Introduction

Influential reports from the early 2000’s on the prevalence of hospital preventable adverse events focused international attention on the urgency of improving quality in healthcare (Baker et al. 2004; Kohn et al. 2000; Thomas et al. 2000; Vincent et al. 2001). Quality in healthcare can be defined by the Institute of Medicine’s conceptualization of six domains: safe, effective, patient centered, timely, efficient and equitable (Institute of Medicine 2001). Quality improvement (QI) refers to improvements in one or more of these areas, often resulting from a range of systematic activities aimed at developing, implementing and evaluating small-scale interventions and the wider implementation of those demonstrated to be most effective (Baily et al. 2006). A premise of the QI field is that every healthcare professional is responsible for improvement activities (Berwick 2013; Institute of Medicine 2003). This has translated into a need for QI education programs to train all healthcare professionals, in addition to healthcare professional undergraduate learners, with the necessary knowledge and skills to contribute meaningfully to QI. Consequently, we have witnessed a significant growth in the number of QI education programs being provided as well as the development of QI competency frameworks (American Association of Medical Colleges 2019; Cronenwett et al. 2007; Royal College of Physicians and Surgeons of Canada 2015). QI education programs being developed have targeted participants from one or a number of healthcare professional groups (e.g., Gleason et al. 2019; Kaminski et al. 2012; O’Leary et al. 2019; Patrician et al. 2012). However, there has been limited exploration of both the professional dimensions of QI education, and the role of uni-, multi- or interprofessional educational approaches in QI (Patrician et al. 2012; Reeves et al. 2017). Further attention to the professional dimensions of doing QI, and, by extension, learning QI, would contribute to more deliberate, and theroetically-informed, planning of QI education.

Sociological theory of professions, and sociological work more generally, provides rich insights into the myriad ways in which professional cultures, socialization and hierarchies influence healthcare professionals’ quality and safety attitudes, knowledge and behaviours (Allen et al. 2016; Waring et al. 2016). As the visibility and significance of sociological work alongside mainstream quality and safety research and practice increases, the field of QI education would benefit from a similar form of theoretical exploration. Deepening our understanding of the ways individuals’ professions influence their QI understandings, expectations and behaviours, and the implications this has on the ways healthcare professionals experience QI education, supports the development of education programs that meaningfully address professional issues and tensions that is better aligned with workplace practices. These insights could inform interprofessional and multiprofessional education approaches in QI education. Interprofessional education, the term favoured in the interprofessional field by scholars and practitioners in this field, is defined as occurring when members of two or more professions learn with, from and about each other to improve collaboration and the quality of care. Multiprofessional education occurs when members of two or more professions learn alongside one another in parallel (Centre for the Advancement of Interprofessional Education 2017). Multiprofessional education is positioned as having different educational goals than interprofessional education, however recent research has demonstrated the potential for overlapping outcomes of these two approaches (Olson and Brosnan 2017).

In this paper, we report on the findings from a qualitative collective case study that examined the interprofessional and multiprofessional processes and outcomes of three QI education programs. In the following section we begin by outlining sociology of professions literature that provided a theoretical framework to this study. This is followed by a description of interprofessional versus multiprofessional education, how sociological theory has been previously used to examine these processes, and how this study is building upon this work.

Background

Theoretical framework: professional socialization, hierarchy and boundaries

In the past few years, scholars have brought attention to the large body of sociological work on QI topics that has typically existed outside mainstream QI research and practice (Allen et al. 2016; Cribb 2018; Waring et al. 2016). This work on matters such as organizational cultures and power dynamics in healthcare, provides theoretical and empirical accounts that allow for a deeper engagement with concepts commonly used in the QI field (e.g. culture, system) and a more thorough understanding of the processes and outcomes of the implementation of QI interventions. In this section, we review concepts from the sociology of professions literature, socialization, hierarchy and boundaries, and their relevance to QI in healthcare, as background to extending this work to QI education.

The notion of professional socialization has been most extensively studied in the context of medical trainees (Becker et al. 1961; Bosk 2003; Veazey Brooks and Bosk 2012) although it is relevant for all healthcare professions. Professional socialization is a process characterized by the acquisition of new knowledge and skills along with an altered sense of self, that results in learners coming to think, act and feel like a healthcare professional (Hafferty 2009; Merton 1957). Socialization transpires through multiple occurrences including exposure to formal, informal and hidden curricula, social interactions across multiple learning environments, and personal experiences and reflections on those experiences. This process has a large tacit component whereby group values, norms and behaviours are transmitted and reinforced through routine actions and interactions (Becker 1963; Haas and Shaffir 1982; Hafferty 2009; Light 1979). The eventual result is the learner taking on the role and status of a professional, including an acquisition of the language of the profession and how to act within professional power structures (Hafferty 2009). The ways in which healthcare professionals view, practice and, by extension, learn about QI, are intimately connected to these professional socialization processes (Farr and Cressey 2015; Liberati et al. 2016). This is demonstrated by research, largely focused on physicians and nurses, showing differing interpretations of quality and safety concepts such as error, risk and quality indicators, and variable attitudes towards common QI interventions such as checklists, protocols and care pathways, which affects their practices and interactions (Allen 2014; Dixon-Woods et al. 2009; Farr and Cressey 2015). For example, healthcare staff expressed varied interpretations of risk of catheter associated urinary tract infections that were shaped by their professional backgrounds, and which impacted their prevention practices (Harrod et al. 2013), and surgeons demonstrated resistance to written protocols, attributed to the value that their profession places on the skill to respond flexibly to the unpredictability of surgical work (McDonald et al. 2006).

While quality and safety discourses may differ across and within professional groups, power dynamics in health care may confer greater authority to one professional group’s discourses over others (Larson 1990). A professional group’s existence occurs in relation to the creation of boundaries with other groups (Lamont and Molnar 2002; Macdonald 1995). Medicine has historically occupied a dominant position in the healthcare division of labour, which has given the medical profession autonomy over their own work and the work of other clinical groups (Freidson 1988; Willis 1989). Professional hierarchies influence how healthcare professionals engage with a wide variety of QI practices. For example, this influence can be observed in the ways that surgical checklists actually get implemented in practice (Fourcade et al. 2012), in how nurses and junior medical staff make decisions about when to activate a rapid response system (Kitto et al. 2015), and in nurses’ difficulty leading improvements in quality of care despite completing leadership training (Martin and Waring 2013).

As Abbott noted though, professional boundaries are not static and professionals engage in ongoing activity to maintain, negotiate and expand the boundaries that define their group’s domains of activity (Abbott 1988; Nancarrow and Borthwick 2005). The extent to which professional boundaries are fixed or elastic depends on macro- (e.g. policy, education, technology) and micro- (e.g. clinical context, professional seniority, perceptions of teamwork and patient safety) level contextual factors (Liberati et al. 2016; Nancarrow and Borthwick 2005; Sanders and Harrison 2008; Xyrichis et al. 2017). For example, legislation which granted authority to nurse practitioners to prescribe has impacted on their interactions and boundaries with physicians (Lim et al. 2017). Alternately, differences in clinical settings, including patient acuity and nurse and physicians’ approaches to patient care, contributed to variability in physician-nurse interactions and professional boundaries across a neurology ward, neurosurgical ward and intensive care unit (Liberati 2017). Thus, although patterns of medical dominance continue to exist (Cooper et al. 2012), there is tremendous variability and fluidity of boundaries across and within professional groups. QI policies over the past twenty years have contributed to the shifting professional boundaries given that healthcare professionals’ roles have changed alongside the QI momentum (Noordegraaf 2015; Sanders and Harrison 2008; McGivern et al. 2015). These changes may be in the form of new professional roles and titles such as a new career pathway in academic medicine for clinicians in QI (Shojania and Levinson 2009), but also may be apparent by evolving patterns in day to day work performed, such as chief medical officers’ increased responsibility for quality and safety issues (Sonnenberg 2018) and nurses’ attention to bed management work, balancing quality of patient care and organization efficiency (Allen 2015). The possibilities for, and nature of, changes in professional QI roles vary within and across professional groups, contributing to varied opportunities for boundary negotiations and modifications.

Sociological approaches to interprofessional education

There has been an effort in the interprofessional field to differentiate between interprofessional and multiprofessional education, based on an understanding that they represent different educational processes. The interactivity that occurs between members of different professional groups with the goal of improving collaborative practice has been viewed as an essential feature of interprofessional education. Without the interactivity component, multiprofessional education is viewed as not having the same opportunity for impacting on interprofessional collaboration (Centre for the Advancement of Interprofessional Education 2017; Reeves et al. 2010). However, it is still important to identify the role that multiprofessional education can play in achieving educational outcomes. Furthermore, recent findings (Olson and Brosnan 2017) have raised the possibility of multiprofessional and interprofessional education approaches having overlapping outcomes. Sociology of professions provides a lens to understanding the myriad of professionally related issues influencing the planning, and range of outcomes, of an education program.

A small amount of scholarship has used sociology of professions theory to study interprofessional education, allowing for an understanding of the linkages between professional boundaries and power and participation in, and impacts of, an interprofessional education program. Baker and colleagues drew upon Witz’s model of professional closure to examine healthcare professionals’ participation in an interprofessional education initiative (Baker et al. 2011). Witz argued for the need to bring a gendered and structural analysis to the notions of professional projects, and put forward four strategies of occupational closure used by professionals to control professional boundaries and secure resources and opportunities to protect and advance their members’ interests (Witz 1990). According to Baker et al.’s findings, healthcare professionals’ participation and physicians’ lack of participation in interprofessional education could reflect their efforts to advance or protect their position in the hierarchy of professions, respectively. Olson and Brosnan (2017) used Barry et al.'s (2008) conceptualization of interdisciplinarity to study the process of interprofessional education through a focus on the relationship between knowledge, identity and professional power in an interprofessional education curriculum for allied health students. Their findings suggest that learning a shared curriculum in a multiprofessional way can contribute to the development of interprofessional practitioner identities that undermine traditional professional boundaries. Despite the impact of professional boundaries and hierarchy on experiences of interprofessional education, power and conflict do not tend to be explicitly theorized and positioned at the centre of these curricula (Paradis and Whitehead 2015). The topics of professional socialization, hierarchy, boundaries and workplace professional cultures require explicit attention in curricula to optimize the impact of interprofessional education on interprofessional practice (Brandt et al. 2018; Goldman et al. 2018).

In this study we build upon this earlier work using sociology of professions to study interprofessional and multiprofessional education, sensitizing ourselves to the varied issues identified in these studies: participation in the program, curricular content, and linkages between education and practice. We also are attentive to Olson et al.’s work that raises questions about the differentiation between interprofessional and multiprofessional education in achieving interprofessional goals. Based on their research noted above, multiprofessional education can affect professional socialization by contributing to a shared knowledge base amongst participants from different professional programs that transcends professional boundaries along with a questioning of professional hierarchies (Olson and Brosnan 2017). In this study we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to explore how both interprofessional and multiprofessional learning processes were occurring, and participants’ perceptions and experiences of them, in the QI education programs.

Methods

We used an interpretive qualitative collective case study methodology. A collective case study approach allows for an in-depth exploration from multiple perspectives of the complexity and uniqueness of a particular phenomenon in a “real life” context (Simons 2009). A collective case study was therefore appropriate for our study of QI education as occurring within three cases. In case studies, researchers make methodological decisions based on their epistemological standpoints (Crowe et al. 2011). We chose to use an interpretive qualitative approach, being attentive to participants’ understandings and experiences, including shared and divergent understandings and behaviours (Crowe et al. 2011). Given the exploratory nature of our study, as data collection and analysis progressed, we narrowed our focus of the studied phenomenon to two specific aspects of QI education: interprofessional and multiprofessional QI education; and project-based QI learning. Analysis of each of these involved attention to particular parts of our data and the use of different theoretical frameworks (Meyer 2001). The analysis of project-based learning in QI education informed by health professions literature on curriculum development, mentorship and experiential learning is the focus of another manuscript (Goldman et al. 2020). This paper reports on interprofessional and multiprofessional education using sociology of professions theory across the QI education programs. This research was approved by the Research Ethics Boards at the university and hospital where the research occurred.

Cases and setting

A collective case study design was used whereby more than one case is studied either simultaneously or sequentially to generate a broader understanding of the phenomenon of interest (Stake 2000). In our study, we had three cases, with each case being an advanced longitudinal QI education program, bounded by the time period of each program, its in-person physical learning space, and the social groups involved (e.g. learners, coaches etc.). These three cases were chosen because they are the three instances of advanced post-licensure QI training programs in our local academic context that provided both similarities and differences that allowed for meaningful study of QI education. The three collective case study programs are a: (1) Master Degree in Quality Improvement and Patient Safety; (2) Certificate program in Patient Safety and Quality Improvement; and (3) Hospital-based Quality Improvement Fellowship. Table 1 provides details of each program, outlining similarities (e.g. longitudinal, QI project as a core element and range of QI topics) and differences (classroom hours, program requirements, setting and title awarded). All three programs involved professionals and administrators with varied clinical and professional backgrounds. The Masters and Certificate programs have a competitive application process and anyone that meets the criteria are eligible to apply. The Fellowship is only for hospital employees and aligns with the hospital QI strategic plan. Fellowship program directors select clinical programs to participate and consult with managers regarding individuals to invite to participate in the program.

Table 1 Quality improvement education program descriptions
Full size table

Data collection and analysis

Case studies typically involve the collection of multiple sources of evidence to develop a more holistic understanding of the phenomenon (Crowe et al. 2011). We used interview, observation and documentary data collection methods. Data collection largely occurred between April 2016 and July 2017. The interviews and observations both occurred over this time period and informed each other. Given our aim to interview graduate learners, the timing of the Fellowship allowed us to interview the prior cohort as well as the group of learners that were observed. For the Certificate and Masters programs, graduate learners recruited for interviews differed from the group of learners observed.

JG conducted semi-structured interviews with learners, coaches, program directors and institutional leaders, to gain insight into their perceptions and experiences of the QI education programs. Potential interview participants were recruited through e-mail. All Fellowship program participants for the period 2015–2016 and 2016–2017, and Certificate and Masters’ program participants for the period 2014–2015 and 2015–2016, were eligible to participate in an interview. Following a purposive maximum variation sampling approach (Patton 2002), we aimed to interview learners representing a variety of professional, clinical and organizational groups and years of work experience. We interviewed all individuals who volunteered to participate. The Certificate and Masters’ participants who volunteered reflected our sampling goals, however we recruited a Masters participant who attended in 2016–2017 to interview one more person working outside of Toronto. We had difficulty recruiting from the Fellowship program and had fewer participants than planned. We invited all program directors and institutional leads identified as having a link to the program by the program directors to participate in an interview. We recruited coaches purposively to represent a variety of professional and QI training backgrounds. Informed consent was obtained from all those who agreed to be interviewed. The interview guides were adapted to the type of participant. The guide for learners included questions about professional backgrounds and roles in quality and safety, perceptions and experiences of the education program and learning with individuals from other professions, and the impact of the education on their professional QI practices in the workplace. We asked program directors, coaches and institutional leaders about the objectives, planning and implementation of QI education and coaching for learners representing varied professions. We conducted 58 interviews (mean 50 min, range 26–70 min) with 35 learners, 8 coaches, and 13 program directors/institutional leads (two participants were interviewed twice, as a participant and a coach). Learners were from the following professional groups: medicine, nursing, physiotherapy, occupational therapy, respiratory therapy, dietetics, laboratory workers, and health administration or graduate training. The majority of participants were interviewed in person at a private space in their workplaces (e.g. office, meeting room), with a small number (n = 7) of interviews conducted by telephone due to preference or geographical distance. Interviews were audio recorded and transcribed verbatim.

JG conducted observations of each QI education program (Green and Thorogood 2004) to support the attainment of an in-depth understanding of the phenomenon of QI education, including processes of interprofessional and multiprofessional education. She observed most of the Fellowship program sessions (March 2016–January 2017) and a sampling of topics and sessions for the Certificate and Masters programs (September 2016–June 2017), for a total of 135 h of observations. The observations were ethnographically-informed (Spradley 1979) whereby JG was attentive to details such as space, objects, people, interactions, activities, time, goals, and feelings. She recorded notes during the observations and transcribed them following the session, adding descriptive details and analytical interpretations. JG also collected relevant documents such as curricular outlines, course syllabi and classroom handouts.

We collected and analyzed data in an iterative approach. We analyzed the interview data through a movement back and forth between within-case and across-case comparisons. Analysis involved a process of immersion in all interviews to become familiar with the data, immersion in each interview, comparisons for particularities and commonalities within and across cases, and a return to the data (Ayres et al. 2003; Stake 2000). We used an interpretive thematic analysis (Braun et al. 2019) approach that involved stages of generating initial codes, searching for themes, reviewing themes, and defining and naming themes. The evolving coding framework and themes were informed by a conventional content analysis approach, being derived directly from the data, as well as by a directed approach, being informed by sociological literature on professional socialization, boundaries and hierarchy, and quality and safety (Hsieh and Shannon 2005). We reviewed observation notes and documents for data related to professional and interprofessional issues and analyzed them using the coding framework derived from the interview data; the data were examined for within and across-case comparisons, and in relation to ongoing interview data interpretation.

Data, method and researcher triangulation allowed for an exploration of the key issues, sociology theory of professions, and interprofessional and multiprofessional education in QI, through different perspectives (Flick 1992). The research team, that met over time to review and discuss data collection and analysis, included individuals with various roles related to leading and studying the curricula, clinical work, health professions education and/or QI research, and theoretical positioning in education and QI.

Results

The results are organized in three parts. In the first part we report on the multiprofessional aspects of QI education, where participants learn a shared curriculum. In the second part we describe the interprofessional aspects of QI education, where participants learn from and about each other. In the third part we report on tensions with both of these approaches. All three sections are informed by the sociology of professions concepts socialization, hierarchy and boundaries. The term ‘health disciplines’ refers to participants from physiotherapy, occupational therapy, respiratory therapy, dietetics, and laboratory. They are not specified to optimize anonymity due to the smaller numbers of these learners in the QI education programs.

Learning a shared curriculum

The three education programs were structured so that all learners experienced the same curriculum. In the Masters program, in addition to the core shared curriculum, learners chose two out of four electives that were exclusively for the Masters learners and/or an external practicum. Our findings highlighted the advantage of adopting a common curricular approach given the participants’ shared interests in some curricular topics, the opportunity to develop a shared QI language across professionals and the blurring of professional boundaries for quality and safety roles in some situations.

During the interviews, participants from multiple professional groups shared similar opinions regarding the importance of certain topics, as illustrated in the quotations below from a nurse and physician regarding learning the plan-do-study-act framework. These similar responses underscore the rationale for bringing healthcare professionals together to learn alongside each other.

The PDSA stuff was very good…I think that has been ingrained in my head, in terms of how we can have small sample sizes and it can run well, that kind of stuff was very, very helpful. (Nurse, Interview 38, Certificate course)

Largely, the Master’s program, to me, was an exercise in how to solve problems and they gave us great tools in how to approach small PDSA cycles and not getting bogged down in the clinical epidemiology approach. (Physician, Interview 18, Masters course)

Participants noted that a shared QI language and enhanced expertise in QI topics enabled them to participate in QI projects and committees in their workplaces which involved working with individuals from different professional groups and therefore across professional boundaries. Masters participants in particular described how their QI proficiency strengthened their QI credibility, which optimized their interactions with others on QI initiatives, particularly with individuals from other professional groups viewed to be in positions of power:

…it helped me a lot in terms of being able to do a project in a very structured way, and it made it so much easier to deal with…people like surgeons…because I brought that knowledge and education with me, they actually sit down in a meeting and listen to me…they’re willing to learn… (Nurse, Interview 17, Masters course,)

In some instances, participants, mainly from the Certificate and Masters programs, used the shared knowledge and credibility gained through the QI education programs in their re-negotiation of professional roles and boundaries. These participants reported that the knowledge and credentials gained were instrumental to their obtaining a hospital QI position that might not have traditionally been considered for someone from their profession, as noted in the following quote:

I know, historically, that (hiring a nurse) has been the hiring practice. So, I really had to be very strategic about that and really talk a lot about this course. (Health disciplines, Interview 37, Certificate course)

Interactive learning

The program directors for all three QI education programs used a variety of strategies to promote interprofessional interactions and learning, including adopting criteria to select leaners with varied professional backgrounds, and deliberate seating arrangement and facilitation approaches that encourage discussion among learners. Participants overwhelmingly commented on the value of being in a classroom with individuals from different professions to learn from and about each other’s perceptions and experiences of QI, with some discussing how they used these insights in their consequent quality and safety work.

The interactive learning amongst the participants was beneficial in two main ways. Firstly, participants gained a heightened appreciation for the varied perspectives that individuals had about QI, shaped by their professional backgrounds and socialization. This perception was shared across professional groups, as exemplified by the two quotes below from a physician and nurse:

…the work that I want to do will involve a lot of non-physicians, so I’m learning, and I learned, what they see through their experiences and through their background, which we don’t gain that thought process in medicine, really. It’s really a different way of thinking and it’s nice to be exposed to those individuals. (Physician, Interview 4, Certificate course,)

I’ve really limited opportunity to hear about the perspective of physicians…So the fact that we had all the trainees from medicine, as well as physicians from a variety of hospitals, and people from other types of roles, I thought was a very, very positive thing. (Nurse, Interview 3, Certificate course)

Secondly, participants valued other healthcare professionals’ input and feedback on their QI project work. These interprofessional discussions happened amongst the QI teams in the Fellowship where different healthcare professionals worked together over the course of the program. These interprofessional discussions also happened in the Certificate and Masters programs through small group project presentation and feedback sessions with learners providing input on each other’s projects. Participants described the various ways in which different professional perspectives were shared and were instrumental in providing different understandings that were critical to the planning of a QI project. These interactions included contributions to QI processes (e.g. fishbone diagram, process map), interpretations of quality and patient care, explanations for why an intervention may or may not succeed and insights about how QI initiatives may have conflicting goals. The composition of the class with learners with varied professional backgrounds also provided opportunities to practice networking and promoting one’s QI project to stakeholders. In addition, in the Fellowship, an interprofessional approach allowed for each member to contribute in ways afforded by their professional role to optimize the planning and implementation of the QI project.

When we were doing project work, for example, I could bring a little bit more of the nursing focus in… In our group, we had a physiotherapist, a couple of physicians, and a dietitian…you looked at all different aspects of a project in a situation…I would look at it as I’m always talking about caring and nurturing… (Nurse, Interview 23, Masters course)

A small number of participants described instances of using these new insights about the importance of understanding different professional perspectives in their quality and safety work back in their workplaces.

I recognize that in order for things to be fruitful and positive, they need to be derived from the group who is going to make a change. So, my first role, really, is to engage in a huge stakeholder engagement process around what the major issues are with care in our (clinical department name). And to include our nurses, to include our physicians, to include our clerks… (Physician, Interview 18, Masters course)

Tensions, power dynamics and disconnects

Our findings above demonstrate multiprofessional and interprofessional processes that were valued by the participants. However, we also found tensions with these learning processes. These included challenges with a common curriculum for all participants, the existence of power dynamics, and a disconnect between classroom learning and workplace practices.

Tensions with multiprofessional education

A common QI curriculum for all healthcare professionals had limitations because learners entered the programs with prior professional training and workplace experiences that affected the degree to which the curricula fit with their learning expectations, interests and needs. Depending on one’s proximity to academic training and workplace interests and opportunities, that were in turn influenced by one’s professional background and trajectories, participants may have had more or less prior exposure to relevant content areas such as statistics, LEAN principles or leadership training, which affected their knowledge needs.

I think there are some people that had done a ton of them (literature review) and then some people that had done very little of them…part of the challenge too is that you come in with clinicians with varying levels of experience. So what would be easy, like really simple and routine for one might be quite a bit bigger for another. It was a huge learning curve for me… (Health disciplines, Interview 58, Masters course)

Beyond simply having learned more about specific topics, professional backgrounds and socialization influenced the types of QI roles available to individuals and the QI and patient safety knowledge valued; these in turn influenced participants’ interest in particular topics. For example, individuals who worked in laboratory settings, whether as technicians or in leadership positions, spoke about their interpretation of patient safety in their workplace context:

there were some examples…I couldn’t really relate to it…especially sometimes when they talked about patient safety, a lot of the times they talked about being on the floor with the patient. I don’t see patients. For us patient safety is making sure we’re reporting the right result and number. Everything with that patient sample is accurate, right tube, right test. (Health disciplines, Interview 36, Certificate course)

The influence of professional backgrounds and socialization on types of QI work available to participants was particularly apparent for physician participants who largely spoke about their QI projects, being responsible for teaching medical trainees and publishing QI work that has local and broader impact; they were therefore keen to gain knowledge and skills in these areas. While a focus on these topics was viewed as essential to attracting physicians to the Certificate and Masters programs, this QI academic work was not within the professional roles and opportunities of many of the other participants. In contrast, for example, individuals in QI positions in primary care settings described the range of QI issues they were working on in their workplaces and therefore had different types of pressures and priorities as they worked to address regulatory quality indicators and support QI work relevant to a primary care context.

Participants described managing disconnects that occurred between their professional background, program expectations, and the curricular content. In some instances, these were sporadic incidents of not feeling like the material was relevant to their own professional role and having to work through it on their own to adapt it to their professional context. A smaller number of participants though expressed more significant disjunctions between the curricula and their own professional roles:

I think maybe something…directed towards physician leaders who, in addition to having to know a bit about the nuts and bolts of quality, also have to supervise junior faculty members who have this as a career choice….the fellowship did a nice job of laying out basic principles, but didn’t inform what I need to be able to do in my role as a division head. (Physician, Interview 41, Fellowship course)

The program directors talked about the challenges creating one curriculum for a range of healthcare professionals with varying levels of prior knowledge and skills who value different aspects of QI. For example, program directors described deliberations about what to include in a patient safety course as what might be essential learning for a surgeon, for instance, was not as relevant to other healthcare professionals or in a non-surgical context. They also noted during the interviews that they were reflecting on potential changes to future iterations of their QI education programs given these professional specific needs:

…it is extremely important that as an organisation, we continue to find ways to support ongoing learning and capacity-building around improving the care that we provide…I think that where we will really see a more significant impact is when we start to think about it from more of a role-based approach versus a general approach that we’ve been taking. (Program director, Interview 24, Fellowship course)

Power dynamics in interprofessional QI learning

Despite efforts by program directors to organize a curriculum that transcended professional boundaries, the power dynamics that exist in healthcare workplaces, where physicians occupy a position of relative power, were also operating in the QI education space. These power dynamics differed depending on the number of physician participants; in the Certificate and Masters programs, physicians made up 50% or more of participants, whereas the Fellowship had lower physician enrollment and attendance.

In the Certificate and Masters programs, there were tendencies towards privileging of a physician perspective. This might take the form of illustrative examples used in class, such as the case of a medical resident being apprehensive about calling a medical staff described to exemplify patient safety and communication. Alternatively, speakers might over-represent the medical perspective on QI and patient safety:

Oh yeah, like a lot of the content, sometimes we would get case studies in class that were very medical, had a lot of terminology that myself and another allied health professional had no exposure to. I found it helpful to be able to contribute in a more meaningful way when the physicians in our group were able to explain some of the content. As much as you were trying to focus on the QI, there was definitely the medical piece that you had to understand some of it in order to really appreciate the significance. (Health disciplines, Interview 58, Masters course)

I don’t know that I thought about it at the time, but I think it would have been helpful if at least one of the speakers had been a nurse. I don’t recall that they were. (Health disciplines, Interview 38, Certificate course)

The formal curricula of all three education programs afforded space to both engage in the systematic activities aimed at developing, implementing and assessing small-scale QI interventions, as well as learn about an array of other topics such as patient safety reporting, teamwork, and healthcare policy. Some participants perceived, though, that certain interpretations of QI knowledge and work, such as academic QI work, were being elevated and other more ‘operational’ QI work, such as patient safety incident reporting, were not receiving as much attention or were being marginalized. This valuing of different topics was described by participants during interviews and observations of informal discussions of their classroom experiences:

Referring to a teacher’s comment that was critical of the use of incident reports, the participant said: ‘Are you kidding me? That is what we use every day. I know that different hospitals have different cultures and different ways of reporting…they said I should be going to the wards and checking on those reports…that’s a research project…I don’t do research….’. (Observation, Masters, October 27, 2016)

Some participants described difficulties with voicing their opinions in what was perceived to be a physician- oriented learning environment, suggesting that the classroom setting had reproduced workplace hierarchies. Observations showed that teachers made efforts to encourage people with different professional backgrounds to speak. However, these efforts could be limited by, for example, guest speakers who may not be attuned to interprofessional power dynamics, or difficulties recognizing entrenched professional hierarchies:

We had a couple of general surgeons and a cardiologist in the program, like they’re living a completely different reality to us. Everybody could lend something to the discussion but at the end of the day, I even felt sometimes it was like just keep your mouth shut because the safety that they’re talking about is not the safety … it was almost like will their safety trump my safety that I deal with… (Nurse, Interview 47, Masters course)

It’s very intimidating when you’ve got an anaesthesiologist with 20 years’ experience and then you’ve got somebody who is a speech and language pathologist, who’s been working for two years. It’s very intimidating and it’s hard to manage as the mentor, to keep some people in line or speaking less, so that others can contribute more. But, for the others, it’s not just about contributing more. It’s about feeling like their contribution is meaningful… (Program director, Interview 31, Certificate course)

In the Fellowship program physician attendance was a problem, despite efforts to recruit physician participants. The findings suggest that their absence could be related to their perceptions of the education program not benefiting their professional interests. Therefore, while interprofessional tensions might not have been playing out in the classroom setting, their absence can be interpreted in relation to what QI knowledge and practices are valued for which professional groups.

The disconnect between curriculum and practice

The majority of interview participants spoke positively about their QI education programs. However, the findings indicated a disconnect for some between participants’ classroom and workplace experiences that relate to professional boundaries and hierarchies, and differing opportunities to apply their QI knowledge in their workplaces depending on professional background and role.

All of the curricula contained sessions on topics of leadership, teamwork, patient safety culture and communication in QI. The language being used to talk about these issues largely reflected more generic discussion of these concepts:

Other things I liked were a lot of the interpersonal stuff. I guess how to interact with your co-workers and how to approach a quality project. How you don’t always want everyone on your team to be on your side. You do want that one or two people to cause friction, because once you know that you can convince them or everything that they throw at you, you know it’s something that you will need to improve, you need to change. (Health disciplines, Interview 36, Certificate course)

Observations indicted that the intricacies of professional boundaries and power in the workplace were less commonly part of the curricula. These types of issues include entrenched professional patterns and hierarchies that impact on opportunities for interprofessional QI work and on QI practices. While these issues were not explicitly apparent in the formal curricula, participants’ interview data demonstrated that individuals grappled with them. These comments included remarks about structural barriers to nurses being involved in QI project work, the physician-centric message of physician engagement in QI, professional routines that impact on patient safety practices in workplaces and limited understandings of other professionals’ contributions to QI.

A number of participants, from across all of the QI education programs, expressed frustration with the extent to which they were able to apply their new knowledge and skills in their workplaces. Individuals from particular professional groups, such as physicians in academic hospitals with protected QI work time and individuals in leadership roles with formal QI responsibilities, described ways in which they were using the knowledge in practice. Despite some examples of movement across professional boundaries noted earlier, some participants, such as front line nurses, dietitians, occupational therapists and physiotherapists, described barriers to individuals in their professions changing the boundaries of their professional roles to engage in QI work.

Well, my job right now it’s 100% clinical….I wouldn’t say I get much of an opportunity to do QI day-to-day in the role I’m in now. I don’t even know what that would look like to be honest…If I wanted to do something like that, I would have to do it in my own time…. (Health disciplines, Interview 10, Fellowship course)

Challenges of applying knowledge to practice also existed for physicians who were working in hospitals where the boundaries between clinical and corporate QI were fraught with tension. The following quote reflects this strain as the participant recounts a hospital leader speaking to the class about its QI program:

One of the physicians in the room asked (leader from hospital) why didn’t you involve physicians and his answer to that was we didn’t think we had to. That in itself was quite telling. Most of us were quite unhappy with that response given that he was talking to a room where physicians were interested in quality improvement, that our involvement wasn’t required in any of what they were actually trying to do in the hospital. (Physician, Interview 51, Masters course)

Discussion

This collective case study provides insight to how professional socialization, hierarchy and boundaries are critical to understanding not only healthcare professionals’ quality and safety healthcare practices, but also their experiences of QI education programs. Distinguishing interprofessional and multiprofessional education may not be useful for privileging the former versus the later as leading to interprofessional outcomes (Olson and Brosnan 2017); however, conceptual clarity is essential for a more nuanced discussion about their role and effectiveness as education approaches (Mitzkat et al. 2016). In addition, our findings reinforce the need for further attention to the integration between QI education and professional workplace practices (Wong and Holmboe 2016).

Our findings suggest that multiprofessional QI education, where learners from different professional groups are brought together to learn about QI tools and processes, can improve capacity building in QI across professional groups and create a shared language that questions professional differences and transcends professional boundaries; these findings are similar to Olson and Brosnans’ (2017) findings that learning with students from other health professions blurred knowledge boundaries and challenged perceptions of power differences. Our study, though, focused on QI education, and in addition to common knowledge interests, the participants also described varied interests in topics given their past training and experiences. While the existence of different learning needs might not be unusual for an education program, the data illuminate that professional QI socialization, and education and workplace trajectories, influence prior exposure to and also valuing of topics, which are particularly pertinent for practicing healthcare professional learners. The Certificate and Masters programs were successful in recruiting physicians to their programs, in contrast to reported challenges of engaging physicians in QI (Zoutman and Ford 2017). This large representation of physicians can be attributed to the education programs catering to their learning needs and professional trajectories, amongst other factors. These findings provide direction for future planning of QI in a multiprofessional context; however, they also raise the question as to whether there is a role for profession-specific QI education. It could be argued that profession-specific QI may be needed for logistical reasons or for education that is dedicated to profession-specific QI roles or topics (e.g. pharmacists and medication reconciliation). Alternatively, it could be argued that the majority of QI issues are interprofessional in nature and therefore bringing healthcare professionals together to learn should always be a priority. Multiprofessional education that does take place needs to occur alongside a recognition of the potential for hidden curricula (Hafferty and O’Donnell 2014) that contribute to a hierarchy of QI knowledge and reinforce or create new professional divisions in QI practice, based on what type of QI knowledge and expertise are valued.

In contrast to a multiprofessional focus, our findings demonstrate that interprofessional education, defined as learning with, from and about other health care professionals, is characterized in three different ways in QI education: QI project work, learning about other healthcare professionals’ perceptions and experiences of quality and safety, and learning about teamwork and communication for QI. While our study did not explicitly focus on interprofessional QI project work, the data collected about this phenomenon suggest that an interprofessional approach could be useful, yet tensions can also exist in terms of willingness and availability to participate and opportunities to contribute given professional roles and hierarchies. A recent scoping review of QI teams concluded that, while interprofessional representation on QI teams is widely endorsed, it has been rarely explored why or how this representation contributes to QI success, and further research is needed (Rowland et al. 2018). All three education programs aimed to facilitate participants’ learning about each other’s perceptions and experiences of quality and safety, and taught about teamwork and communication for QI. However, similar to other IPE programs (Paradis and Whitehead 2015), there were missed opportunities to bring explicit attention to topics such as professional socialization, cultures and power that influence both healthcare professionals’ interpretations and activities concerning quality and safety, and how healthcare professionals interact in the pursuit of QI (Dixon-Woods et al. 2019; Mackintosh and Sandall 2010; Tarrant et al. 2016). Further than missed opportunities, there were undercurrents of professional tensions that influenced participants’ learning experiences. Future QI education planning could draw upon recommendations for interprofessional education planning concerning factors such as group dynamics, facilitation, creation of non-threatening learning environment and status conferred to this type of learning (Reeves et al. 2007), to the sociological literature on quality and safety (Allen et al. 2016; Waring et al. 2016), and to work on teaching themes such as power and culture in medical education (Kuper et al. 2017).

A third way in which professional issues are pertinent to QI education is that professional group membership influences the opportunities for learners to use QI knowledge and skills in their workplaces, given the different professional pathways afforded by professional and organizational structures. As noted by participants in our study, it could be difficult to move from a learning environment fostering an interprofessional QI model to a workplace that does not provide the same opportunity given professional and organizational structures that limit interprofessional QI leadership and work. This finding, again, echoes other interprofessional education research. Changing obstacles in the workplace, including embedded hierarchies, cannot be achieved through education alone (Kuper and Whitehead 2012; Reeves 2011). QI education can play an important role, though, in increasing learners’ awareness of the structures. Education leaders in healthcare organizations and education institutions can work together with organization and system level leaders to promote the conditions for QI in workplaces that addresses existing professional boundaries.

A collective case study approach provided the opportunity to gain insight into multiprofessional and interprofessional QI education due to both the consistent patterns and variability in which the themes identified presented themselves across the three programs. However, our study has limitations. Although this collective case study included three QI education programs, they are limited to one academic centre in Canada. This limits the transferability of findings, as the organization of QI education might differ in other geographical locations. The exploration of three programs with participants from a range of professional, clinical and organizational backgrounds, required a large sample, however it is possible that certain perspectives were not obtained through our data collection. In addition, our analysis focused on healthcare providers and administrators; the issues explored may play out differently at the training stage and in addition, there are likely intraprofessional issues also requiring attention. This study, however, begins to map out the varied details that characterize bringing different healthcare professionals together for QI education, setting the stage for further research and for the application of findings to education practice.

Conclusion

A decision about the use of a multiprofessional and/or interprofessional approach in QI education should be explicit and informed by an understanding of how health care professionals’ QI attitudes, understandings and practices regarding QI are influenced by professional socialization, power dynamics in healthcare and shifting professional boundaries and roles. These understandings have a role to play in both the selection of a multiprofessional and/or interprofessional approach and in the content taught, to support the impact of education on practice as well as the targeting of structural factors beyond the education setting.