Abstract

Introduction

Interprofessional education (IPE) is an educational strategy that aims to prepare students and health professionals to work in interprofessional teams, improving knowledge and skills for collective and collaborative action. It is an important tool for meeting the health needs of the community, transforming these professionals into facilitators through the health education process¹1 Rajadurai S. Interprofessional clinical education in dentistry. Prim Dent J. 2021; 10(1):108-11. doi: 10.1177/2050168420980989.
https://doi.org/10.1177/2050168420980989... .

Health professionals, for the most part, are focused on individual, in-office, ultra-specialized care, fragmenting patients complains, hampering their interactions with other areas and other professions. This individualistic view is presented to students from the beginning of their clinical activities. Implementing IPE is challenging due to the difficulty of team training, mainly because there has not been, until today, an internationally accepted model²2 Rotz ME, Calligaro IL, Kaplan LI, Lu X, Sinnott MC, Spadone S, et al. Design and evaluation of an interprofessional education workshop series for preclinical and prelicensure health professional students. Curr Pharm Teach Learn. 2021; 13(7):885-94. doi: 10.1016/j.cptl.2021.03.023.
https://doi.org/10.1016/j.cptl.2021.03.0... .

Interprofessional collaborative practice has presented benefits that include “improved access to safe, quality care, reduced lengths of hospital stay, improved quality of life for patients and families, and improved recruitment and retention of health and social service providers”³3 Grymonpre RE, Bainbridge L, Nasmith L, Baker C. Development of accreditation standards for interprofessional education: a Canadian case study. Hum Resour Health. 2021; 19(1):12. doi: 10.1186/s12960-020-00551-2.
https://doi.org/10.1186/s12960-020-00551... (p. 2). The evidence for IPE continues to evolve and will develop greater knowledge of how it can most effectively be planned and implemented, and its relationship to developing collaborative competences that can positively affect the delivery of patient care and health outcomes⁴4 Reeves S. Why we need interprofessional education to improve the delivery of safe and effective care. Interface (Botucatu). 2016; 20(56):185-97. doi: 10.1590/1807-57622014.0092.
https://doi.org/10.1590/1807-57622014.00... ^,55 Batista NA, Rossit RAS, Batista SHSS, Silva CCB, Uchôa-Figueiredo LR, Poletto PR. Interprofessional health education: the experience of the Federal University of Sao Paulo, Baixada Santista campus, Santos, Brazil. Interface (Botucatu). 2018; 22 Supl 2:1705-15. doi: 10.1590/1807-57622017.0693.
https://doi.org/10.1590/1807-57622017.06... .

The identification of social determinants is important to comply with the Brazilian National Health System (SUS) guidelines. It contributes to the health-disease process. Therefore, being able to understand the development and progression of diseases in an interprofessional view will lead to a change to healthier choices, prevention, and treatment actions. The practice of health promotion must break with the concept that health is the absence of disease and think of it as a process that involves social determinants. The actions must have social relevance and meet the needs of the community⁶6 Carrer FCA, Cayetano MH, Gabriel M, Melani ACF, Martins JS, Rizzo HGM, et al. The teaching of the Expanded Clinic for Dental course first-year students: an experience report. Rev ABENO. 2017; 17(4):108-20. doi: 10.30979/rev.abeno.v17i4.412.
https://doi.org/10.30979/rev.abeno.v17i4... .

In 2010, the World Health Organization (WHO) recognized interprofessional education and collaboration as an innovative strategy that plays an important role in mitigating the workforce crisis in global health⁷7 World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva: WHO; 2010. (Figure 1).

Although this issue is highlighted in the Guidelines of National Curricula (GNC) of undergraduate Dentistry, Medicine and Nursing courses in Brazil⁸8 Brasil. Ministério da Saúde. Ministério da Educação. Resolução CNE/CES nº 3/2014. Dispõe sobre as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Medicina. Diário Oficial da União. 6 Jun 2014.

9 Brasil. Ministério da Saúde. Resolução CNS nº 573/2018. Dispõe sobre as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Enfermagem. Diário Oficial da União. 6 Nov 2018.^-1010 Brasil. Ministério da Educação. Resolução CNE/CES nº 3, de 21 de Junho de 2021. Institui as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Odontologia e dá outras providências. Diário Oficial da União. 22 Jun 2021., it is not discussed sufficiently during the training of these professionals. Many professors are unaware of the GNC or the Course Pedagogical Project of their courses, just as of IPE initiatives. The process of change has occurred through initiatives such as the National Reorientation of Vocational Healthcare Training (Pró-Saúde)¹¹11 Brasil. Ministério da Saúde. Ministério da Educação. Pró-saúde: Programa Nacional de Reorientação da Formação Profissional em Saúde. Brasília: Ministério da Saúde; 2005., Education Program through Health Work (PET- Saúde)¹²12 Brasil. Ministério da Saúde. Ministério da Educação. Portaria Interministerial nº 421, de 3 de Março de 2010. Institui o Programa Nacional de Educação pelo Trabalho para a Saúde (PET-Saúde) e dá outras providências [Internet]. Brasília: Ministério da Saúde; 2010 [citado 10 Jun 2023]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/pri0421_03_03_2010.html
https://bvsms.saude.gov.br/bvs/saudelegi... , Multiprofessional Residency in Health¹³13 Miranda Neto MV, Leonello VM, Oliveira MAC. Multiprofessional residency in health: a document analysis of political pedagogical projects. Rev Bras Enferm. 2015; 68(4):502-9. doi: 10.1590/0034-7167.2015680403i.
https://doi.org/10.1590/0034-7167.201568... and integrative disciplines in graduation¹⁴14 Olsson TO, Dalmoro M, Costa MV, Peduzzi M, Toassi RFC. Interprofessional education in the Dentistry curriculum: analysis of a teaching-service-community integration experience. Eur J Dent Educ. 2022; 26(1):174-81. doi: 10.1111/eje.12686.
https://doi.org/10.1111/eje.12686... .

According to the Institute of Medicine, every clinical health professional should be able to cooperate, collaborate, communicate, and integrate care with other health teams to ensure that care is continuous and reliable¹⁵15 Ramaswamy V, Karimbux N, Dragan IF, Mehta NR, Danciu T. The status of interdisciplinary education in advanced education programs at U.S. dental schools. J Dent Educ. 2018; 82(11):1213-9. doi: 10.21815/JDE.018.126.
https://doi.org/10.21815/JDE.018.126... . It is necessary to implement teaching strategies in undergraduate courses that favor communication, exchange, and transdisciplinarity between different areas of health, which enable the promotion of individual and collective health¹1 Rajadurai S. Interprofessional clinical education in dentistry. Prim Dent J. 2021; 10(1):108-11. doi: 10.1177/2050168420980989.
https://doi.org/10.1177/2050168420980989... .

To implement an IPE, it is important to create accreditation standards for the programs³3 Grymonpre RE, Bainbridge L, Nasmith L, Baker C. Development of accreditation standards for interprofessional education: a Canadian case study. Hum Resour Health. 2021; 19(1):12. doi: 10.1186/s12960-020-00551-2.
https://doi.org/10.1186/s12960-020-00551... ; formulate curricula that incorporate the methodological bases of IPE¹⁴14 Olsson TO, Dalmoro M, Costa MV, Peduzzi M, Toassi RFC. Interprofessional education in the Dentistry curriculum: analysis of a teaching-service-community integration experience. Eur J Dent Educ. 2022; 26(1):174-81. doi: 10.1111/eje.12686.
https://doi.org/10.1111/eje.12686... ; establish institutional policies and administrative commitment; include IPE during the entire professional formation, not only in the begin of the course⁴4 Reeves S. Why we need interprofessional education to improve the delivery of safe and effective care. Interface (Botucatu). 2016; 20(56):185-97. doi: 10.1590/1807-57622014.0092.
https://doi.org/10.1590/1807-57622014.00... ; and incorporate IPE into education and health policies⁷7 World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva: WHO; 2010.^,1616 Freire Filho JR, Costa MV, Forster AC, Reeves S. New national curricula guidelines that support the use of interprofessional education in the Brazilian context: an analysis of key documents. J Interprof Care. 2017; 31(6):754-60. doi: 10.1080/13561820.2017.1346592.
https://doi.org/10.1080/13561820.2017.13... .

Health education in Brazil still places a lot of emphasis on interdisciplinary professional training and practice with multiprofessional action without introducing students to an interprofessional approach¹⁷17 Peduzzi M, Norman IJ, Germani ACCG, Silva JAM, Souza GC. Interprofessional education: training for healthcare professionals for teamwork focusing on users. Rev Esc Enferm USP. 2013; 47(4):977-83. doi: 10.1590/S0080-623420130000400029.
https://doi.org/10.1590/S0080-6234201300... . According to Prevedello et al.¹⁸18 Prevedello AS, Góes FSN, Cyrino EG. Interprofessional health education’s training in Brazil: scoping review. Rev Bras Educ Med. 2022; 46(3):e110. doi: 10.1590/1981-5271v46.3-20210006.
https://doi.org/10.1590/1981-5271v46.3-2... , the challenges pointed out by professors, preceptors, and tutors for the implementation of IPE learning in Brazil, may difficult due to the distance between the academic and work universes, or insufficient institutional support and adequate articulation teaching-service, compatible curriculum, and adequate academic training.

In their scoping review, Prevedello et al.¹⁸18 Prevedello AS, Góes FSN, Cyrino EG. Interprofessional health education’s training in Brazil: scoping review. Rev Bras Educ Med. 2022; 46(3):e110. doi: 10.1590/1981-5271v46.3-20210006.
https://doi.org/10.1590/1981-5271v46.3-2... observed that there was an increase in the number of Institutions introducing IPE in their courses in the health area, seeking to adapt them to the GNC, and transforming the training and qualification of professionals according to the demand of the population’s health and with the guidelines of SUS. They identified initiative in under graduated and post-graduated levels.

The perception and comprehension of IPE by professors is fundamental for understanding the difficulties and challenges that may occur in the implementation of an IPE.

It is worth noting that this study involves innovative methodologies, using online focus groups¹⁹19 Tuttas CA. Lessons learned using web conference technology for online focus group interview. Qual Health Res. 2015; 25(1):122-33. doi: 10.1177/1049732314549602.
https://doi.org/10.1177/1049732314549602... ^,2020 Kite J, Phongsavan P. Insights for conducting real-time focus groups online using a web conferencing service. F1000Res. 2017; 6:122. doi: 10.12688/f1000research.10427.1.
https://doi.org/10.12688/f1000research.1... . These new methodologies seem to be useful to researchers considering Web conference technology to carry out focus group data collection in qualitative research¹⁹19 Tuttas CA. Lessons learned using web conference technology for online focus group interview. Qual Health Res. 2015; 25(1):122-33. doi: 10.1177/1049732314549602.
https://doi.org/10.1177/1049732314549602... ^,2020 Kite J, Phongsavan P. Insights for conducting real-time focus groups online using a web conferencing service. F1000Res. 2017; 6:122. doi: 10.12688/f1000research.10427.1.
https://doi.org/10.12688/f1000research.1... .

Based on what was presented above, we present the guiding question of this research: “What is the professors’ perception about IPE in different courses in the health area?”

The objective of this study was to understand the interprofessional education, in the perception of professors, between different health courses of a public institution.

Methods

It was a qualitative study based on an online focus group, that were carried out addressing IPE in the health courses of a public institution in Rio de Janeiro. The meetings were held synchronously, through a web conferencing platform (Google Meet)¹⁹19 Tuttas CA. Lessons learned using web conference technology for online focus group interview. Qual Health Res. 2015; 25(1):122-33. doi: 10.1177/1049732314549602.
https://doi.org/10.1177/1049732314549602... .

This research was carried out with one of the largest educational institutions in Brazil, Federal University of Rio de Janeiro, with 16 courses in health.

Participants selection

Professors from three health-related courses of the target institution—Medicine, Dentistry, and Nursing—were invited to participate in the focus groups. Those three courses were selected because they are the most involved in the family health strategy, which is the basis of the SUS in Brazil.

Professors were invited to participate in the focus groups through a random selection. They were contacted by the researchers via e-mail explaining the purpose and method for carrying out the online focus groups. Upon confirming their participation, professors received a second e-mail with the Free and Informed Consent Terms and guidelines for the day of their scheduled meeting.

Each invited professor should be a member of the permanent teaching staff of the selected courses, teach clinical disciplines, have a master’s and/or doctorate degree, and have worked as a professor at the institution for more than three years. Professors involved in clinical area of each course were invited because patient care considers several aspects of the individual’s health, seeking to care for the patient, including the social determinants of the health-disease process.

Data collection

Video-recorded focus group interviews were undertaken with Professors from three health-related courses. Mixed focus groups were chosen as the method of data collection to facilitate a rich discussion among the courses. Furthermore, enabling participants to comment on and discuss the views expressed by someone from a different course²¹21 McKinlay E, Brown M, Beckingsale L, Burrow M, Coleman K, Darlow B, et al. Forming inter-institutional partnerships to offer pre-registration IPE: a focus group study. J Interprof Care. 2019; 34(3):380-7. doi: 10.1080/13561820.2019.1685476.
https://doi.org/10.1080/13561820.2019.16... .

The focus group researchers included a moderator, reporter, and reviewer. The focus groups were facilitated by experienced moderator using a semi-structured interview schedule to guide the discussion. The topics discussed are presented in Table 1. The questions were presented in the form of a pre-established script (Table 2). The script was developed and validated in a pilot study with three professors before its application in the study group. The pilot study participants were not included in the selection of participants in the focus groups.

The moderator was responsible for presenting the questions, guiding, and encouraging the professors’ participation so that everyone had the opportunity to speak. The reporter was responsible for recording the meeting and, later, for transcribing the reports. The reviewer was responsible for writing down relevant reports and opinions¹⁹19 Tuttas CA. Lessons learned using web conference technology for online focus group interview. Qual Health Res. 2015; 25(1):122-33. doi: 10.1177/1049732314549602.
https://doi.org/10.1177/1049732314549602... ^,2222 Abrams KM, Wang Z, Song YJ, Galindo-Gonzalez S. Data richness trade-offs between face-to-face, online audiovisual, and online text-only focus groups. Soc Sci Comput Rev. 2015; 33(1):80-96. doi: 10.1177/0894439313519733.
https://doi.org/10.1177/0894439313519733... .

The professors were identified by codes for the transcription process (P1, P2, P3…). The topics covered in the predefined script were discussed by the participants.

The focus group was used to debate issues and after transcribing this debate, an analysis of the content of the texts generated by the groups was carried out, emphasizing the most important points expressed by the participants²³23 Sweet C. Designing and conducting virtual focus groups [Internet]. Sysurvey; 1999 [citado 10 Jun 2023]. Disponível em: http://www.sysurvey.com/tips/designing_and_conducting.htm
http://www.sysurvey.com/tips/designing_a... ^,2424 Kitzinger J. Focus groups with users and providers of health care. In: Pope C, Mays N, organizers. Qualitative research in health care. 2th ed. London: BMJ Books; 1999. p. 20-9..

All meetings were recorded with the agreement of the participants. The groups were dissolved when enough information was observed, or the focus groups were ended when researchers obtained information saturation²⁵25 Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. Plos One. 2020; 15(5):e0232076. doi: 10.1371/journal.pone.0232076.
https://doi.org/10.1371/journal.pone.023... . “Saturation” is frequently mentioned in qualitative methodological discourse. Reviews reveal that this concept is often poorly specified and far from corresponding with the original meaning of this concept²⁶26 Carlsen B, Glenton C. What about N? A methodological study of sample-size reporting in focus group studies. BMC Med Res Methodol. 2011; 11:26..

Data analysis

The qualitative data were analyzed in two complementary moments: specific analysis of each group and cumulative and comparative analysis of the set of groups performed, as recommended by Tradd²⁷27 Tradd LAB. Focal groups: concepts, procedures and reflections based on practical experiences of research works in the health área. Physis. 2009; 19(3):777-96. doi: 10.1590/S0103-73312009000300013.
https://doi.org/10.1590/S0103-7331200900... . The purpose of this process was to identify the perception of professors in relation to interprofessional activities in courses, trends and challenges associated with the subject of study.

It was decided to describe the data collected in text format to be able to better explore the similar or opposed opinions of the participants, as well as highlight phrases said by them which is usually used for this kind of qualitative research.

Responses from pilot study participants were not included in the final study analysis.

The present study was submitted to and approved by the Research Ethics Committee (registration number 3.313.556). All participants were informed of the objectives, benefits, and risks of the research, and they read and signed the informed consent before participating.

Results

Four focus groups were carried out, with an average duration of 75 minutes each session, comprising a total of 5 hours and 7 minutes of discussion among the professors on the proposed subject. Ten professors from the three courses participated in the focus groups, two from the Faculty of Medicine, three from the Faculty of Nursing, and five from the Faculty of Dentistry. Figure 2 presents a scheme with the participants of each focus group carried out.

We must also emphasize that 25 professors were invited but did not attend the focus groups. Most of the refused or unanswered invitations were from professors from the Medicine course. Of the 14 invited professors of Medicine, only two chose to participate. Of the nine invited professors of Nursing, three participated, and of the 12 invited professors of Dentistry, five participated in the focus groups.

The results achieved with the questions/script mentioned in tables 1 and 2 will be presented below.

Common disciplines among health courses: All participating professors reported not having knowledge of mandatory disciplines that have interprofessional activities.

Some professors believed that there was interaction between students from the different health-related courses in basic cycle disciplines.

In this case, was observed that the professors’ believed that being present in the same room can characterize interprofessionality. Other professors believed that students took basic cycle disciplines together, but that there was no interaction between them. However, this is not the case, as each course offers the subjects separately to its own students.

All participants agreed that these interprofessional interactions in electives or extramural activities occur more as the result of the individual effort of each department, and not as an institutional norm. The professors also observed that, in some disciplines, there must be interprofessional action due to their integrative character, or because they work within clinics or hospitals with different professionals.

In Nursing, as students work directly with other health professionals within the hospital, there is interaction between these different areas.

The professors, despite having great experience in their courses, were not sure if they had interprofessional activities between their courses.

Interprofessional internship activities: Most of the participating professors worked, coordinated, or had already worked on internship projects involving students from different health courses.

They emphasize the importance of extra-walls activities, with the interaction between the professions for better patient and community care.

There are individual initiatives by some disciplines and professors, but interprofessionality is not regularly present in the pedagogical projects of the courses.

Interprofessional research activities: When asked about research projects involving students or professors from other areas of health, only one participant reported that all the research she developed was in this line of interprofessionality and involved undergraduate and graduate studies.

Social determinants in health planning: The importance of knowing social determinants was unanimous among the participants. All professors believe that future professionals need this knowledge to be able to define diagnosis and treatment.

Some professors reported thinking that students are being prepared to have this concern. They believe that some of the basic science subjects are intended to prepare students to observe social determinants in planning their patients’ treatment.

Other subjects in the professionalizing stage, according to the professors, also aim to prepare the student for understanding social determinants, where they are key concepts in the subject and the objective is for the student to understand an expanded concept of health.

A professor considered that the Faculty of Dentistry’s vision is still very technical.

A Nursing professor reported working in secondary care and receiving students for internship practice who, in most cases, are unable to scale this issue of social determinants and how it impacts the patient’s conditions.

In this topic there was a polarization in the professors` perception. Some believe that students can understand social reality, and others believe that they cannot.

Interprofessional activities during the COVID-19 pandemic: Most of the professors were not aware of collaborative activities or practices between the health courses during the pandemic. Some professors reported knowledge of volunteer programs, which worked to help inform the population about the virus and ways to prevent it.

Although most of the participating professors were not aware of interprofessional collaborative activities, some mentioned participating in collaborative projects to face COVID-19.

Discussion

Analyzing the responses obtained through the focus groups, it was observed that the professors believe that interprofessional education in the areas of health in higher education institutions enables students to learn and share their knowledge and to improve care and quality of treatment. This interaction requires the active participation of students through activities and/or methodologies in which students from different health disciplines are responsible for the exchange of knowledge²⁸28 Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016; 38(7):656-68. doi: 10.3109/0142159X.2016.1173663.
https://doi.org/10.3109/0142159X.2016.11... ^,2929 Morrell BLM, Cecil KA, Nichols AM, Moore ES, Carmack JN, Hetzler KE, et al. Interprofessional Education Week: the impact of active and passive learning activities on students’ perceptions of interprofessional education. J Interprof Care. 2021; 35(5):799-802. doi: 10.1080/13561820.2020.1856798.
https://doi.org/10.1080/13561820.2020.18... .

In contrast to what some professors reported, in the analyzed course, there are no common disciplines among the courses in the basic cycle. And they believed that the presence in the same room would be considered an interprofessional experience. To reach IPE, there are ways to have interaction between the subjects, mixing directed theory and practice, through discussions and interprofessional experiences and strategies for evaluating the ability of future professionals to work as a team¹¹11 Brasil. Ministério da Saúde. Ministério da Educação. Pró-saúde: Programa Nacional de Reorientação da Formação Profissional em Saúde. Brasília: Ministério da Saúde; 2005.. In addition, the availability of professors to develop IPE is also important, integrating it into learning objectives and assessment strategies³⁰30 King G, Shaw L, Orchard CA, Miller S. The interprofessional socialization and valuing scale: a tool for evaluating the shift toward collaborative care approaches in health care settings. Work. 2010; 35(1):77-85.^,3131 Almoghirah H, Nazar H, Illing J. Assessment tools in pre-licensure interprofessional education: a systematic review, quality appraisal and narrative synthesis. Med Educ. 2021; 55(7):795-807. doi: 10.1111/medu.14453.
https://doi.org/10.1111/medu.14453... .

In our study, it was also observed by many professors that these initiatives are generally individual efforts by professors or teams, offering elective courses, internship programs, research projects or activities outside the walls of the academic institution. IPE initiatives have been shown to benefit communities and student satisfaction with their lived experience, in addition to positively influencing the training of health professionals¹⁴14 Olsson TO, Dalmoro M, Costa MV, Peduzzi M, Toassi RFC. Interprofessional education in the Dentistry curriculum: analysis of a teaching-service-community integration experience. Eur J Dent Educ. 2022; 26(1):174-81. doi: 10.1111/eje.12686.
https://doi.org/10.1111/eje.12686... . Sharing this view with those authors¹⁴14 Olsson TO, Dalmoro M, Costa MV, Peduzzi M, Toassi RFC. Interprofessional education in the Dentistry curriculum: analysis of a teaching-service-community integration experience. Eur J Dent Educ. 2022; 26(1):174-81. doi: 10.1111/eje.12686.
https://doi.org/10.1111/eje.12686... , we noticed that our results did not include an institutional standardization implemented in the mandatory curriculum that leads the knowledge acquired in interprofessional experience to be explored and disseminated in more activities during a student’s professional training.

Institutions need to train future professionals to work as a team, understanding the social determinants and reality of the population, as reported by P4. With a real-world experience, students gain a different perspective of care. However, it was observed in some professors’ answers that in the daily life of health courses, there is a perceived lack of student knowledge and involvement regarding social determinants.

Social determinants of health are key concepts in the course and its objective is for the student to understand the expanded concept of health. Institutions need to train their future professionals to work as a team, understanding the social determinants and the reality of the population served³²32 Silveira JLGC, Garcia VL. Curricular change within dentistry: meanings according to the subjects of the learning. Interface (Botucatu). 2015; 19(52):145-58. doi: 10.1590/1807-57622014.0530.
https://doi.org/10.1590/1807-57622014.05... . This theme must be discussed from the first years of the training course, so that future health professionals recognize its importance from the diagnosis to the treatment plan of an illness or a problem situation.

The Brazilian public health service called SUS presents the Primary Health Care, as the most embracing health service in the country³³33 Brasil. Ministério da Saúde. Estratégia saúde da família [Internet]. Brasília: Ministério da Saúde; 2023 [citado 24 Jan 2023]. Disponível em: https://www.gov.br/saude/pt-br/composicao/saps/estrategia-saude-da-familia/
https://www.gov.br/saude/pt-br/composica... . Its conception is based on the Family Health Strategy which deals with interprofessional and intersectional approaches, however it seems that the health educational strategies still must consider it a lot further. Some experiences have shown the relevance of the IPE⁵5 Batista NA, Rossit RAS, Batista SHSS, Silva CCB, Uchôa-Figueiredo LR, Poletto PR. Interprofessional health education: the experience of the Federal University of Sao Paulo, Baixada Santista campus, Santos, Brazil. Interface (Botucatu). 2018; 22 Supl 2:1705-15. doi: 10.1590/1807-57622017.0693.
https://doi.org/10.1590/1807-57622017.06... ^,3333 Brasil. Ministério da Saúde. Estratégia saúde da família [Internet]. Brasília: Ministério da Saúde; 2023 [citado 24 Jan 2023]. Disponível em: https://www.gov.br/saude/pt-br/composicao/saps/estrategia-saude-da-familia/
https://www.gov.br/saude/pt-br/composica... .

In Brazil, since 2012, the quota regime was created to ensure that 50% of vacancies in public higher education institutions were allocated to students who came entirely from public secondary education³⁴34 Brasil. Presidência da República. Lei n° 12.711/2012, de 29 de Agosto de 2012. Dispõe sobre o ingresso em Universidades Federais e Instituições Federais de ensino médio técnico e dá outras providências. Diário Oficial da União. 29 Ago 2012.. This can influence the reality of students, and consequently, the perception of professors, improving their understanding of the determinants of health and disease.

Most of the participating professors reported not being aware of collaborative activities during the Covid-19 pandemic period. However, several actions were developed in the institution’s health units, such as telemonitoring of patients, vaccination, guidance to patients, among others. It is important to publicize these actions for the knowledge and participation of professors, students, and employees, showing a need for a better divulgation.

Santos et al.³⁵35 Santos GLA, Valadares GV, Santos SS, Moraes CRBM, Mello JCM, Vidal LLS. Interprofessional collaborative practice and nursing care. Esc Anna Nery Rev Enferm. 2020; 24(3):e20190277. doi: 10.1590/2177-9465-EAN-2019-0277.
https://doi.org/10.1590/2177-9465-EAN-20... , when looking at the IPE from the perspective of Nursing and Medicine students, verified the presence of stereotypes in relation to the colleague’s area which indicates the need for this pedagogical practice begins in the first year of graduation in the health professions.

The curricular structure presented by the undergraduate dentistry courses in Brazil, despite the governmental guidelines¹⁰10 Brasil. Ministério da Educação. Resolução CNE/CES nº 3, de 21 de Junho de 2021. Institui as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Odontologia e dá outras providências. Diário Oficial da União. 22 Jun 2021.^,3636 Brasil. Ministério da Saúde. Ministério da Educação. Resolução CNE/CES nº 3, de Fevereiro de 2002. Dispõe sobre as Diretrizes Curriculares Nacionais dos cursos de graduação em odontologia. Diário Oficial da União. 4 Mar 2002., is still a barrier to the implementation of IPE due to its segmentation³⁷37 Rossit RAS, Freitas MAO, Batista SHSS, Batista NA. Constructing professional identity in interprofessional health education as perceived by graduates. Interface (Botucatu). 2018; 22 Suppl 1:1399-410. doi: 10.1590/1807-57622017.0184.
https://doi.org/10.1590/1807-57622017.01... . Currently, IPE is mandatory in undergraduate dentistry courses in supervised internships, which comprise 20% of the total workload of dentistry courses¹⁰10 Brasil. Ministério da Educação. Resolução CNE/CES nº 3, de 21 de Junho de 2021. Institui as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Odontologia e dá outras providências. Diário Oficial da União. 22 Jun 2021.^,3636 Brasil. Ministério da Saúde. Ministério da Educação. Resolução CNE/CES nº 3, de Fevereiro de 2002. Dispõe sobre as Diretrizes Curriculares Nacionais dos cursos de graduação em odontologia. Diário Oficial da União. 4 Mar 2002..

Medicine and Nursing have governmental guidelines to structure their curricula⁸8 Brasil. Ministério da Saúde. Ministério da Educação. Resolução CNE/CES nº 3/2014. Dispõe sobre as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Medicina. Diário Oficial da União. 6 Jun 2014.^,99 Brasil. Ministério da Saúde. Resolução CNS nº 573/2018. Dispõe sobre as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Enfermagem. Diário Oficial da União. 6 Nov 2018. as well as Dentistry¹⁰10 Brasil. Ministério da Educação. Resolução CNE/CES nº 3, de 21 de Junho de 2021. Institui as Diretrizes Curriculares Nacionais dos Cursos de Graduação em Odontologia e dá outras providências. Diário Oficial da União. 22 Jun 2021. which the guidelines also guide the formation of a professional capable of acting in interprofessional activities.

Proposals for the implementation of IPE in health area courses require institutional changes: creation of mandatory subjects that provide interprofessional experience with different courses³⁸38 Saraiva AM, Silva IRG, Lolli LF, Fujimaki M, Alves RN, Miguel ERA, et al. Interprofessional discipline in health: assessment of dentistry students. Rev ABENO. 2018; 18(4):3-13. doi: 10.30979/rev.abeno.v18i4.598.
https://doi.org/10.30979/rev.abeno.v18i4... ; mandatory insertion of students in activities with collaborative practices in the public service from the beginning of the course and throughout training³⁹39 Batista N, Batista SHSS. Interprofessional education in the teaching of the health professions: shaping practices and knowledge networks. Interface (Botucatu). 2016; 20(56):202-4. doi: 10.1590/1807-57622015.0388.
https://doi.org/10.1590/1807-57622015.03... ; implementation of active methodologies with the participation of students from different courses in the health area³⁸38 Saraiva AM, Silva IRG, Lolli LF, Fujimaki M, Alves RN, Miguel ERA, et al. Interprofessional discipline in health: assessment of dentistry students. Rev ABENO. 2018; 18(4):3-13. doi: 10.30979/rev.abeno.v18i4.598.
https://doi.org/10.30979/rev.abeno.v18i4... , seeking an interprofessional approach to case resolution; the offering of inter professional internship projects; and partnerships to implement IPE²¹21 McKinlay E, Brown M, Beckingsale L, Burrow M, Coleman K, Darlow B, et al. Forming inter-institutional partnerships to offer pre-registration IPE: a focus group study. J Interprof Care. 2019; 34(3):380-7. doi: 10.1080/13561820.2019.1685476.
https://doi.org/10.1080/13561820.2019.16... .

In our study, only two Medicine professors participated, both work in primary care and have extensive experience in IPE. In our opinion, this lack of participation may reflect less interest of some professors in discussing interprofessionality. Correa et al.⁴⁰40 Correa CPS, Hermuche LS, Lucchetti ALG, Ezequiel OS, Lucchetti G. Current status of Brazilian interprofessional education: a national survey comparing physical therapy and medical schools. Rev Assoc Med Bras. 2019; 65(10):1241-8. doi: 10.1590/1806-9282.65.10.1241.
https://doi.org/10.1590/1806-9282.65.10.... found that medical schools perceive more difficulties in incorporating IPE and offered fewer mandatory courses, which can indirectly reflect and corroborate the fact that medical students are less open to IPE than others. However, seems to be clear that IPE is a strategy in public health care⁴4 Reeves S. Why we need interprofessional education to improve the delivery of safe and effective care. Interface (Botucatu). 2016; 20(56):185-97. doi: 10.1590/1807-57622014.0092.
https://doi.org/10.1590/1807-57622014.00... ^,2626 Carlsen B, Glenton C. What about N? A methodological study of sample-size reporting in focus group studies. BMC Med Res Methodol. 2011; 11:26..

The participation of Nursing professors was greater because it is a profession that already includes interprofessional performance⁴¹41 Santos LC, Simonetti JP, Cyrino AP. Interprofessional education in the undergraduate Medicine and Nursing courses in primary health care practice: the students’ perspective. Interface (Botucatu). 2018; 22 Suppl 2:1601-11. doi: 10.1590/1807-57622017.0507.
https://doi.org/10.1590/1807-57622017.05... , where professors have experience and know the importance of these relationships between courses. In Dentistry, acceptance was also good, but the professors’ knowledge of the subject matter was a little more limited, showing that there is still a need for a greater emphasis on this approach in the course. Overall, many professors declined the invitation to participate.

We opted for the development of online focus groups due to the epidemiological crisis that is the Covid-19 pandemic. As the lack of interest described above, this can also have compromised the adhesion of the professors invited to participate in the focus groups, with the adaptation of class hours, remote teaching, and professorial overload. This fact was a limitation of our study. Although some studies recommend up to 12 participants in a focus group²²22 Abrams KM, Wang Z, Song YJ, Galindo-Gonzalez S. Data richness trade-offs between face-to-face, online audiovisual, and online text-only focus groups. Soc Sci Comput Rev. 2015; 33(1):80-96. doi: 10.1177/0894439313519733.
https://doi.org/10.1177/0894439313519733... , the researchers of this study decided to hold focus groups with a smaller number of participants to develop more detailed discussions about the chosen themes. Consequently, it was more fruitful to promote discussions on the proposed subjects with a small number of participants.

Abrams et al.²²22 Abrams KM, Wang Z, Song YJ, Galindo-Gonzalez S. Data richness trade-offs between face-to-face, online audiovisual, and online text-only focus groups. Soc Sci Comput Rev. 2015; 33(1):80-96. doi: 10.1177/0894439313519733.
https://doi.org/10.1177/0894439313519733... showed that the richness of data from an online focus group can be compared to that of a face-to-face focus group. One of the biggest advantages of synchronous online focus groups via web conferencing is the real-time participation of geographically distant people¹⁹19 Tuttas CA. Lessons learned using web conference technology for online focus group interview. Qual Health Res. 2015; 25(1):122-33. doi: 10.1177/1049732314549602.
https://doi.org/10.1177/1049732314549602... ^,4242 Matthews KL, Baird M, Duchesne G. Using online meeting software to facilitate geographically dispersed focus groups for health workforce research. Qual Health Res. 2018; 28(10):1621-8. doi: 10.1177/1049732318782167.
https://doi.org/10.1177/1049732318782167... . In relation to online text focus groups, an advantage is the possibility to see and hear all participants through cameras and microphones connected to the computer, allowing interaction between them. In our experience, we considered this methodology very useful.

Face-to-face focus groups are characterized by both verbal and non-verbal communication¹⁹19 Tuttas CA. Lessons learned using web conference technology for online focus group interview. Qual Health Res. 2015; 25(1):122-33. doi: 10.1177/1049732314549602.
https://doi.org/10.1177/1049732314549602... . It is possible for the moderator and his assistants to observe the facial and body expressions of the participants while another person is talking, either as a form of agreement or disagreement. This methodological characteristic may be impaired in online focus groups. Even though the participants had their cameras on, it was difficult for the moderator to observe this non-verbal communication.

Another limitation of this sort of study is that participants kept their microphones off to avoid interrupting another participant, and maybe the discussions between them may have been lost, as they were waiting to turn on their microphones and speak. This is an important feature of face-to-face focus groups¹⁹19 Tuttas CA. Lessons learned using web conference technology for online focus group interview. Qual Health Res. 2015; 25(1):122-33. doi: 10.1177/1049732314549602.
https://doi.org/10.1177/1049732314549602... , where participants can speak up for or against, generating a spontaneous and healthy debate for data collection.

Overall, at a national level, several efforts have been made to implement more interprofessional care in the Brazilian public system, through important public policies, suchs as: The National Program for Professional Reorientation in Health (Pró-Saúde) and the Education through Work for Health Program (Pet-Saúde) stand out, as a joint action of the Ministry of Health (MS) and the Ministry of Education and Culture ( MEC), aimed at bringing about change in the training of health professions, with a greater focus on their sustainability over the years⁴³43 Haddad AE, Brenelli SL, Cury GC, Puccini RF, Martins MA, Ferreira JR, et al. Pró-Saúde e PET-Saúde: a construção da política brasileira de reorientação da formação profissional em saúde. Rev Bras Educ Med. 2012; 36 Supl 1:3-4.; Programa de Residência Multiprofissional⁴⁴44 Rossit RAS, Santos CF Jr, Medeiros NMH, Medeiros LMOP, Regis CG, Batista SHSS. The research group as a learning scenario in/on interprofessional education: focus on narratives. Interface (Botucatu). 2018; 22:1511-23. doi: 10.1590/1807-57622017.0674.
https://doi.org/10.1590/1807-57622017.06... ; and continuing education programs.

Conclusion

According to the professors’ perceptions, the IPE is beneficial, however its implementation in the institution is a challenge for the teaching staff in different courses in the health area. IPE exists in individual initiatives made by groups or professors in the evaluated institution. They demonstrated the difficulties in implementing interprofessional methodologies, and that the pedagogical project must present several interprofessional opportunities throughout the courses involved. The results showed a need for IPE guidelines for academic health programs to better care for the Brazil’s population. Future studies on this topic may bring more important data for the creation of this guidelines.

Acknowledgments

The authors would like to thank the financial support provided by the following Brazilian funding agencies: National Council for Scientific and Technological Development (CNPq), Coordination for the Improvement of Higher Education Personnel (Capes), and the Federal University of Rio de Janeiro, for supporting this search.

References

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