1. INTRODUCTION
The World Health Organization (WHO) emphasizes the importance of interprofessional collaboration and education as healthcare services increasingly require team-based practice [1]. Stereotype, defined as “a set idea that people have about what someone or something is like, especially an idea that is wrong” [2], could be an obstacle to collaboration, to communication between all members of the healthcare team and negatively affect the care of patient [3, 4].
Interprofessional education (IPE) “occurs when two or more professions learn about, from each other to enable effective collaboration and improve health outcomes” [1]. WHO acknowledges that IPE is an effective intervention to increase collaboration among health professions students, which enables a future collaboration-ready workforce. IPE helps students to cooperate with each other as a team and helps students understand their and others’ roles and responsibilities [1]. There have been studies on healthcare student stereotypes to find methods to enhance interdisciplinary collaboration for future healthcare workers because most healthcare students tend to rate their profession more positively than others’ [5-8]. If a stereotype is based on inaccurate perceptions, it can negatively impact group interactions [5, 6]. Changing stereotypes about the healthcare profession is necessary to ensure high quality patient care [1, 9-15]. It is especially poignant about nursing profession as many healthcare students do not fully appreciate the role of nurses in the modern healthcare team [16]. A study found that some students believed that the role of nurses was mainly to support doctors [15].
On stereotypes about nursing in Vietnam, the Ministry of Health and the Vietnam Nursing Association have affirmed that the roles and responsibilities of nurses include giving independent nursing care of patients, along with collaborating with doctors and other healthcare workers [17, 18]. Vietnamese people and healthcare professionals tend to hold the stereotype that the sole role of nurses in the healthcare team is to follow doctors’ orders [19]. Nurses are still regarded as assistants to doctors, as illustrated by how the Vietnamese classification list of occupations still uses the designation “Y tá” (doctor’ assistant in Vietnamese) for nurse [20-22]. Stereotypes about nursing could hamper communication and cooperation between nurses, the biggest shares of healthcare workforce, and other healthcare professionals [23]. Notably, a recent study found that half of the healthcare students thought that only doctors treated illnesses and saved patients’ lives [24].
Vietnam’s health system is increasingly recognizing the importance of interprofessional collaboration and education. The University of Medicine and Pharmacy at Ho Chi Minh City (UMP-HCMC) was the first health sciences university in Vietnam to launch an IPE course in 2019. From workforce building and education perspective, understanding and transforming student stereotypes about healthcare professions will prepare future healthcare workers to better understand the other healthcare professions, and to respect and to collaborate with others to protect the interests of patients [25, 26]. This is especially true for stereotypes about nursing; however, this topic is not fully clarified in Vietnam.
This study aimed to assess healthcare students’ stereotypes about nursing, and to explore factors affecting student stereotypes about nursing.
2. MATERIALS AND METHOD
This cross-sectional survey was conducted at UMP-HCMC. The university is a major health sciences university located in the southern region of Vietnam and provides healthcare workforce for the region and other parts of the country. The university is the home to about 15,000 students and has seven faculties including Basic sciences, Medicine, Pharmacy, Dentistry, Public health, Traditional medicine, Nursing and medical technology.
The university organizes five consecutive IPE courses each school year. Each course takes place one day per week and lasts eight weeks. Each course enrolls approximately 200 students, who are grouped into 24 groups with similar structure. Each group has seven to nine students, including one third-year nursing student, one third-year rehabilitation therapy student, three fourth-year medical students, and three fourth-year pharmacy students. The group structure is formed based on the number of enrolled students in each profession program. The reporting of this study was done in accordance with the CROSS checklist [27].
The study invited students to answer an online survey one week before the start of the IPE course in September 2020. Students were included if they had never participated in an IPE course and if they agreed to participate in the study. Students were excluded if they had not filled in the questionnaire within the survey time.
With no previous similar study in Vietnam, we used the reported standard deviation of student perception about nursing in an American study [26], which included 528 interprofessional students with similar health professions, for sample size calculation. With the expected standard deviation of 4.7, our study aimed to recruit at least 85 students to get a confidence level of 95% and estimation error of 1 point. Since each course had about 200 students and was divided into groups with similar size and structure, we used stratified random sampling to select randomly 12 groups out of 24 groups. We used the RAND function in Excel to select the groups randomly.
We sent an invitation email to the students’ university email address. Upon accessing Microsoft Forms survey link, students were prompted to indicate whether they agreed to complete the survey before reading the actual survey questions. If they chose the “Disagree” option, the survey would automatically end, and no data was collected. We collected demographic information including age, gender (male, female), ethnicity (Kinh, other), professions (nursing, rehabilitation therapy, medical, pharmacy).
Attitudes toward interprofessional education were assessed using RIPLS, the version developed by McFadyen et al. in 2005 [28]. The instrument was first created to assess whether the students were ready for interprofessional education event, but later used to assess students’ interprofessional attitude in general. The RIPLS has 19 questions with four subscales, including nine items about Teamwork and collaboration (Q1-Q9), three items about Negative professional identity (Q10-Q12), four items about Positive professional identity (Q13-Q16), and three items about Roles and responsibilities (Q17-Q19) [27]. Each item is on a 5-point Likert scale, ranging from 1 (Strongly disagree) to 5 (Strongly agree). Negative professional identity (Q10-Q12) and Roles and responsibilities (Q17-Q19) items are negative statements: a lower score shows more favorable attitude toward interprofessional collaboration and education. The scale has shown good reliability [28], and good internal consistency [13].
Student stereotypes about nursing were assessed using SSRQ, an instrument developed by Ateah et al. in 2011 [29]. The questionnaire includes nine questions about academic ability, leadership ability, ability to be a team player, ability to make decisions, ability to work independently, professional competence, interpersonal skills, practical skills, and confidence. Students answered each question by marking one response on a 5-point Likert scale, ranging from 1 (very low) to 5 (very high). When students had little or no knowledge regarding a characteristic of a profession, they can select “Do not know” for each question. Higher scores represent more positive perceptions. The SSRQ has been validated and widely used in various settings and countries [7, 26, 29-32].
Both SSRQ and RIPLS were translated to Vietnamese and validated according to WHO guideline by a researcher team at UMP-HCMC in an unpublished study (Supplement). For both instruments, mean scores were interpreted as follow: from 4.0 and above was high; from 3.5 to 3.99 was mid-range, and from 3.49 and below was low [6, 7, 29].
We used Microsoft Excel for data management and STATA 10.0 for analysis. Gender, ethnicity, and profession were reported as frequency and percentage when appropriate. Age, total score, and item-scores of SSRQ, total score, subscale-scores, and item-scores of RIPLS were reported as mean and standard deviation. The “Do not know” option in SSRQ was coded as 1-point [33]. For RIPLS, the answers for items Q10–Q12 and Q17–Q19 were reversely scored before adding up to the total score, as was done by McFadyen et al. [28]. Descriptive statistics for individual items were presented using the original scaling.
One-way analysis of variance (ANOVA) or Kruskal Wallis test was used to compare the mean difference in scores of SSQR and RIPLS among groups when appropriate. We used univariate linear regression to explore the association between SSRQ scores (dependent variable) and other factors (independent variables), including age, gender, ethnicity, profession and RIPLS total score. All analyses were done with confidence intervals of 95% and p-value less than 0.05.
This study was approved by the Ethics Committee of UMP-HCMC (Approval No. 852/HĐĐĐ-ĐHYD). Students gave informed consent before data was collected. The data were de-identified before analysis by a non-instructor researcher. Whether the students participated did not affect their performance evaluation in the course.
3. RESULTS
We sent invitation emails to 102 students from the 12 randomly selected groups. Ninety students gave informed consent and completed the survey. The response rate was 88%. Students, who did not respond, reported overlooking the invitation email or forgetting to respond in time. The characteristics of participants were described in Table 1.
The Readiness for Interprofessional Learning Scale showed good internal consistency (Cronbach alpha = 0.84) in the study. The total score of 19 items was 80.2 ± 7.2, ranging from 62 to 95. No statistically significant difference was observed between students in different professions. The total scores, subscale-scores, and item-scores of RIPLS by professions were reported in Table 2.
Subscale mean scores for Teamwork and collaboration and Positive professional identity subscales were 4.4 ± 0.5 and 4.2 ± 0.5 respectively, both above 4.0. Subscale mean scores for Negative professional identity and Roles and responsibilities subscales were respectively 1.8 ± 0.8 and 2.5 ± 0.8, whereas reversed scores were respectively 3.2 and 2.5.
Mean score for item Q17 “The function of nurses and therapists is mainly to provide support for doctor” was 2.5 ± 1.2, which was below 3.5 threshold. Numerically, nursing students disagreed with this statement more strongly than other health professions. However, this difference was not statistically significant.
The Student Stereotypes Rating Questionnaire showed good internal consistency (Cronbach alpha = 0.84). The total mean score of nine items was 37.1 ± 4.0, ranging from 28 to 45. No statistically significant difference was observed between students in different professions. The total scores and item-scores of SSRQ about nursing, in all students and by professions, were reported in Table 3.
The SSRQ item mean scores ranged from 3.8 to 4.5. The top three items were Practical skills (4.4 ± 0.5), Interpersonal skills (4.3 ± 0.7), and Ability to be a team player (4.3 ± 0.6). The middle three items were Academic ability (4.1 ± 0.7), Professional competence (4.2 ± 0.6), and Confidence (4.2 ± 0.7). The three least rated items were Ability to make decisions (3.9 ± 0.7), Ability to work independently (3.8 ± 0.8) and Leadership skills (3.5 ± 1.0). Numerically, nursing students rated nursing profession higher than students of other professions in 8 out of 9 items.
Univariate regression analysis results were described in Table 4. There were no association between SSRQ total score and demographic variables including age, gender, ethnicity, and profession. The analysis found an association between SSRQ total score and RIPLS total score (Coefficient 0.25, 95%CI: 0.15; 0.36, p<0.01), which means that the SSRQ score nursing increased by 0.25 points with every point of increase in RIPLS total score.
4. DISCUSSION
The participant age, gender and ethnicity characteristics were typical for mid-training healthcare students in urban Vietnam. The students were younger compared to western studies since they went directly to health professions training directly from high school in Vietnam [29]. There were more female students in health sciences university, especially in nursing. Most students were of Kinh ethnicity, the ethnic majority in Vietnam, and less than 10% were of other ethnicities. Our population was generalizable to other mid-training healthcare students in Vietnam, especially at urban health sciences universities [34, 35].
The total mean score of RIPLS was 80.2 ± 7.2, which meant an average score of 4.2 points per item. This finding was higher than of an Indonesian study by Lestari E et al. (2016) including 248 medical, nursing, midwifery, and dentistry students with a total score of 68.5 ± 6.1 [36]. However, the finding was lower than the result of a Saudi Arabian study by Alruwaili A et al. (2020) including 233 undergraduate interprofessional healthcare students with a score of 86.8 ± 11.6 [14]. This finding showed that students had a favorable attitude toward interprofessional collaboration and education and were ready for an IPE course. However, there might be a gap between the baseline interprofessional attitude in Vietnam and other developed countries.
Subscale mean scores for Teamwork and collaboration and Positive professional identity subscales were both high in our studies. These scores showed that healthcare students had a willingness to cooperate and work in a team and were open to shared learning experiences. The results were similar to previous studies conducted on healthcare students [13, 37, 38] and on practicing health professionals [39]. However, the Negative professional identity and Roles and responsibilities subscales in our study had reversed scores of 3.2 and 2.5 respectively, both considered low or less favorable attitude. The finding was similar to that reported by Al-Shaikh et al (2018) when healthcare students might have thought that the patient’s problems should be solved within each profession [15].
The Roles and responsibilities subscale had the lowest reversed score in our study, of only 2.5. The less favorable subscale score might be due to the lack of clinical exposure at the time of survey. As a pre-course survey, the results showed that the students might need more collaboration opportunities to know the role and responsibility of different professions. This result might help educators to strengthen the provision of knowledge on the roles and responsibilities of each profession in interprofessional collaborative practice.
Notably, the item Q17. The function of nurses and therapists is mainly to provide support for doctors had an alarmingly low score of 2.5. The result was similar to that of the study by Al-Shaikh et al (2018) where both medical and dental students thought that function of nurses was only to support doctors [15]. This problem was also previously reported in Vietnam where healthcare students did not fully acknowledge the roles and responsibilities of nurses [37]. Numerically, nursing students disagreed more strongly with this item than students of other professions, which could suggest the self-acknowledgement of their own profession.
Total mean score of SSRQ about nursing was 37.1 ± 4.0, which meant an average of about 4.1 points per item. According to our pre-determined thresholds, the score was high and showed that nursing was highly regarded by the respondents. The result was higher than that of a study by White et al. including 22 undergraduate public health students with a total SSRQ score of 32.7 ± 11.4 [32]. However, the result was lower than of an American study including 528 students from six different professions with a total SSRQ score of 39.5 ± 4.7 [26]. The observed differences might be due to differences in student populations.
Even though nursing was highly regarded by healthcare students in our study, looking at the item-scores revealed a more nuanced picture of nurses. Out of nine, six item-scores were above 4.0 and considered high (Table 3). These results were similar to those of a study by Ateah et al. with scores ranging from 4.5 to 4.8 [29], and a study by Hean et al. with mean scores ranging from 4.2 to 4.5 [7]. Like in other countries, the results showed that healthcare students in Vietnam had appreciation for nurses’ qualities: good practical skills, professional competences, confidence; effective communication and collaboration skills; and good academic ability.
However, the students rated the ability to make decisions, ability to work independently, and leadership ability of nurse only average. Notably, the leadership ability of nurses was only rated as 3.5. The results were similar to that of a Canadian study by Ateah et al. where the three items were also rated as average, ranging from 3.8 to 3.9 [29]. These results might be due to traditional model of healthcare team where nurses and other team members heavily depends on physicians. It is still common perception and practice that nurses work and follow physician orders in Vietnamese healthcare system. Instead of nurses, the doctors dictate the level or form of nursing care for the patients. In response to this, Vietnamese regulations have recognized more the importance of the nurse’s roles and responsibilities as a healthcare profession in its own right, not simply an assistant to doctors [20, 21]. Nurses have been trained with a higher level of professionalism. They are expected now to assess the patients, make nursing diagnosis, discuss and implement management plan with other healthcare team members. The stereotypes that nurses have lower ability to make decisions, ability to work independently, and leadership ability could be a barrier for them to share their professional opinions and actively engage in healthcare team activities. The results were meaningful for health profession educators and suggested that IPE course should give nursing students opportunities to show and develop their abilities in these domains, especially the leadership ability.
Numerically, nursing students assessed about nursing (auto-stereotypes) higher than other healthcare students (hetero-stereotypes), across total scores and most item-scores. In addition to the finding of Q17 item of RIPLS, this pattern further suggest that nursing students had self-acknowledgement and were proud of their profession. Previous study also showed that students tended to rate their own professions higher than students of other professions do [5-8].
We found no association between SSRQ total score about nursing and demographic characteristic including age, gender, and ethnicity. Notably, the analysis found a statistically significant association between SSRQ total score and RIPLS total score. We hypothesized that students who had more favorable attitude toward interprofessional collaboration and education would also have more positive stereotypes about nursing. Further studies are needed to better understand which subscales or domains of RIPLS have the strongest association with student stereotypes. This finding also suggested the importance of an IPE course on student interprofessional attitude and stereotypes. A study has shown that an effective IPE program could help students feel more willing to engage in interprofessional collaborative activities [40]. For students with less favorable interprofessional attitude, educators should provide information on the roles and responsibilities of nursing in the interprofessional healthcare team through simulations to reduce stereotypes and increase students’ respect for nursing profession [41]. More studies are warranted to better understand how IPE could transform student interprofessional attitudes and stereotypes, especially about nursing.
This cross-sectional study had certain limitations. First, even though minimum sample size was met, a larger sample size could increase the results’ certainty. Future studies should include more nursing and rehabilitation therapy students to achieve a more balanced population. Second, the study could not address other potential factors affecting students’ responses on interprofessional attitude and stereotypes about nursing. One such factor could have been the growing social expectation that valued teamwork and collaboration. A comparative appraisal of stereotypes about nursing and about other professions would mitigate this confounder effect. Third, as one previous study show that cultural idealization of femininity could affect stereotypes about nursing [42], our study could not assess the possible association between Vietnamese social view of women and student stereotypes about nursing. Finally, to the extent of our knowledge, our study was the first on student stereotypes about nursing in Vietnam; therefore, we could not relate the results to other Vietnamese studies given the distinctive health system and culture characteristics.
In general, our study found that Vietnamese healthcare students highly regarded nursing profession. However, stereotypes about nursing existed and students viewed nurses as someone who had good practical and communication skills, and had less abilities to make decision, to work independently and to lead. In short, nurses were considered a capable team player, almost followers. Positive student stereotypes about nursing were associated with more favorable interprofessional attitude. We need to study how IPE courses could improve interprofessional attitude and student stereotypes in future research.
