Interprofessional Relationships for Work-Integrated Learning in Healthcare: Identifying Scope for Ongoing Professional Development

Interprofessional collaboration is an important aspect of delivering healthcare. However, helping students learn to work with other health professions continues to pose challenges. Students’ interprofessional relationships are an important aspect of learning to work with other professions. The complexity of educators’ interprofessional relationships is less easily recognised. Existing relationships between educators were the intentional foundation underpinning the development and implementation of a recent interprofessional workplace learning initiative over 18 months involving undergraduate students from speech pathology (n = 12) and nutrition and dietetics (n = 18) programs. As part of a larger collaborative inquiry, educators involved in the initiative explored the nature of interprofessional relationships involved in developing, delivering and participating in the initiative. The aim was to develop a deeper understanding of such interprofessional relationships in order to provide guidance for ongoing development of students’ and educators’ collaborative practice. Transcripts of five focus groups undertaken with students (n = 5), academic educators (n = 4) and clinical educators (n = 4) were compiled into a text set and interpreted using tools of philosophical hermeneutics. Findings of this study were iteratively dialogued with earlier findings of the collaborative dialogical inquiry to ensure “fusion of horizons” between studies. The three interpreted themes transcended professional affiliations: facilitating interprofessional mutuality, appreciating the multifaceted nature of “respect” and considering the visibility of interprofessional relationships. The themes highlighted the importance of educators’ ongoing development and understanding of interprofessional relationships as they help students learn to work with other professions. Based on a practice-based education framework, we pose reflective questions for educators to inform their ongoing development. We conclude that it is important for all those involved in healthcare education to embrace the responsibility of developing interpro-


Introduction
Collaboration between health professionals is receiving increasing attention and support as a means to address multiple challenges facing health care systems.These challenges include the growing number of people with complex chronic health conditions, fragmented healthcare services, increasing specialisation of health professions, the ongoing need for resource efficiency, and humanistic expectations for patient satisfaction and staff wellbeing (WHO 2010;Croker, Croker, & Grotowski, 2014).Interprofessional relationships are integral to collaboration in healthcare (Canadian Interprofessional Health Collaborative, 2010).However a number of barriers to developing such relationships have been identified, including "problematic power dynamics, poor communication patterns, lack of understanding of one's own and others' roles and responsibilities, and conflicts due to varied approaches to patient care" (Zwarenstein, Goldman, & Reeves, 2009: p.2).
Despite the recognised importance of collaboration and awareness of barriers to interprofessional relationships, health professionals tend to be educated in discipline-specific university and work-based learning programs.While discipline-specific health education programs are valuable for ensuring profession-specific competencies are achieved, they are often limited in offering opportunities for students to learn about other health care professions or to get to know others from these professions.Further, educators themselves may have experienced difficulties with collaboration in health care systems and bring these to their current educational role in academic or clinical settings.
Interprofessional education (IPE), "when two or more professions learn with, from and about each other to improve collaboration and the quality of care" (CAIPE, 2002) is a key strategy addressing the need to prepare students to work with other professions by facilitating interactions with students and educators from other professions.A range of IPE strategies are described in the literature including (but not limited to) shadowing of other professions, e-learning modules, and interprofessional groups of students involved in problem-based learning, small and large group discussions, and simulations (Abu-Rish et al., 2012).However, IPE strategies tend to be an "add on" rather than integrated into the education of health professional students.
Collaborative relationships between educators as they facilitate IPE strategies are important (Lindqvist & Reeves, 2007).However, the nature of such relationships is not necessarily made explicit in literature describing IPE strategies (Croker & Hudson, 2015).It can be argued that these educators may have experienced in their clinical practice the same collaborative difficulties that IPE is intended to address.The complex nature of educators' relationships tends to be alluded to in the literature rather than specifically described.
By addressing this gap in understanding how to help students learn to work with other professions, our recent research identified the importance of interprofessional collaborative relationships between students (Croker, Fisher, & Smith, 2015) and between educators (Croker, Smith, Fisher, & Littlejohns, 2016).These findings provided the impetus to understand more deeply the complexity of relationships in specific IPE strategies in order to investigate how these relationships can be explicitly developed.The study reported on in this article is centred on the interprofessional collaborative relationships involved in a recent work-integrated learning IPE (WILIPE) initiative.This innovative initiative intentionally built on academic educators' and clinical educators' established relationships within and between an academic setting and a health service organisation (Little et al., 2015).
The WILIPE initiative aimed to enhance interprofessional learning and practice opportunities between students enrolled in the undergraduate degrees of Nutrition and Dietetics and of Speech Pathology on concurrent clinical placements.In healthcare settings, as well as working with a range of other professions, these particular professions work closely in supporting people with feeding difficulties, hence the importance of students developing an understanding of how the professions interact.The development of the initiative relied on the existing, strong interprofessional relationships within and across academic and clinical settings.These relationships were facilitated by the close proximity of the University of Newcastle Department of Rural Health (UONDRH) to the health service organisation.During their professional practice placements students received curriculum support from academic educators as well as direct clinical supervision from clinical educators.The initiative was designed by academic educators in consultation with clinical educators to focus on common core competencies for professional practice in the domains of professionalism, teamwork and communication.The aim was for students to develop an understanding of the other health professionals' role, whilst achieving discipline-specific professional placement competencies.Topics of mutual interest to both professions formed the basis of student projects centred on the development of continuing education and quality improvement activities to inform healthcare practice.Additionally, opportunities such as cross-discipline shadowing enabled further interactions between students and staff.The initiative involved students from speech pathology (n = 12) and dietetics (n = 18) working together over a five week period, and has now run six times over the past 18 months.More recently it has been expanded to facilitate interprofessional practice between students from occupational therapy (n = 3) and nutrition and dietetics (n = 3).
Higgs' (2011) view of practice-based education provided a suitable conceptual framework for the WILIPE initiative.Locating interprofessional workplace learning as a practice-based education pedagogy enabled us to bring into focus the relationships and partnerships between universities and practice worlds and among the profession-specific groups of educators in both contexts.Higgs explains that supervised workplace learning "involves students learning through engaging in practice in real workplace 'placements' with formal or informal supervision by workplace educators and/or more experienced practitioners.…The educators or practitioners act as mentors and role models" (p.4).The framework also emphasises the contextualised nature of learning, the need for learning to reflect expectations of practice, and the importance of educators' role modelled behaviours being authentically grounded in "the expectations, norms, knowledge and practices of the profession" (p.3).
Into this practice-based education pedagogy framework we brought our specific focus on relationships between and amongst students and educators across the university and health service settings.In relation to the WILIPE initiative we sought to explore the relevance of the interpersonal behaviours identified during our ongoing research investigating how students learn to work with other professions.In particular we sought to explore the relevance for our initiative of: being interested in other professions; being inclusive of other professions; developing interpersonal connections with colleagues from other professions; bringing a sense of own profession in relation to other professions; giving and receiving respect to other professions; and being learnercentred for students' collaborative practice (Croker, Fisher, & Smith, 2015;Croker, Smith, Fisher, & Littlejohns, 2016).The research question we sought to answer was: "In relation to the WILIPE initiative, what is the nature of the interprofessional relationships involved in developing and delivering such an initiative?"The aim of the study was to develop a deeper understanding of the relationships involved in helping students learn to work other professions in order to provide guidance for ongoing development of both students' and educators' collaborative practice.

Method
Research approach: This study is part of an ongoing collaborative dialogical inquiry being undertaken at the UONDRH to explore how students learn to work with other professions.The four stages of collaborative dialogical inquiry, based on Bridges & McGee (2010), are (1) involvement of the research group; (2) cohesion of the research group; (3) immersion in issues for development of practice; and (4) consolidation of changed practice.This article reports on the third stage of the collaborative dialogical inquiry, immersion in issues for development of practice and considers implications for practice.Collaborative dialogical inquiry was chosen as a research method to enable co-production of knowledge between educators as researchers, and to ensure that issues explored were relevant to their practice.The underpinning assumptions of this choice were that educators have needs and scope for ongoing development of their practice, and that such development is a life-long undertaking.The collaborative dialogical inquiry group is composed of academic educators at UONDRH representing eight professions (in alphabetical order): diagnostic radiography (n = 2), medicine (n = 3), dietetics (n = 2), nursing (n = 2), occupational therapy (n = 2), pharmacy (n = 1), physiotherapy n = 3), and speech pathology (n = 1).The subgroup exploring interprofessional relationships in relation to the WILIPE initiative reported in this article were co-researchers from the professions of dietetics (n = 2) and speech pathology (n = 1).These co-researchers worked with the principal researcher (AC).
Data sources: The primary data sources were focus groups undertaken with students, with academic educators, and with clinical educators involved in the WILIPE initiative (see Table 1).Transcriptions of these focus groups were compiled into a text set for interpretation.
Interpretation of data sources: Informed by philosophical hermeneutics (Gadamer, 1976), text sets were interpreted using the tools of question and answer dialogue, hermeneutic circle and fusion of horizons.Our beginning horizon of understanding for the initial question and answer dialogue was based on the interpersonal capabilities and behaviours identified in our earlier research including: being interested in other professions, being inclusive of other professions; developing interpersonal connections with people from other professions; bringing a sense of own profession in relation to other professions; and giving and receiving respect to other professions (as per Croker et al., 2015, Croker et al., 2016).AC, with no responsibilities for staff or students, coordinated the running of the focus groups and interpreted the text sets.Questions posed by AC to the texts during iterative cycles of interpretation included: "What relevance do interpersonal capabilities and behaviours have for the ongoing development of interprofessional relationships?" and "How can their complexity be understood more deeply?"Emerging themes were explored with co-researchers.The existing relationships between co-researchers facilitated rich discussion about, and fine-tuning of, these emerging themes.During these iterative cycles of interpretation and discussion, new insights challenged our beginning horizon of understanding.Emerging findings interpreted from the WILIPE focus groups were also iteratively dialogued with text sets compiled earlier in the collaborative inquiry to ensure fusion of horizons with the parts (the WILIPE initiative text set) to the whole (all previous text sets compiled during the collaborative dialogical inquiry) (see Table 2).
Limitations: The difficulty in recruiting speech pathology students to participate in focus groups related to their smaller numbers and shorter term placements.The higher numbers of dietitian co-researchers was consistent with the staffing of UONDRH.
Ethics: Ethics clearance was obtained by the University of Newcastle Human Research Ethics Committee and the Hunter New England Human Research Ethics Committee.All data are securely stored and are reported anonymously.

Findings
The findings highlight the complexity of interprofessional relationships and their component parts.Ongoing development of interprofessional relationships for helping students learn to work with other professions tended to be framed as a worthwhile yet, at times, elusive goal.Interprofessional relationships were not static entities; they drew on the past, were used in the present and were valued for the future.Regular negotiation and problem solving was required in response to the dynamic nature of healthcare practice and health professionals' relationships, which in itself facilitated opportunities for continued evolution of these relationships.Interpersonal behaviours were confirmed as being relevant for the ongoing development of interprofessional relationships, in particular: being interested and inclusive of other professions, developing interprofessional connections with colleagues, bringing a sense of own discipline and giving and receiving respect to other professions (as per Croker et al., 2015, Croker et al., 2016).However beyond confirming the relevance of these interpersonal behaviours, three themes were interpreted that encompassed and extended the relevance of these behaviours for the ongoing development of interprofessional relationships: facilitating interprofessional mutuality, appreciating the multifaceted nature of "respect" and considering the visibility of interprofessional relationships.The themes transcend professions as well as roles of students or educators.For this reason, quotes chosen to illustrate the themes do not identify particular professions or collaborative situations.The roles of students and educators are identified, as the implications of themes were different in some situations for these different stages of ongoing development.Unless indicated, quotes from focus groups comprising the WILIPE text set were used to portray their relevance to the WILIPE initiative.

Facilitating Interprofessional Mutuality
There was a sense that learning to work with other professions was like a "two-way street" requiring contributions from both "sides" (although not necessarily in equal parts).The nature of these contributions was contextualised as interprofessional mutuality.Mutuality between people of different professions was both facilitated by, and the result of, intertwined interpersonal behaviours being interested in other professions, and bringing a sense of own discipline.A student expressed how intertwined interprofessional behaviours could be experienced: If a professional [from a different profession] is interested in a learning experience for me, then I feel like, they're inclusive of my profession so …I bring a more positive sense of my profession to that meeting, definitely.Because I feel like they show an interest and if people show an interest I'm going to feel more like I want to do a great job.(L3, student) At times interpersonal behaviours needed to be explicitly addressed to facilitate interprofessional mutuality, as described by an educator in relation to ensuring readiness for interprofessional learning projects.

Facilitators all need to be advocating for their own profession, because that's where the interest and the inclusiveness comes from. If you're not advocating for it, people don't know what to expect from the [particular profession]. (F17, clinical educator)
Once established, interprofessional mutuality could lead to ongoing positive interactions between students in the workplace.
I wanted her opinion, she wanted to know mine and we just …negotiated from there.(R2, student) However, facilitating interprofessional mutuality was not necessarily straightforward as the "other person" (for example another clinician) working with the student may not have the requisite interpersonal behaviours.

So say if you're communicating with an individual who may not utilise some of these [interprofessional]
qualities [when] they haven't made the student feel included, they weren't interested, they didn't listen.…So then you need to …get through to that other individual.And playing the politics, tapping into egos, it can be quite a complex game to play.(G4, clinical educator) Alternatively, students could be the "other" person disrupting interprofessional learning, depending on their interest in, and readiness for, engaging with IPE activities.

[The interest and inclusivity] between groups of students wasn't mutual. There was dissent among the ranks [of students of a particular profession] I think from the beginning [of the group project]. (R20, academic educator)
Dealing with such situations required interprofessional mutuality between educators.When "things went wrong" existing strong relationships and mutuality enabled conversations to be solution focused rather than being a "blame game".
In the discussions we've had recently [between our professions] about the recent difficulties [with a group of it's about what went wrong, not who's to blame although obviously there's discussion around what [issues have] contributed to this.(K7, academic educator) Established interprofessional mutuality was highly prized and considered worthy of protection.
We have a great relationship with [particular] department and it's been built up over many years and we make sure our students know that we're proud of that relationship because we don't want to lose it based on a 10 week placement.It could go wrong, yeah.It could be jeopardised.(A14, clinical educator) This theme identifies the interdependency of intertwined interpersonal behaviours and interprofessional mutuality.While interpersonal behaviours can be teased out for specific attention, considering them as intertwined may be more consistent with the direction needed for ongoing development of mutuality between people of different professions.

Appreciating the Multifaceted Nature of "Respect"
Respect was a valued element of interprofessional relationships.
[As educators from different professions] we already had the working relationships, the friendships, the professional stuff that we've shared.…we've got that respect for each other importantly.(R20, academic educator) However integral to its portrayal as a positive aspect of relationships was the multi-faceted nature of respect.Respect was viewed in a range of ways.On one hand it was associated with longevity of relationships.
We have a strong respect for each other's professions I would say and we have rapport and we've worked and we have time on our side.We've all worked together.We went to university together [LAUGHTER].We've worked together for years.(R9, academic educator) On the other hand, it needed to be present to in order to develop relationships.
So we try at the beginning of placements, we really drum into them that everyone is equal and that you will treat [particular person] with respect and you will treat the [particular role in healthcare] with respect, because we've had a lot of issues in the past.(A14, clinical supervisor) Importantly, the notion of respect was interdependent of other interpersonal behaviours: I find it hard to separate [being inclusive, developing interpersonal bonds from respect] to be honest.(G4, clinical educator) However there was benefit in it being broken down into observable parts to be explicitly facilitated in others.As such, valuing professional contributions was integral to educators and students feeling respected by people from other professions.
[However] I've found on numerous occasions that because of the lack of understanding of what our particular role may be and the subsequent at times disregard for our opinion, you have to build and chip away until you gain that respect, until they value your input.(G4, clinical supervisor) I think respect for me is acknowledging that my profession has a place that their profession is not necessarily covering.So for a [particular profession] to respect me, for me I need them to understand that we're in a position where we have the tools to deal with [a particular situation] and to a degree more so than them.(L3, student) Beyond valuing the contributions, understanding the constraints faced by the person as a member of the profession was an important aspect of respect, as expressed in the quotes below (re-interpreted earlier text sets).Such understandings, appeared to be gained from working with people from different professions over time, and enabled interactions to take into account others' competing responsibilities and moment-to-moment contexts.

I guess over time in that setting I've built up enough rapport with the [people of a particular profession]. I guess I know when the appropriate time is to go and talk to them. [K12, academic educator]
Understanding constraints faced by other professions enabled frustrating interactions and practices to be appropriately contextualised.
I guess if you're voicing frustrations [to students] about certain things …I always try and qualify something.… "Sometimes this can be difficult because of this," but not all of that profession are difficult to deal with.[K7, academic] Such understanding and contextualisation provided a basis for respectful interactions as students learned to work with other professions.
We [students and myself] would usually talk about that [the person and his or her context], "Who are you going to call and what do you think they're going to be doing at the moment, so how are you going to approach that?" (M8, clinical educator) While being intertwined with being interested, being inclusive and developing interpersonal bonds, respect can be viewed in relation to its component dimensions of valuing the contributions of other professions and understanding the constraints of other professions and the people within them.

Considering the Visibility of Interprofessional Relationships
Despite the importance of interprofessional mutuality and the multifaceted nature of respect for their interprofessional workplace learning, students were not necessarily aware of how their professions, or indeed how their educators, work with other professions.

"At no point before [the WILIPE initiative] did I know how involved [a particular profession] was [with the care of our patients] until we had the [interprofessional learning sessions] and one of the [educator's]
was "so we work together a lot" and I'm like "do we?" and then after a week on the wards I'm like "wow we do, how has no-one mentioned this before?".(R2, student) For some students, the WILIPE initiative was the first time they had seen educators' interprofessional relationships in play where the focus was specifically around IPE.
[Before the WILIPE initiative] I don't think we actually physically saw [educators' interprofessional relationships relating to education] but it doesn't feel like it doesn't happen.Does that make sense?I guess because the only opportunities we would actually see that would be in an [IPE strategy] or maybe in a tutorial (T3, student) Despite the lack of visibility the potential value of seeing educators' interactions was recognised.

I guess [educators interacting with other professions is] very much of a role model kind of thing that they do. I mean you only really see in an [IPE strategy], when you think about it to be honest. (M33, student)
Being privy to educators' interprofessional discussion provided students with another dimension to how educators worked together.

It was the first time I'd seen all those [educators] together discussing something and it was really interesting because they discussed it on a whole other level. …They were talking [amongst themselves].
There was a lot of discussion about interprofessional learning.Yeah and just seeing and that's when I realised…that they knew each other that well.I think that the rapport they have with each other [is] probably behind closed doors.(T3, student) Interestingly when students understood that value of interprofessional relationships, the subtleties of positive relationships became more visible, subsequently impacting on their own behaviour.

I feel like when I see someone on the wards, I mightn't be friends but I know them from the [shared accommodation]
, so probably more an acquaintance.We live in the same place, I'm quicker to go and talk to them …I just go ask them "do you know [something about the patient]"…I'm just a lot quicker probably because I know them, it's familiarity.I've seen our [clinical educator] do that.She'll be on the ward and she'll look for the nurse she knows to talk to over a [less familiar] nurse because although she already has the rapport and knows how respond.(R2, student) While role modelling positive relationships with other professions was valued by educators, it was not necessarily a practice that they were explicitly conscious of or reflected upon.
That we just do it [role modelling positive relationships] and I think it's, I don't know, I suppose we've been doing it for a while now.It's just second nature.(A14, clinical educator) To ensure that the interprofessional mutuality and multifaceted nature of respect continues to be part of ongoing learning for students and staff, consideration may need to be given to the visibility of educators' interprofessional relationships and the opportunities for students to develop them.Increasing the visibility of educators' interprofessional relationships may provide an impetus for, and a source of, "own" and "others" professional development.

Discussion
The findings of this research highlight the importance of taking a broad view of "what needs ongoing attention for professional development" and of "the life-long nature of developing interprofessional relationships".Collaborative practice is an important end point of IPE (Canadian Interprofessional Health Collaborative, 2010) and also forms part of the professional placement competencies for students studying speech pathology and nutrition and dietetics.However, beyond these elements, educators' interprofessional relationships were highlighted as also being worthy of explicit ongoing development.Framing this facilitation are the themes of: facilitating interprofessional mutuality, appreciating the multifaceted nature of "respect" and considering the visibility of interprofessional relationships.The findings encourage educators working with other professions to go further than seeking role clarity (as highlighted in Canada, 2010).Additionally, educators are encouraged to explicitly value the contributions of and understand the constraints of other professions and furthermore, consider how to make these behaviours visible to students.A primary focus on developing profession-specific clinical and technical skills of students may overshadow the development of interprofessional relationships and capabilities for collaborative practice.This is not to say that such development is not sought, but rather gives rise to issues worthy of consideration around the extent to which interprofessional relationships can be and should be deconstructed and overtly explored.Thus as students become clinicians, and clinicians become educators in clinical or academic settings, there is scope to explicitly focus on developing interprofessional relationships as an ongoing and life-long pursuit.The ultimate goal is to achieve effective collaborative healthcare practice.
Consistent with Higg's (2011) framework of practice-based learning, we highlight the importance of facilitating the development of students' and educators' interprofessional relationships across all learning environments.We argue that educators' interprofessional relationships within educational institutions need to be reciprocally supported by interprofessional relationships within health organisations, and vice versa.Such reciprocity would arguably enhance students' transition between different learning contexts, and provide rich opportunities for making educators' interprofessional relationships visible.Within the work-place context, developers of interprofessional strategies may need to incorporate explicit opportunities for students and for educators to explore and develop their relationships with other professions.Beyond being interested and inclusive of other professions, developing interpersonal connections with other professions, and bringing a sense of own profession in relation to other professions, they may need to ensure that the respect that is given and received is founded on valuing the contributions of other professions and understanding the constraints other professions face.We argue that there is potential for the development of interprofessional relationships to go beyond being part of student education, to continue to become an explicit part of ongoing professional development for health professionals.This ongoing focus on developing interprofessional relationships should continue as they become involved in helping students learn to work with other professions as clinical educators and as educators in academic settings.
Based on Higgs' (2011) model of practice-based education we pose in Table 3 a series of reflective questions for those developing and participating in interprofessional work integrated learning programs.As our findings transcended professional affiliations, we contend that these questions are of relevance to professions beyond those involved in the WILIPE initiative.The questions may be explored individually or collectively within individual professions or interprofessionally.
Locating interprofessional work-integrated learning in the broader context of practice-based education enabled relationships between students and between educators of different professions across and within university and healthcare organisation settings to be highlighted, and the complexity of interprofessional workplace learning embraced.Within this complexity there is scope for future research to explore contextually relevant ways for students and educators, over time, to facilitate interprofessional mutuality, appreciate the multifaceted nature of "respect" and consider the visibility of interprofessional relationships.

Conclusion
In the spirit of lifelong learning, it is important for all those involved in healthcare education to embrace the responsibility of developing interprofessional relationships across academic and workplace settings in an ongoing manner and not view the development of interprofessional relationships solely as the domain of students.We highlight the importance of educators engaging in interprofessional education practice that both reflects the authentic practice of the profession and encompasses appropriate role modelling of interprofessional behaviours.Resonance between the practice expected of students during workplace learning and the practice students experience from educators is also important.Ultimately an individual's transition between the development of interprofessional relationships as a student, health professional and, perhaps, educator, will be seamless and will be integrated into the life-long learning inherent in being a health professional.

Table 1 .
Data sources of WILIPE initiative text set.
1 Both professions were represented in each focus group.

Table 2 .
Data sources of text sets compiled earlier in the collaborative inquiry.

Table 3 .
Practice-based education and the ongoing development of students' and educators' interprofessional relationships.How do I/they/we make it visible to others that I am/they/we are being interested in other professions, inclusive of other professions, bringing a sense of my own profession, valuing the contributions of other professions and understanding the constraints people within other professions face when working and learning? How can I/they/we work with other educators to ensure that positive relationships with other professions are made visible?