at the respondents’ facilities. Due to restrictions related to COVID-19, the last seven interviews could only be conducted digitally via the cloud-based video conferencing provider Zoom. The length of the interviews ranged from 20 to 70 min and were recorded on tape. The interviews were then transcribed, anonymized and analyzed using MAXQDA (Analytics Pro 2022).

2.2.4. Data Analysis

The authors analyzed the transcripts independently of each other by evaluating the data using structured qualitative content analysis according to Kuckartz [20]. They coded the material by defining the main and sub-categories and discussing these in close dialogue. The main and sub-categories were developed consensually, deductively and inductively: deductively based on the interview guide and inductively supplemented by close textual work. In order to close the existing gaps, categories were formed in parallel via case summaries with the aim of comparing the categories with each other.

3. Results

3.1. Quantitative Results

A total of 798 institutions were identified throughout Germany where the three professions of human medicine, nursing and physiotherapy are trained. Contact was successful with 594 (74%) and interprofessional courses were offered at 134 (23%) institutions. A total of 125 of the stakeholders contacted agreed to complete the online questionnaire, which 76 people (61%) did in full. Only excerpts from the questionnaire are presented below. The complete questionnaire can be requested from the authors. The socio-demographic data are summarized in

Table 2. Socio-demographic data of the IPE teachers surveyed in Germany; n = 76.

Profession	n	%
Human Medicine	9	12
Nursing	26	34
Physiotherapy	29	38
Other	10	13
No answer	2	3
Age categories	n	%
26–30 years	3	4
31–35 years	7	9
36–40 years	14	18
41–45 years	15	20
46–50 years	12	16
51–60 years	20	26
Over 60 years	5	7
Gender	n	%
Female	54	71
Male	22	29
Degree/function	n	%
State Examination	11	14
Bachelor’s degree	6	8
Master	21	28
Dr.	12	16
Prof.	11	14
Other	15	20

. The study focused on the three professions of human medicine, nursing and physiotherapy. However, teachers from other professions, such as educators, occupational therapists, social workers, etc., can also work in interprofessional teaching settings. The criterion “other” here includes all professions other than the three professions mentioned above.

Table 3. Teaching experience in years in IPE teaching; n = 72.

Teaching Experience in Years	n	%
Less than 1 year	8	11
Between 1 and 3 years	22	31
Between 3 and 5 years	16	22
More than 5 years	26	36

also shows the teaching experience in years in IPE teaching.

Interprofessional Competences

One part of the questionnaire focused on IPE competences and asked which competences interprofessional teachers should have. The results are shown in

Table 4. Response in absolute numbers and in percentage terms to the question ‘In your opinion, what skills should an interprofessional teacher have?’ (n = 76). Multiple answers possible.

Answer Option	n	%
Interprofessional communication	56	74
Respecting the other profession(s)	54	71
Recognizing profession-specific boundaries	53	70
Clarity of one’s own role	52	68
Teamwork	49	64
Interprofessional reflection	48	63
Interprofessional conflict resolution	36	47
Joint assumption of responsibility	35	46
No answer	14	18

.

For 56 IPE stakeholders (74%), interprofessional communication is considered very important as a competence that IPE teachers should have. Recognizing profession-specific boundaries is also very important and is cited as important by 53 people (70%). In contrast, assuming joint responsibility appears to be less important as a competence for IPE teachers. This was not even mentioned by half of the respondents (35 people).

The participants were asked whether they considered it necessary to have knowledge of the other profession(s) for interprofessional teaching. Out of 76 respondents, 70 people answered this question, of which 60 people (86%) answered ‘yes’ and 10 people (14%) answered ‘no’.

With regard to the free text responses, in which respondents were able to justify their decision as to whether knowledge of the other profession(s) is necessary for collaborative teaching, six areas were identified, which are summarized in

Table 5. Justification of the decision as to why knowledge of the other profession(s) is necessary for interprofessional teaching, with n = 39 and a total of 44 answers in six identified areas.

Six Identified Areas	n	%
A basic understanding facilitates dialogue and collaboration	14	32
A basic understanding is necessary for recognizing professional boundaries	9	20
A basic understanding is necessary to be able to recognize similarities and differences	8	18
Deeper knowledge is not relevant	7	16
A basic understanding is necessary for recognizing the diversity of activities	3	7
A basic understanding is necessary to be able to change perspective	3	7

. For seven people (16%), in-depth knowledge of other professions is not necessary in the context of collaborative teaching. However, 14 respondents (32%) stated that a basic understanding facilitates dialog and collaboration. For nine interviewees (20%), a basic understanding was deemed necessary in order to recognize profession-specific boundaries; for eight people (18%), it was considered necessary in order to recognize similarities and differences. Meanwhile, three people (7%) described it as necessary for recognizing the diversity of activities and being able to change perspectives.

3.2. Qualitative Results

Nine main categories were generated from the 15 interviews with five interviewees each from human medicine, nursing and physiotherapy. All of the main categories and their subcategories that are relevant to the context of the research questions are shown in

Table 6. A partial representation of the main categories and subcategories resulting from the interviews. The complete list of categories can be requested from the authors.

Main Categories and subcategories
Main categories and   ● Subcategories
Basic knowledge   ● Competence limits
Teachers’ competences   ● Difference between interprofessional competences and monoprofessional competences   ● Role model function   ● Understanding as learning support   ● Curiosity/openness/appreciation   ● Thinking in a team   ● Change of perspective   ● Authenticity   ● Role of the teacher—current   ● Role of the teacher—ideal   ● Understanding one’s own role

.

The interview went into more detail about which competences teachers should have in interprofessional teaching, and also about where the limits of competence are and what is needed for a joint assumption of responsibility in interprofessional teaching to succeed. In summary, all 15 interviewees commented on these points.

Working together as equals and being aware of one’s own prejudices

The interviews showed that cooperation on an equal footing is important in interprofessional teaching:

“That in interprofessional teaching, for example, it would be essential that both teachers work at the same level, at eye level [...], that you have an equal share of speech, that you are perceived as equals by the learners.”

[Interview no. 2]

It is also important to be aware of one’s own prejudices. The ability to reflect on one’s own thought and action patterns in order to influence learners as little as possible in the classroom appears to be essential. For this reason, teachers in interprofessional teaching are seen more as facilitators and learning guides, and pedagogical skills are emphasized over professional skills:

“So I think the most important competence [...] is that you know your own, precise fixations and prejudices, that you know them and preferably have also clarified them, so that you can actually take on the role of a really good moderator and not, so to speak, on such a semi-covert level (...) transport your own ideas about one professional group or another into such a slight encroachment, which can happen quickly.”

[Interview no. 1]

Teamwork and knowledge of skills

Another competence that was mentioned is interprofessional teamwork. This includes the joint creation of concepts, the joint planning of teaching, joint teaching and subsequent joint reflection:

“Exactly, so the colleague and I actually sat together and discussed it together, discussed the amount of time and also the content and didactic-methodical design.”

[Interview no. 9]

Knowing one’s own competences is just as important in interprofessional teaching as recognizing the boundaries of competences. Where does one’s own competence end and where does the competence of the other profession begin? This was also discussed in the interviews. This question is not easy to answer, as there are overlaps in the professions’ job profiles. In the interviews, it was more a question of how one deals with areas of competence:

“Then I withdraw and, for heaven’s sake, leave it to the other profession to do what they do professionally where I have no idea or where I have a bit of basic knowledge at best. Yes, that’s very important.”

[Interview no. 8]

“I always notice that it’s always difficult to say where my area ends and where the other begins, but where there are also very clear overlaps. And to make that clear from the outset. In any case, a common basic understanding, a common goal.”

[Interview no. 7]

In order to adequately carry out interprofessional teaching, it is important for the interview partners to have basic knowledge of the other profession. This involves being able to make good use of one’s own skills, recognizing competence boundaries and not getting in each other’s way in the areas of competence. Acquiring basic knowledge of the other profession is perceived as appreciative:

“And I can treat the other person more respectfully if I also have an understanding of what they can do and what they do.”

[Interview no. 2]

These statements tie in with the six identifiable areas from Table 6 (see above), whereby it became clear that a basic understanding facilitates dialogue and cooperation, but it is equally important in order to recognize differences and similarities and to change perspectives.

Joint assumption of responsibility

Another aspect that was mentioned in relation to the success of interprofessional teaching is the joint assumption of responsibility:

‘Well, I can’t teach interprofessionally with someone who doesn’t reliably take on their part of the work or their part of the tasks.’

[Interview no. 2]

The joint assumption of responsibility is seen as an essential aspect of interprofessional collaboration, which must be developed jointly:

“I think it should be more about developing something like this, saying that we are jointly responsible for this.”

[Interview no. 1]

One interviewee spoke of “WE thinking” in order to make it possible to assume joint responsibility. For this interviewee, it is important that students see themselves as part of a team, both in the practical healthcare environment and in interprofessional teaching:

“If I think in terms of the ‘we’ and don’t see myself as a person, but don’t replace this ‘I’ with the ‘we’, but see myself as part of the ‘we’, then I can also practise taking responsibility together.”

[Interview no. 12]

The “... most beautiful form of interprofessional work” is seen in the joint assumption of responsibility.

[Interview no. 12]

4. Discussion

4.1. Teacher Competencies

In Germany, different requirements are placed on teachers in the three professions of human medicine, nursing and physiotherapy. The fact that the design of the training courses is decided individually by the individual federal states makes it difficult to compare the requirements for teachers. Human medicine is taught exclusively at universities, and the qualifications that teachers should have in this context are not specified in the Higher Education Framework Act [21]. For teachers in medical studies, entry into teaching usually comes unexpectedly. Management assumes that teaching works automatically. Due to their medical socialization, teachers are more likely to teach as they have experienced it themselves [12,22,23].

Training in nursing and physiotherapy can take place either at a vocational college or at a university of applied sciences. Here, too, the requirements of the federal states apply, which are very vaguely formulated. In the federal state of North Rhine-Westphalia, for example, teachers only need their own professional qualification and the school management and deputies also need an additional pedagogical qualification. Teachers do not necessarily have to have these [24,25].

“Those who learn to teach will teach learning” [12].

This study has shown that it is important for interprofessional teachers to communicate with each other and to recognize profession-specific boundaries. These points were already addressed by Böss-Ostendorf et al. [13] in 2014, who discuss the improvement of teaching skills. In order to improve, it is necessary to be open to feedback. Teachers should actively seek this feedback from students and colleagues. Regular exchange and mutual support in the form of advice are just as important as self-reflection and reflection on one’s own teaching practice in order to be able to deal critically with failures.

4.2. Assuming Responsibility in Interprofessional Teaching

“If I think in terms of the “we” and don’t see myself as a person, but don’t replace this “I” with the “we”, but see myself as part of the “we”, then I can also practise taking responsibility together.”

[Interview no. 12]

The quantitative data from this study showed that IPE teachers, particularly nursing teachers, tended to be more cautious about taking responsibility. The reasons for this can be manifold, e.g., a lack of competence, a lack of knowledge about the content of the other profession’s activities (see above), but also silo thinking. Offering more opportunities for self-reflection in IPE can improve the balance of teachers in taking on responsibility. However, further empirical research is needed to establish this link.

In schools, teachers generally teach alone, and this continues in vocational schools, colleges and universities. Teachers are not used to teaching in teams and tend to see themselves as lone wolves [26]. But how can teachers manage to engage in reflective dialog with colleagues and plan and implement lessons together if they do not learn to do so? The quote from interview 12 picks up on what Feldmann [26] means by the step from ‘I’ to ‘we’, which is a prerequisite for being able to act in a team. If this first step is taken, silo thinking can be overcome through cross-professional team teaching. This enables collaboration on an equal footing [27]. Rohr et al. [28] go one step further and see team teaching as a move away from a lone-wolf approach and towards communicative, cooperative teamwork.

Moreover, increasing the opportunities for self-reflection among IPE trainers, as mentioned above, can help to promote a more balanced approach to taking responsibility. After all, the aim of sharing responsibility is to provide optimal patient care. To ensure this in the best possible way, responsibility should be shared across all shoulders [6,29].

4.3. Need for Content Knowledge About Other Professions

Another finding of this study relates to the importance of content knowledge about the other professions for successful interprofessional teaching. Respondents emphasized that a basic understanding of the competences, roles and mindsets of other health professions is necessary for effective teaching. This finding is consistent with previous research showing that interprofessional learning is more successful when teachers have sufficient knowledge of the roles and responsibilities of the other professions [30].

Various strategies can be pursued to promote this interprofessional competence of shared responsibility. One possibility is the introduction of joint training courses for teachers from different healthcare professions, in which central concepts and working methods of the respective disciplines are taught [2]. In addition, interprofessional tandems could be formed in which teachers from different disciplines regularly work together and learn from each other. Such models have already proven effective in international studies in improving mutual understanding and cooperation [2]. In addition, interactive teaching methods such as case studies and simulations, as well as shadowing other interprofessional teachers, could be used to prepare students specifically for interprofessional teaching situations [31]. These recommendations are not new, but they are not (yet) universally implemented in teaching.

5. Conclusions and Outlook

This study investigated which competences interprofessional teachers should have in the context of their teaching, to what extent it is necessary to have knowledge of the content of the other profession(s), and how a joint assumption of responsibility for teaching can succeed. The quantitative analysis showed that 70% of teachers (n = 53) emphasized the recognition of professional boundaries, while only 46% (n = 35) valued shared responsibility. The qualitative analysis showed that it is essential for teachers to have basic content knowledge of the other professions in order to enable effective interprofessional teaching.

Therefore, IPE can be effective if self-reflection among teachers is encouraged and an environment is created in which professionals can learn from each other as equals.

Further training to improve teamwork is offered in the university context as part of university didactics. These courses are often offered for a short period of time and therefore do not appear to be sustainable. In 2007, Postareff et al. [32] were able to prove empirically that university didactics training courses that are designed for delivery over a longer period of time have a significant influence on teaching. In order to increase the quality of teaching, institutions should develop tailor-made offers for teaching staff. This was also shown in a study conducted by Griewatz et al. (2017), which focuses on skills-based lecturer training [33].

Limitations

This study focused on the three professions that have the greatest overlap in treatment in the clinical setting. In order to obtain a more global overview, it would be useful to include other professions involved in healthcare.

Furthermore, although the response rate for the online survey was good, at just under 61%, the participation rate among doctors was rather low. All medical faculties in Germany were contacted with the request to complete the online questionnaire. It is questionable why only nine doctors (12%) completed the questionnaire. This is especially significant when one considers that the Robert Bosch Stiftung stipulated the participation of medical faculties in cooperation as part of its funding, and that IPE was initiated at 24 locations after the end of the project. The increased involvement of medical teachers makes perfect sense, especially as doctors play an important role in many areas of healthcare.