Towards an interprofessional competency-based model in South Africa: A Delphi study

Ethics

The study was approved by the Senate Research Committee of the University of the Western Cape, South Africa (registration number: 14/9/25). Participation in the study was voluntary and written informed consent was obtained from participants beforehand to use their data for analysis and publication. The data were collected and processed anonymously.

Research design

Denzin and Lincoln states that qualitative research offers methodological tools with which to understand the deeper meanings associated with multifaceted phenomena and processes in practice.¹⁵ Besides the traditional approaches to qualitative inquiry, such as grounded theory, phenomenology, constructivist inquiry, and narrative inquiry, the Delphi method is an additional approach not often highlighted in the literature. The Delphi method is a logical approach based on the philosophical assumptions of philosopher and educator John Dewey, who believed that social science research should directly relay and inform everyday practice and decision-making.¹⁶ According to Birdsall, the Delphi method stresses structured anonymous communication between the authors and the expert on a certain topic with the aim of reaching consensus in the areas of policy, practice, or organizational decision-making.^17,18 The Delphi method used in research usually involves approximately three rounds of surveys that are distributed to a panel of experts, with each round being informed by responses to the previous one. The Delphi process can be continuously repeated until consensus is reached. In this study the Delphi method was used to reach consensus on the most appropriate activities and assessment methods to use in an interprofessional curriculum, that would assist in instilling interprofessional core competencies in undergraduate health care students.

Panel participants

Selection of the appropriate participants is regarded as one of the most important phases in the entire Delphi process, as it directly impacts on the quality of the results produced.^19–21 Since the Delphi technique concentrates on prompting expert views over a short period of time, the selection of participants is usually reliant on the disciplinary areas of knowledge and skills required by the specific issue at hand.²² As interprofessional education is a relatively developing area in South Africa, and as such it was initially difficult to identify local experts in the field. The authors aimed to recruit 15 and 20 participants and names were garnered from the initial experts identified, so as to include as diverse a group of experts as possible. The authors approached 95 experts which were more participants than required, in the event that if some were not available, there would be enough participants for the study. Following this process, the participants made up a group of 29 participants. The first phase of the study had 11 out of the 29 invited participants positively respond to participate in the study, yielding an initial response rate of 37.93%. Ludwig¹⁵ indicates that “the majority of Delphi studies have used between 15 and 20 respondents”. Based on this, a decision to expand the expert panel base and invite more participants with a target of achieving a positive response of between 15 and 20 was made and executed. Forty potential participants from the African Interprofessional Network (AfrIPEN) were invited to participate in the study. Eight gave a positive response, making a total of 19 participants. The demographics of 17 of these participants can be found in Table 1. In round one, all 19 experts participated and in round two, 16 of the experts completed the questionnaires in the Delphi process.

The experts in this group were initially contacted via e-mail and came from various organisations, both local and international. International organisations included the Centre for the Advancement of Interprofessional Education (CAIPE), UK, University of Missouri, U. S, Suez Canal University, Egypt, University of Cairo, Egypt, University of North Carolina, U. S, University of North Texas, U. S, Curtin University, Australia, University for Development Studies, Ghana, and the University of Sudan. South African institutions included Stellenbosch University, University of the Western Cape, University of Cape Town, University of Pretoria, University of KwaZulu-Natal, University of the Free State, and Psych Care in Pietermaritzburg.

Procedure

The authors obtained contact information of potential participants from publications of experts in high impact journals, organisations/networks like the Africa Interprofessional Education and Collaborative Practice Network (AfIN) and African Interprofessional Network (AfrIPEN). Participants contacted, also identified other experts and made their contact details available to the authors. All the identified participants and experts in the field of IPE received an invitation letter via e-mail, containing information regarding this study and a request for their assistance as an expert in the field of IPE (see Extended data⁴⁹). A consent form was attached to the e-mail, which needed to be completed and returned to the authors, should they agree to participate in the study (see Extended data⁴⁹). Once all the consent forms had been received, the participants were sent a link to begin the Delphi process, by completing an online questionnaire in Google Forms. The first section of the questionnaire included a demographic aspect whereby participants had to indicate their profession, years of experience in IPE, year level of student engagement in IPE and the average number of students engaged in IPE per annum. The Psychology Ethics Committee of the University of Aberdeen posits that it is good practice to assign a numerical reference to participants in research studies for the purposes of anonymity.²³ This was particularly necessary in this study in order to track participants’ replies and verify their responses during the next round of the Delphi study. The questionnaire was based on the six interprofessional core competencies identified by the Canadian Interprofessional Health Collaborative (CIHC), whereby participants were asked to identify activities and methods of evaluation for each competency domain.²⁴ The questionnaire was sent online, which allowed participants to complete it at a time and space in which they were comfortable. The authors enabled settings in Google Forms to be notified via e-mail when questionnaires had been completed by participants, according to their allocated participant number and, through this method, the panel of experts could keep track of the total number of completed questionnaires.

Prior to the Delphi study, the authors presented the two competency documents (CIHC & Interprofessional Education Collaborative Expert Panel) to faculty who collectively recommended the use of the six competency domains outlined by the CIHC.^4,24 The participants in the Delphi study had to review the combined six competencies listed by the CIHC and the two additional competencies suggested by an Interprofessional Education Collaborative Expert Panel. For the purposes of this study, the focus is primarily on the six competencies listed by the CIHC, together with the additional core competencies of the Interprofessional Education Collaborative Expert Panel, i.e., values/ethics for interprofessional practice and roles, as well as responsibilities for the sake of comprehension. Round one required participants to list as many activities as possible, to instil each of the eight core competencies into undergraduate students. While listing activities, they had to think of different assessments that could be used to evaluate the different competencies.

During round two, the authors compiled a second questionnaire whereby participants had to rate the activities and assessment practices most favourable to instil IPE core competencies as presented in round one. The scale of reply extended from one to five, ranging from strongly agree to strongly disagree. The most common activity types and assessment methods were selected by the authors from round one. Items were considered as ‘common’ where three or more participants made the same comment. The participants were given a space on the questionnaire to make any further comments should they feel that the items list was not appropriate or in alignment with comments they had made previously. Participants had to state whether they agreed with the listed assessments and activities by clearly stating “yes” or “no”. Since there were no objections and no comments made indicating the inappropriateness of the listed items, the authors concluded that consensus was reached at the completion of round two. This decision was communicated to all participants, in addition to giving participants a final opportunity to dispute the decision, of which there were none.

Reliability and validity

Hasson et al., states that the Delphi technique is based upon the assumption of safety in numbers (i.e. many experts are less likely to arrive at a wrong decision than a single person).²⁶ Choices are then strengthened by logical argument in which assumptions are confronted, thus helping to increase validity. Threats to validity arise primarily from pressures for convergence of predictions which challenges the Delphi's forecasting capability. However, the use of experts on a particular topic, can assist to increase the content validity of the Delphi technique by using successive rounds of the questionnaire which increases the concurrent validity.²⁶

Trustworthiness

Trustworthiness of the data was ensured by using Guba’s¹¹ four criteria of trustworthiness:

Delphi round one

Suggested activities and assessments made by the participants for the IPE core competencies were ranked and captured accordingly (see Table 2).⁴⁸

Delphi round two

Fourteen of the experts participated in this round. The suggestions given for activities and assessment strategies that were common to the majority of participants, were summarised and sent back to the participants for confirmation in the form of round two.⁴⁸ Participants were requested to rate common suggestions on activities and assessments given as Likert items (see Table 3 and Table 4) and make necessary comments should there be any discrepancies.

Activities used to develop interprofessional competencies

Considering the above-mentioned assortment of activities, it is evident that similar activities can be used to instil more than one competency, for example, case studies that mention interprofessional communication, patient/client/family/community-centred care, role clarification, interprofessional conflict resolution and values/ethics for interprofessional practice. Another example is role play, which can be used to develop the core competencies of role clarification, collaborative leadership, interprofessional conflict resolution, and values/ethics for interprofessional practice. However, when considering such overlap, it could appear repetitive and confusing in nature when designing new IPE activities and curricula. Barr et al. provide some guidance on how to classify different learning activities that are frequently used in IPE.²⁷ They state that using different methods in combination with each other can be very advantageous for students. The classification is as follows and the results are discussed accordingly:

The following main activities that were highlighted by the expert panel and were common to most of the IPE core competencies; case studies, joint clinical placements, simulations, role plays and workshops/discussions.

Case studies

Case studies can be considered as a problem-based learning approach and classified under exchange-based learning, according to Barr et al.²⁷ Bonney highlights several advantages of using case studies as a teaching strategy.²⁸ Firstly, case studies improve the development of the higher levels of Bloom’s taxonomy of cognitive learning,²⁹ which moves beyond not only recalling knowledge, but includes analysis, evaluation, and application. Secondly, case studies facilitate interdisciplinary learning and can be used to facilitate connections between specific theory and real-world societal issues and applications. Case studies have the ability to increase student motivation to participate in class activities, which promotes learning and improves performance on assessments.

Students in groups can be presented with a well-structured problem or case study in which they have to work collaboratively in a once-off session of a week or longer duration, depending on the outcomes of the session. This would encourage active learning among team members. A case study lends itself to being open-ended; it allows for realistic problems to be used to stimulate interdisciplinary discussions; promotes critical thinking, learning and participation among students, especially in terms of their ability to view an issue from multiple perspectives and to grasp the practical application of core course concepts.³⁰

Workshops

Workshops demonstrate modern principles of teaching such as active engagement of the learners. They provide opportunities for the interaction that enables the teachers to connect the material to the context of the learners. They provide an opportunity for group interaction, which is important for trainees who are becoming increasingly isolated in their work.³¹ When planning workshops, it is suggested that student preparation and attendance should be a requirement, allowing for a greater success of the workshop.³²

Simulation based activities

There are two activities classified under simulation-based activities, role plays and simulations. Simulations provide students of all professions a safe space to interact with each other collaboratively, as well as opportunities for a novice’s eventual transition to becoming an expert. Simulated activities provide students with an opportunity to explore and appreciate the roles of other health professionals. Fowler-Durham and Alden confirm that simulation intends to mimic reality whilst offering a skills-based clinical experience in a safe and secure setting.³³ Hovancsek describes the aim of simulation as ‘to replicate some or nearly all of the essential aspects of a clinical situation so that the situation may be more readily understood and managed when it occurs in reality in clinical practice’.³⁴ Russell et al., state that role plays and simulations function as learning tools for teams and groups or individuals, as they can either engage with each other online or face to face.³⁵

Joint clinical placements

Joint clinical placements are a vital part of undergraduate education, allowing students to transform theory into practice by engaging in ‘real-life’ experiences, to strengthen the academic programme content covered at the institution. Koh warns that students who are unable to link theory and practice could possibly be left ‘floundering, lacking in confidence and disenchanted, with some being forced to leave’.³⁶ The core element of a clinical placement is that learning occurs by doing, since problems associated with clients/patients are placed in context and critical thinking can be developed.³⁷

Assessment activities

The main suggestions given by the expert panel on assessment methods aligned to the suggested activities are portfolios, reflection and the development of appropriate rubrics which will be discussed below.

Portfolios

Portfolios are ideal as an assessment tool as they allow for critical analysis of their contents, which reflects on a particular student/group/community. They can therefore be considered as multipurpose instruments, since they can be used for assessments, monitoring and planning, reflection, learning, and for personal development.³⁸ Portfolios are known to stimulate reflection, as students are often required to look back on work they have done and analyse what they have or have not achieved and supply reasons for this. Portfolios are often compiled over a long period of time to allow a sufficient interval in which to collect information and to reflect on the knowledge that has been gained from these experiences. Brown defines a portfolio as ‘A private collection of evidence, which demonstrates the continuing acquisition of skills, knowledge, attitudes, understanding and achievements. It is both retrospective and prospective, as well as reflecting the current stage of development and activity of the individual’.³⁹ Students can sort the evidence in their portfolios into sections corresponding to the different competencies to be assessed and use captions to explain what the evidence shows about a specific competency, since many medical curricula are based on competency criteria.³⁸

Reflection as an assessment tool

Sandars states that many assessments include ‘levels of reflection’ and that this hierarchical model is based on the notion of depth of reflection.⁴⁰ Superficial reflection is considered to occur when there is only a report of events, but deeper reflection includes a ‘stepping back’ from events and actions with evidence of the encounter and possible change to current views and perceptions. This deeper level is equivalent to ‘transformative learning’ taking place. Reflection can be considered as a purposeful critical analysis of knowledge and experience in order to achieve a deeper meaning and understanding of a specific body of information. Reflection cannot be seen in isolation from reflective learning and reflective practice.⁴⁰ In a study done by Morison et al. on reflection, students felt that learning together in both lectures and on clinical placement allowed them to gain optimum understanding on their own and others’ roles and that the real-world experience helped them to appreciate the importance of teamwork and communication skills.⁴¹ Mann et al., confirm that professional competencies can be assessed through reflection and that different levels of reflection should be established for each year level.⁴²

Rubrics

The third assessment method highlighted by the expert panel is the use of rubrics. Rubrics are a good indicator to students of what aspects of their performance will take priority and how marks/percentages will be allocated to specific tasks for assessment purposes. The use of rubrics in assessments offers a means to provide the desired validity in assessing complex competencies, without forfeiting the need for reliability.^43,44 When designing rubrics, Reddy strongly suggests that assessors ensure that the scoring criteria reflect the desired core competencies that would suggest success in curriculum design and practice.⁴⁵ The scoring/rating of rubrics are descriptive scoring schemes that are developed by educators or others (clinicians/supervisors/peers) to guide the analysis of written work or practical work in terms of a process towards students’ efforts.⁴⁶

Considering how the activities above can instil core competency development and the suggestions given on how to assess the activities, it cannot be successfully adopted without the suggestions given by experts. For novice higher education institutions that are wanting to design an IPE curriculum, the experts in the field of interprofessional education suggested the application of principles such as treating all the health professions as equals, showing mutual respect, valuing differences, working towards common goals, commitment from the faculty including its leadership, alignment of timetables which includes shared curriculum and assessment practices, to name but a few. Core competency development has been hugely guided from international influences but cannot be applied to all contexts without adaptations.

Limitations

Although the number of experts who were classified as the participants for the study fell into the normal range for Delphi studies, a larger number of participants would have yielded a more enriched data set. The first round of the Delphi study took almost a year to complete as the authors had to send out monthly reminders to participants who had consented to participate in the study.

Recommendations for future research

IPE is an emerging field and the literature is constantly growing with more and more experienced academics and practitioners emerging. In light of the COVID-19 pandemic, many higher education institutions have resorted to online learning and activities for IPE. Thus, it would be worthwhile to do a follow-up survey to get feedback on these activities and assessment strategies which can be added to this study.

Underlying data

Figshare: Consensus on activities and assessment methods that instil interprofessional core competencies (data sets), https://doi.org/10.6084/m9.figshare.17134679.v1.⁴⁸

This project contains the following underlying data:

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Extended data

Figshare: Consensus on activities and assessment methods that instil interprofessional core competencies (appendices), https://doi.org/10.6084/m9.figshare.18771038.v1.⁴⁹

This project contains the following extended data:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).