Team building initiative by an Indonesian university to promote interprofessional education of undergraduate health professional students in community practice

Phase 1

This study aimed to identify the factors influencing interprofessional collaboration among health workers in community practice. It uses qualitative data collected through focused group discussions (FGD) with health workers, including doctors, dentists, nurses, midwives, pharmacists, nutritionists, physiotherapists, and surveillance officers. Participants were selected based on their experience in hospitals or health centers in Makassar City, South Sulawesi Province, Indonesia. FGDs were conducted in two sessions between the doctor/dentist and non-doctor groups, guided by moderators and note-takers with social psychology backgrounds, to explore respondents’ responses without psychological constraints. The discussion sessions, lasting 90 minutes in Bahasa Indonesia were recorded and reviewed by the moderator and note-taker. A summary of the results was shared with participants to ensure data credibility.

FGD questions list:

“Based on your daily experience in health care,”

The data obtained were analyzed using thematic analysis, specifically inductive analysis.¹² The researcher determines themes based on codes that emerge from primary data to find interrelationships between patterns in a phenomenon and reexplain the phenomenon from the researcher’s point of view.¹³ Subsequently, the researcher looked at its compatibility with the literature related to factors that support and hinder collaboration using a grounded theory approach.¹⁴

Phase 2

Phase 2 aimed to develop a team-building intervention model based on the findings of the first phase. The model development method used was the ADDIE approach ( Table 1), which includes analysis, design, development, implementation, and evaluation.¹⁵ This method was chosen because it can be used to efficiently and effectively design intervention programs. Three expert judges and 11 students from various health study programs were involved in this phase of the research. Data collection was conducted using questionnaires and FGDs, and data analysis was performed quantitatively and qualitatively.

Phase 3

This phase aimed to assess the effect of the interprofessional team-building intervention model on teamwork skills when applied to students participating in KKN PK. The interprofessional team-building intervention model as a result of the Phase 2 study was applied to students participating in KKN PK using a quasi-experimental design. The effect of the intervention on students’ teamwork skills was measured through a pre-test–post-test control group design using a questionnaire.^14,16 The subjects were students over the age of 18 that participating in the KKN PK in 2022 who provided written informed consent from several study programs.

Students were invited, explained the research, and consented to a 30-minute teamwork skills questionnaire¹⁷ using Google Forms.

The intervention group underwent team-building training consisting of four 75-minute activities (Table 2). After the fourth series, both groups were assessed using the same questionnaire to determine whether training improved their teamwork skills.

This study aimed to investigate the impact of a team-building intervention on the teamwork skills of professional health students. Using the SPSS application, independent and paired sample t-tests were used to analyze the differences between the intervention and control groups, ensuring that the data were normally distributed (p > .05).

Ethical consideration and consent statement

This study was conducted under the ethical standards of The Council for International Organization of Medical Science (CIOMS) Geneva and approved by the Health Research Ethics Committee of the Faculty of Medicine-Unhas, State-owned University Hospital-Unhas, and Dr. Wahidin Sudirohusodo General Hospital with Decree Number 72/UN4.6.4.5.31/PP36/2022. The participants in Phases 1 and 3 were informed of the objectives and methods of the study. The subjects were students over the age of 18 that participating in the KKN PK in 2022 who provided written informed consent from several study programs.

Phase 1

In total, the two FGD sessions were attended by 15 participants from various backgrounds who acted as informants ( Table 3).

From the two FGD sessions conducted, factors that act as supporters and barriers to collaboration, both internal and external to health workers, were obtained.

Supporting factors

Participants mentioned internal support factors more than external ones. There were some decisions on effective communication, and health workers needed to practice effective communication within a team, emphasizing a positive communication style and not being rude or bossy. As stated by P1 (participant) (a doctor, 36 years old), “… if we communicate as if we are the ones begging for help… it… can be well established. But when we tell them to… they seem to be a bit reluctant”.

In addition, willingness and desire to cooperate regardless of position and role, will facilitate collaboration. This was stated by P2 (a doctor, 34 years old): “… for example, there is an example of the nurse not coming. Why am I the one doing the infusion? I’m a doctor, why am I the one doing it? If there is no one else in the position, why not do it first? Back to each individual”.

Moreover, collaboration is strongly supported by an open personality and the humility and clarity of one’s heart. As expressed by P3 (a dentist, 42 years old): “the skill or ability to mingle with other people, colleagues for example.” And “…we should not be like that, arrogant. It does come from clarity of heart.”

Like any other behavior that requires a driver, collaboration also requires motivation to collaborate. This motivation is cultivated from the beginning of doctors’ education in the pre-clinical stage. They must be instilled with ideas that motivate collaboration. P3 said: “…Why don’t we instill in students that referring patients is not an insult but one of the most appropriate help when we cannot do anything”.

If it is related to referring to patients as a form of collaborative service, it certainly requires understanding the limits of competence. This can also be influenced by understanding each other’s role. P4 (midwife, 51 years old) mentioned the importance of understanding duties and responsibilities based on their competencies: “…to go down to the community, we in the program have backgrounds of midwives, nurses, and pharmacists. For example, when a case of malnutrition was found in the clinic. The doctor must contact the surveillance officer, nutrition officer, and environmental health officer before visiting”.

A confident attitude is needed so that health workers do not always consider their professional positions lower than other professions. This was expressed by P5 (nurse, 33 years old): “…first of all, I call all my friends Nurse, so that I have confidence.” And “So, at least from small things, raise the self-esteem. We are nurses. We are partners, not servants, not doctors’ helpers”.

Another important aspect is the cohesiveness of fellow professionals, which can increase solidarity. As expressed by P5 (a nurse, 33 years old), doctors are more compact and protect each other. This needs to be emulated by other professions instead of bringing down their colleagues: “…they are compact, they are good. We have damaged our profession”. Self-confidence and group or family spirit can encourage better collaborative practices.

The last internal support factor is the mutual need between health workers to contribute to collaboration. This is more directed towards the interests of each individual in the work interactions of health service agencies. P5 stated that when a doctor needs information from other professions, collaboration will tend to occur: “Yes, they need information from us, so they will also be happy to share the information”.

External factors such as environmental factors that support collaboration include leadership support, interprofessional education, collaboration, and organizational/workplace policies.

The importance of the leader’s role in realizing collaboration in a healthcare institution was expressed by P6 (doctor, 40 years old). “…if for example there are no people, it is also difficult for us to run the program. So actually it also depends on the head of the puskesmas (public health center)…”. Directions from leadership and program design that can be conducted together can encourage collaboration.

In this regard, joint programs and rules related to the division of tasks can be a condition that requires collaboration. This was mentioned by P7 (midwife, 35 years old) who mentioned that the program at the public health care (puskesmas) where she works does require health workers to work together: “Yes, in my experience at the puskesmas, having worked as a midwife for 10 years, there are programs that we have to work together. No program to the community is done alone”.

Organizational policies can also facilitate collaboration. These policies can take the form of written rules, as well as the structure and function of each part of the organization. This was mentioned by P8 (a nurse, 35 years old): “Our tasks have been written down, sir. Some are professional competencies or those that require collaboration, this is a mandate. … so indeed, we have set the path, when we go off track, we sit together again…”.

The next generation of health professionals must be prepared from their educational stage to be ready to collaborate in their future workplaces. P9 (a physiotherapist, 32 years old) mentioned the idea of familiarizing collaboration through interprofessional education: “Well, this is what maybe our job is to explain to these next generations since they are still in education, socialize each other, what a nurse is like, what a doctor is like. Well, so that we can respect each other”.

Inhibiting factors

The various factors that hinder it also consist of the internal and external aspects of the health profession. The results of this study show that some internal factors that hinder collaboration practices are age, seniority and tenure, negative self-perception (self-deprecation), egoism, negative personal character, ineffective communication, lack of competence, lack of understanding of competence, and lack of experience and understanding of collaboration.

Health workers who are older and have worked longer in an institution perceive themselves as senior who must be respected. Therefore, juniors who enter later feel reluctant to collaborate, especially when asking for help from their seniors. As stated by P10 (a doctor, 34 years old): “So they feel they know more. And think that you’re the new guy, why am I the one being told what to do”.

Additionally, ineffective communication is a barrier to the creation of IPC practices. As stated by P11 (a dentist, 27 years old): “Sometimes communication is not good or does not go as it should, which is a problem in my work environment”.

Lack of competence can be attributed to someone occupying a position, not because they have the ability but for other reasons. As mentioned by P2 (doctor, 34 years old), “…for what P4 said earlier, not competent because it is related to political positions…”.

In addition, not understanding the boundaries of competence and professional roles can result in overlapping professional duties. This can lead to conflicts in service delivery because it inhibits collaboration, which is a barrier for health workers. As stated by P1 (doctor, 36 years old): “For example, eee… a midwife is often also called a doctor because she practices all kinds. That was like an overlap earlier, yes sir”.

Furthermore, aspects associated with negative attitudes, perceptions, and personalities can hinder collaboration. The first is negative self-perception, especially with a sense of inferiority towards one’s professional position. This can hinder effective collaborations. Several participants, especially nurses and other non-physician health workers, viewed their position as subordinate to doctors. Among them, as stated by P5 (a nurse, 33 years old): “Because I see it here sir, because from our side we are also putting ourselves down. Why do I say that? Because there is a friend of mine who is a senior, if there is a doctor he looks very submissive”.

Furthermore, professional egoism remains a personal aspect that hinders collaboration. This egoism is associated with a lack of acceptance of doctors if other health workers can perform an intervention that is under their competence and role. This was expressed by P12 (a pharmacist, 39 years old): “….. but more doctors have not accepted. Because they feel..ee… our presence is to intervene in their therapy, but not at all”.

Third, negative personal characteristics can be a barrier to collaboration among health workers. This negative personal character leads to individual personality traits that tend to persist. As stated by P5 (a nurse, 33 years old): “…I consider it a personal thing. So I don’t think it’s the doctor’s fault as a profession, but it’s the person’s fault”.

The first factor that can hinder collaboration is workload. This can be attributed to the uneven distribution of tasks, overlapping tasks, and excessive work demands. As stated by P6 (a dentist, 40 years old): “… already have the task of handling patients. Then you add additional workloads, for example as a nutrition program holder or you have to be involved in vaccination activities”.

Furthermore, certain types of health professionals are perceived to hinder collaboration because they are considered competitors, especially between doctors and nurses. This finding has implications for the lack of cooperation among health workers. P11 (a dentist, 27 years old) mentioned: “…the potential competitor is the dental nurse. … also has the competence to perform the same basic actions as the dentist”.

At the macro-level, an unsupportive national system is a barrier to collaboration. This concerns the placement of health workers in hospitals and health centers, which encourages them to pursue income and careers rather than collaborative work. This was conveyed by P3 (a dentist, 42 years old): “…collaboration is still against government policy”.

Still related to policy, it is undeniable that there is a perception of injustice in terms of remuneration, which can hinder effective collaboration. P6 (a dentist, 40 years old) mentioned this: “So how do they want to be energized if the capacity is not the same”.

Finally, community culture seems to be indirectly related to collaboration practices is community culture. Cultural aspects such as customary norms and values, especially regarding patterns of social relations between individuals, can also hinder collaboration. This was described by P5 (nurse, 33 years of age): “..here, definitely with DPJP, we say yes doc, yes doc. It’s not like that out there. We can laugh together with them.. here it won’t be like that”.

Phase 2

In developing the team building intervention model, the ADDIE development model was used in five stages: analysis, design, development, implementation, and evaluation.

Stage of analysis

The phase 1 study revealed that the interprofessional team-building intervention model focuses on internal personal barriers to collaboration, such as seniority, negative self-perception, ego, negative character, professional arrogance, ineffective communication, lack of understanding of competency boundaries, and lack of experience.

In this study, the researcher applied a positive approach because interventions using positive concepts tend to be more effective in influencing behavioral.^18,19 Therefore, the six inhibiting factors were transformed into positive aspects that included the supporting factors identified in the previous study: aspects of humility, empathy, effective communication, and collaboration. However, the aspect of self-awareness needs to be added because, according to Goleman (1998), it is also an important basic competency to develop cooperation.²⁰

Collaboration enablers and post-transformation collaboration inhibitors can overlap in terms of humility, openness, desire, and willingness to cooperate, which can be collected in the latter ( Table 4).

An interprofessional team-building intervention program aims to develop six self-esteem, humility, empathy, effective communication, collaboration, and self-awareness factors among health professional students.

Stage of design

The interprofessional team-building intervention model employs an experiential learning approach that focuses on individual experiences.²¹ Participants received information in the cognitive domain and practiced an activity that described the material provided in the affective domain (Table 5).

Stage of development

The interprofessional team-building intervention model prototype includes a training module validated by three experts with over five years of experience in social psychology, group development, and psychology, assessing its suitability with objectives, material coverage, activities, methods, and media (Table 6).

The following is a list of activities in the interprofessional team-building intervention program module that has been revised and made ready for testing ( Table 7).

Stage of implementation

After successfully passing the validation test at the development stage, the research continued by piloting the interprofessional team-building intervention module to 11 6^th-semester students from various health science study programs at Hasanuddin University: Medical Education, Dentistry Education, Nursing, Physiotherapy, Public Health, Community Nutrition, Veterinary Medicine, Pharmacy, and Psychology study programs. Two facilitators will lead a two-day training at Faculty of Medicine, Hasanuddin University, accommodating over 30 students from 09.00 to 17.00 WITA (Central Indonesian Time or UTC +8).

Stage of evaluation

The reaction rate was assessed using a questionnaire adapted from Philips and Stone (2002) supplemented by qualitative data from participants through FGDs, evaluating training materials, methods, facilitator performance, and overall program comments.²⁵

Training contents

Regarding the materials (see Figure 2), participants stated that the content provided followed the objectives of the intervention model. They also perceived that the training contents were in line with the desired objectives and relevant to daily life. In addition, they also reported that the training provided meaningful insights for them after attending the session: “The training has gone well, the material has been delivered very well and is easy to digest and understand, there are also fun games, and I have gained experience and also valuable lessons” (S6, Medical Education student).

Figure 2. Evaluation results of training content.

Although the contents have been successfully delivered to the participants, some aspects need to be developed. For example, the instructions on the “draw it” activity still need a more detailed explanation to ensure better understanding from participants: “…the material is fun so I know myself and others. The material also fits the objectives. But I got it wrong in the draw it activity” (S2, Veterinary Medicine student).

Training activities and materials

Participants found the activities and materials effective in facilitating their understanding of the material, particularly for adolescents and early adults. The evaluation was based on the suitability of the activities to the content and the respondents’ characteristics. As stated by several participants:

“The components are good so that the activities are not boring. But hopefully it can still be developed so that it can be even better” (S4, Dentistry Education student).

“The media used is very helpful and varied so that participants are not too bored in participating in the event, even though the duration is fairly long” (S9, Public Health student). ( Figure 3)

Figure 3. Evaluation results of the training activities and materials.

Therefore, researchers must improve the effectiveness of the role-play method by setting a more structured time limit. One of the participants stated, “I am very happy to participate in this training because it turned out to be fun and there were many games. In the future, the thing that might be improved is the time management of the implementation of this activity, especially in the role play part which takes up a lot of time” (S6, Medical Education student).

Training facilitator

Regarding the facilitator ( Figure 4), all participants stated that the facilitator had good command of the material. The facilitator was considered capable of explaining the material in a way that made it easy for the participants to understand, creating a room atmosphere conducive to discussion, and maintaining the focus and continuity of activities in accordance with the training objectives.

Figure 4. Evaluation results of the facilitators.

The same was also obtained for qualitative data during FGDs, as conveyed by several participants:

In this context, facilitators are equipped with modules to support the optimal understanding and implementation of activities following the training objectives.

Overall implementation assessment

Participants rated the effectiveness of interprofessional team-building intervention training on a 1-10 linear scale, with 1 indicating low effectiveness and 10 indicating high effectiveness, considering content, activities, equipment, and facilitators.

Participants scored from 8 to 10 on the overall training implementation and effectiveness, with a mean score of 9.45 (±0.687), indicating that the activity was highly effective in practicing interprofessional team building ( Table 8).

In addition, participants also stated that after attending the interprofessional team building intervention training, there were changes in themselves and in their perspectives towards diverse groups and professional backgrounds. Several participants said the following.

Phase 3

In this third phase, interprofessional team-building training was provided to students who participated in the 62nd batch of the Health Professions Community Outreach Programme (KKN PK) in 2022, located in Bone Regency, South Sulawesi. In both intervention and control groups, subject selection required voluntary participation, complete questionnaire completion, and no outlier data. A total of 38 students from various health science programs at Hasanuddin University Makassar were selected through purposive sampling, with 20 in the intervention group and the remaining in the control group ( Table 9).

The results of the assumption test using the Shapiro-Wilk test showed that the teamwork skills score data were normally distributed in both the intervention and control groups (p>.05). However, there was no homogeneity of variance, as analyzed using the Lavene’s test for equality of variances (p>.05). The significance value must refer to the table with the value of the assumption of variance that is not met.

Based on the results of hypothesis testing with an independent sample t-test, it was found that the interprofessional team-building intervention improved teamwork skills in the intervention group (M = 115.2, SD = ±10.8) compared to the control group that did not receive the intervention (M = 104.1, SD ±16.9) (p<.05). Thus, it can be concluded that there was a significant difference between teamwork skills in the intervention and control groups ( Table 10).

Furthermore, it is also important to see a significant difference in teamwork skills before and after the provision of training in the intervention and control groups using a paired sample t-test.

The results showed a significant difference in teamwork skills between the group that received the interprofessional team-building intervention (M = -16.3, SD ±7.7) and the group that did not (M = 2.7, SD ±8.3). The group that received the interprofessional team-building intervention experienced significant changes in teamwork skills (p<0.05), while the group that was not given the intervention did not experience changes (see Table 11). Thus, it can be concluded that the provision of interprofessional team building interventions can significantly improve the teamwork skills of health professional students.

Phase 1

This research identifies internal and external factors that influence collaboration among health workers, including communication skills, personal character, openness, humility, motivation, self-perception, self-confidence, solidarity, and personal interests. External factors affecting collaboration effectiveness include leadership support, work demands, workplace cultures, professions, job titles, interprofessional education, local culture, and policies at various levels.

Bollen et al. (2018) identified four main themes influencing collaboration between community pharmacists and general practitioners: negotiation of professional boundaries, willingness to cooperate, competence, understanding of competency boundaries, position, and self-perception, which align with the findings of the first theme.²⁶ This study identified two themes related to perceived knowledge and skills in health workers: communication, collaboration, professional abilities, and different perspectives. Factors such as leadership support, collaborative situations, work demands, work environment, remuneration, support systems, cultural aspects, education, and training were also identified.

Prasitanarapun and Kitreerawutiwong (2023) developed an instrument to measure IPC competencies in Thailand’s primary health care teams.²⁷ They identified five factors that qualify IPC: collaborative teamwork, population-centered care, communication, role clarification, interprofessional reflection, interprofessional values, and mixed skills. These factors were highly relevant to the instrument’s six main factors.

Previous research on the practice of IPC among health workers in Makassar City revealed that personal qualities, skills, knowledge, attitudes, beliefs, values, and individual professionalism, such as competence, thought processes, and motivation, influence this practice. Interpersonal relationships in health care involve shared values, beliefs, attitudes, role clarity, effective communication, decision-making processes, language differences, mutual respect, and active roles with patients, including self-management, goals, and team membership.^28,29

This research has implications for strengthening theoretical concepts and models related to IPC. Although contextual, the factors that emerged are in line with previous qualitative research related to IPC. Understanding these factors can lead to the determination of appropriate interventions to improve IPC practices in the health world.³⁰

Phase 2

Based on the results of Study 1, several factors hindered collaboration, including seniority, negative self-perception, ego, negative personal characteristics, professional arrogance, ineffective communication, a lack of understanding of competency boundaries, and a lack of experience and understanding of collaboration. Nelson and Prillenstensky (2017) stated that interventions targeting personal and relational aspects aim to be developed or improved.³¹ Therefore, it is necessary to identify the factors that support the development of inhibiting factors.

For example, the aspect of seniority in this study could be interpreted as a culture of seniority where a junior or younger person is expected to respect an older person. The ego aspect of the self refers to an excessive level of pride or arrogance, resulting in the rejection of others’ views and difficulty accepting constructive criticism or feedback.

In training development, it is important to identify and address these aspects while recognizing that these inhibiting factors can coincide with enabling factors that can be strengthened through appropriate interventions.

The analysis phase involves identifying aspects and needs, followed by the design phase, in which researchers design training activities based on analysis results. The target was students in professional community service programs that promote interprofessional collaboration among health workers.

The researcher chose experiential learning methods for training, focusing on individual experiences and the cognitive and affective domains. The selection was adapted to adolescent or early adult participants, aiming to overcome boredom and increase enthusiasm for training activities. Kolb (2015) and Muarif and Adiyanti (2020) supported the effectiveness of these methods.^21,32

After passing through the design phase or stage and successfully formulating the prototype of the intervention program module, the research continued by conducting validation through three experts (expert judgment) with knowledge and experience in the field of team building and collaboration. The results showed that the training met the expected standards and criteria to be implemented.³³

The implementation phase involved trials on participants with characteristics similar to those of the target subjects, lasting two days. Facilitators were briefed to understand the activity material and provided with modules. Preparation focused on ensuring that facilitators were appropriate and optimal for the implementation stage.

The evaluation phase revealed good results in the material, methods, facilitators, and overall implementation assessment of the training, indicating that it met the expected objectives. Technical input from the participants did not affect the training substance. The shift in attitudes towards oneself, groups, and diverse professional backgrounds through training is evident.

Phase 3

This study focuses on interprofessional team-building activities aimed at developing self-esteem, humility, empathy, effective communication, collaboration, and self-awareness. These aspects are crucial for effective cooperation, conflict resolution, and communication efficiency, thereby fostering a strong foundation for individuals to work effectively in teams.

The sense of self-worth developed in this interprofessional team-building intervention is to increase awareness of the importance and worth of individuals so that they do not feel discouraged from being actively involved in a group of various program backgrounds. Health professionals with greater self-esteem are more open to feedback and constructive criticism, which encourages the development of better teamwork.³⁴

In addition to self-esteem, individuals also need to have humility to be more open to accepting themselves, as they are with all their limitations and shortcomings. Humility is the basis of many behavioral changes that can lead to the development of team performance.³⁵

Empathy is also an important skill for health professionals to improve their teamwork.³⁶ Through emotion recognition games in this interprofessional team-building intervention, subjects can learn about the various emotions that exist in humans and recognize the mode of expression of each emotion.^37,38

Effective communication skills are crucial for improving the collaboration and teamwork among team members. This study suggests that initiating interprofessional team building during college can help future health professionals develop strong cooperative skills, which will be beneficial in their professional practice.