hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh Copyright © 2022 Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-Non Commercial 4.0 International license https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. Original Article Abstract Professionalism has been recognized as an essential component of inter-professional collaboration (IPC), and hence this study aimed at exploring elements of inter-professional professionalism (IPP) affecting IPC among surgery teams. This qualitative study had been conducted from 2019 to 2021. Fifteen participants in surgery teams including surgeons, anesthesia nursing, and surgical technology nursing at hospitals of Shahid Sadoughi University were contributed to this study. Data was collected through semi-structured interviews and analyzed through inductive content analysis, an approach introduced by Lundman and Graneheim. Data analysis process included the following: (i) Developing verbatim transcription of interview, (ii) Extracting semantic units and classifying them under the top compact unit, (iii) Summarizing and classifying the compact units and selecting appropriate labels for them, and (iv) Sorting subcategories according to their similarities and differences. *Corresponding Author Azam Hoseinpour Address: University of Medical Sciences Campus, Al Ghadeer Blvd., Qom, Iran. Postal Code: 3736175513 Tel: (+98) 25 31 97 10 94 Email: ahoseinpour@muq.ac.ir Received: 9 Mar 2022 Accepted: 1 Oct 2022 Published: 29 Oct 2022 Citation to this article: Keshmiri F, Hosseinpour A. Interprofessional professionalism as a motivating force in interprofessional collaboration. J Med Ethics Hist Med. 2022; 15: 8. Two hundreds and forty-two codes, five sub-categories, two categories, and a theme entitled "reciprocal accountability in IPP” were extracted. The barrier category was named “weakness in accountability to team-based values" and the facilitator category was called "responsibility of maintaining empathetic relationship within the IP team". Development of IPP and professional values (e.g., altruism, empathetic communication, and accountability to individual’s and team’s roles) can facilitate collaborative processes among different professions. Keywords: Interprofessional; Professionalism; Values; Collaboration; Team; Semi-structured qualitative study. Interprofessional professionalism as a motivating force in interprofessional collaboration 1. Associate Professor, Medical Education Department, Education Development Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. 2. Instructor, Department of Operating Room, School of Allied Medical Sciences, Qom University of Medical Sciences, Qom, Iran. Fatemeh Keshmiri1, Azam Hosseinpour2* Interprofessional professionalism as a motivating force in interprofessional collaboration J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. 2 Introduction Professionalism has been recognized as an essential component of inter-professional collaboration (IPC) (1). Inter-professional professionalism (IPP) has been introduced as an integrated concept in professionalism and Inter- Professional (IP) care fields (2). IPP focuses on respecting professional values in IPC process through maintaining an atmosphere of mutual respect and shared values (3) that should be considered by providers in all fields involved in providing healthcare services to improve individual’s and team’s competencies as well as to develop an educational atmosphere (4). In the definition of IPP principles and values such as respect, communication, excellence, altruism, and accountability in IPC process have been emphasized (4). For example, surgery teams should acquire IPC competencies as they are required in complex and sensitive situations in the operation room (OR) environment. Developing IPP and respecting team-work values can facilitate IPC (3,5). IPP aimed at defining professionalism aspects of teamwork rather than just the concept of experts in various profession working together as a team (1). Thus, viewpoints of those with IPP experiences on various dimensions of IPP can help perceive it. IPC is a multi-dimensional and complicated concept affected by various factors, including personal, professional, and cultural factors (6). However, factors affecting the facilitation of IPC and the development of professional values in various fields can be different, and hence a qualitative approach should be used to explain the factors affecting diverse cultural contexts. Although recent studies on professionalism and IPC as two separate fields have been conducted, few have been focused on professionalism in the IP team. Moreover, recent studies on education and IPC have been mainly quantitative, and hence qualitative research has been recommended to be conducted in this field (6). Regarding the importance of understanding the IP values influencing IPC in OR environment, as critically- sensitive clinical settings, the present study aimed at exploring OR team members' experiences on IPP’s facilitators and barriers in surgery team. Methods Qualitative approach This qualitative study had been designed and conducted from 2019 to 2021. Content analysis in Keshmiri F., et al. 3 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. qualitative research is a systematic method to describe the depth and breadth of a phenomenon (7). Researcher characteristics All members of the research team were female. At the time of and during the study, AH was MSc candidate in surgical technology. FK were faculty members of Education Development Center at SSU. All authors were involved in all steps of the study. FK conceptualized and designed the study. A.H collected the data, and F.K and A.H analyzed and interpreted data. Sampling strategy The purposive sampling method was used in the study. As inclusion criteria, the team members had worked in the surgery team for at least four months and had attended the IP meetings. To obtain maximum diversity within the samples, the participants included from both genders and various age groups (young, middle-age, and older adults) and experience levels (novice, advanced beginner, competent, proficient, expert), with diverse professions and education levels (B.Sc, M.Sc, M.D, Specialists). Ethical issues The interviews were audio recorded after obtaining informed consent to participate in the study. Principles of information confidentiality and obtaining informed consent were ensured in interviewing participants, interviews’ recording, and offering the right to withdraw from the study. To increase result accuracy, the findings were presented to the participants to reconfirm, which was among the ethical considerations observed in this study. This study was approved by the Ethics Committee of the National Center for Strategic Research in Medical Education, Tehran, Iran (IR.NASRME.REC.1400.094). Data collection methods Data was collected through semi-structured interviews. The research team members prepared interview questions. The interview guide and questions were reviewed and approved by experts with experiences in the fields of professionalism, IP education and IPC and health professions’ education. According to the interview guide, interviews initiated with open-ended questions: How are you collaborating with different professions? What professional principles do you or other team members comply with to improve IPC? What professional behaviors have facilitated your IP relationship and IPC? Which unprofessional issues have disrupted your collaboration in an IP team? Probing was conducted to facilitate participants’ explanation of Interprofessional professionalism as a motivating force in interprofessional collaboration J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. 4 their experiences. Interviews’ place and time were scheduled considering participants’ preferences. The interviews lasted 40 to 60 minutes. The data collection was continued until data saturation when no new code emerged. Units of the study Participants were selected from the surgery teams including surgeons, anesthesia nurses, and surgical technology-nurses of hospitals affiliated with Shahid Sadoughi University. Fifteen participants contributed in semi-structured interviews, of which six were surgeon, four were anesthesia nurses, and five were surgical technology nurses. Seven male and eight females were participated in our study (Table 1). Data processing, analysis and confirmation All interviews were transcribed verbatim, and audio files were reviewed several times to ensure transcripts’ accuracy. Then, all interviews were coded and extracted according to the content analysis method based on the Lundman and Graneheim approach (7). The data analysis process was performed in several stages, including transcribing the interviews, extracting semantic units and classifying them under the compact unit, summarizing and classifying the compact units and selecting appropriate labels for them, and sorting subcategories based on their similarities and differences. Content analysis was performed on the data based on qualitative content analysis. Meaningful segments of data were identified and labeled as open codes. The extracted codes were compared considering their differences and similarities. Then, the categories and subcategories emerged after sorting the extracted codes. The themes were extracted through comparing the extracted categories. The researchers conducted the analysis process. In cases of disagreement over the coding, the researchers discussed until reaching a consensus. Techniques to enhance trustworthiness To obtain credibility criteria, the extracted codes and categories were examined and confirmed by the participants (member checking). Furthermore, the research team members (peer- checking) examined the extracted results. Two experts in the qualitative field reviewed and validated the correlations of the extracted results to achieve confirmability and dependability (expert- checking). The suggestions for changing the extracted findings have been discussed until reaching a consensus. Moreover, field notes, memo writing, and prolonged engagement with the participants were conducted. The participants and the context of the study were described to reach transferability criteria. Keshmiri F., et al. 5 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. Reporting This study is reported according to the “Standards for Reporting Qualitative Research (SRQR) guideline. Results Table 1 presents participants’ demographic and background characteristics. Two hundreds and forty codes, five sub-categories, two categories, and a theme were extracted. Table 1 – Participants’ demographic and background characteristics Study participants N (%) Gender Male 7 (46.66) Female 8 (53.33) Age (Mean ± SD) 40±7 Work Experience (Mean ± SD) 8±4 Profession Surgeons 6 (39.99) Anesthesia Nurses 4 (26.66) Surgical Technology Nurses 5 (33.33) This study explored a theme of "reciprocal accountability in IPP" (Table 2). In this study, two categories, including "weakness in accountability to team-based values" and "responsibility of maintaining empathetic relationship within IP team", were also explored. The category of "weakness in accountability to team-based values" includes ignoring human and professional values and team-based challenges. The second category, "responsibility of maintaining empathetic relationship within IP team" includes empathy in IP team’s communications, accepting and responding to team roles, and maintaining mutual and respectful relationships. Table 2- The participants’ experiences regarding IPP’s elements Theme Category Subcategory Reciprocal Accountability in IPP Weakness in Accountability to Team-Based Values Ignoring Human and Professional Values Team-Based Challenges Responsibility of Maintaining Empathetic Relationship within IP Team Empathy in IP teams communications Accepting and Responding to Team Roles Mutual and Respectful Relationships Interprofessional professionalism as a motivating force in interprofessional collaboration J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. 6 1.Weakness in Accountability to Team-based Values In this category, the challenges of cooperation among surgery team members were included. Team members believed that ignoring human and professional values would create unfriendly atmosphere in OR and decrease team members' performance. Lack of commitment to professional values such as disrespecting team members' personal and professional status, disregarding altruism and individualism, and disrespectful communication disrupts IPC. 1.1. Ignoring Human and Professional Values In this category, team members' lack of commitment in adhering to professional principles and human values prevents IPC. Several inappropriate behaviors, such as undermining others for self-aggrandizement and appearing imperative as well as demeaning others in the eyes of the leader or team leader, are significant barriers to cooperation. Ignoring OR team members, disrespecting other team members’ personality or profession, and disregarding the altruism principles were among personal barriers inhibiting initiating an appropriate team atmosphere. A participant stated: "We should all respect each other, but the physicians consider us their slaves". [Participant No. 3] "A significant characteristic of hospital nurses and staff is pulling the rug under colleague’ feet". [Participant No. 6] Communication was introduced as a core element in IPC process. In this study, disrespectful communication was stated as a cooperation barrier. A participant stated: “Some hospital wards have harsh attending physicians that humiliate chief resident who in a row act similarly with freshman residents, and they also do the same with scrub or circular nurses. Who can work in such teams?" [Participant No. 4] Lack of empathy among team members was another barrier. A participant stated: "Altruism is not respected in the workplace. Some staff do nothing in one room while a critical operation is underway in OR where help is needed". [Participant No. 9] Feeling superior in terms of the field of the study, work experience, and administrative hierarchy prevents empathy in team. A participant stated: "More experienced staff mistreat us. For example, I had been in the hospital from morning to afternoon and in different ORs. A senior staff sent Keshmiri F., et al. 7 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. me to OR again in the afternoon instead of another senior just because I was recently employed". [Participant No. 7] 1.2. Team-based Challenges This category included IPC barriers such as professional discrimination and injustice, professional irresponsibility, ignoring team members' decision-making process, and disregarding their opinions. The individualism among members and ambiguity in professional responsibilities hinders IPC. Discrimination among different professions, professional antagonisms, and discrimination due to the hierarchy prevent IPC. Income discrimination was identified as a significant barrier contributing to social class gap. Furthermore, involving hierarchy and discriminatory aspects makes team members feel ignored and dissatisfied with IPC. Discrimination due to physician dominance in hospitals was mentioned as another barrier. According to participants, physicians are always responsible for decision-makings and may judge with bias and support their physician colleagues. Therefore, the right of other professions can be disregarded. Regarding physician dominance and understanding of the hierarchy in different professions, a participant stated: "We are constantly experiencing physicians' commanding tone, humiliating look, and behavior”. [Participant No. 4] A staff member referred to income discrimination: "There is a negative attitude regarding physicians’ salary, leading to hatred of novice staff towards medical team without even knowing them. It is an initiation and determining behavior in other interactions among them”. [Participant No. 11] Regarding the understanding of IP discrimination, a participant stated: "The decision is always made by a doctor; even if the anesthesia nurse makes a mistake, one from the paramedic group is not allowed to fix the problem. Rather, the decision is made by the medical team. Unfortunately, doctor dominance has been a disaster for years and affects our interactions and behaviors”. [Participant No. 5] Regarding ambiguity in professional responsibilities, personnel stated: "Defining and assigning tasks are important. Almost all my colleagues do not know what to do or not to do. We studied anesthesia for four years and were taught about its principles. But, we do not know what each of us needs to do". [Participant No. 13] Regarding individualism and excellence in IP team, a participant stated: “Power in a team is a Interprofessional professionalism as a motivating force in interprofessional collaboration J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. 8 determining factor that is a function of the level of knowledge and money. Physicians see themselves as having more money and more knowledge than others, while they just play a different role. Since physicians do not know the importance of others’ duty, they consider themselves superior and maybe even leaders”. [Participant No. 1] Disorder in individual behaviors and team planning has been explained as barriers to IPC. A staff stated: "Fatigue and boredom affect our behavior. There is an excessive workload, and without planning, inappropriate ethical conflicts occur between surgeon and OR manager". [Participant No. 2] Regarding the staff's misbehavior, a participant stated: "I do not know why there are no specific working hours for the attending physician and others. Personnel is present, the patient is present, but the attending physician is not. There is no obligation for the physician to be on time”. [Participant No. 8] 2. Responsibility of maintaining empathetic relationship within IP teams This category introduced a commitment to professional values and empathetic implementation of IP responsibilities as essential factors in facilitating IPC. 2.1. Empathy in IP teams communications In addition to accountability, empathy among team members of different professions in achieving IPC is vital. Mutual understanding and helping among team members to provide quality services are essential. A participant stated: "Now I am a resident, and I need the staff to help me when the attending physician is not present. They have more experience, and later when I become an attending physician, I can train the staff with less work experience”. [Participant No. 14] 2.2. Accepting and Responding to Team Roles Believing in teamwork in providing services in OR, accountability in professional and team activities, and respecting all professions facilitate IPC. Regarding the commitment to the team roles and responsibilities, a participant stated: "We are all like interconnected chains; if a team member does not do well, the whole team faces difficulties. Now, if we want to cooperate effectively, first we need to admit teamwork concept”. [Participant No. 15] 2.3. Making Mutual and Respectful Relationships Participants considered contributors to respectful behavior and team interactions as essential factors in creating closeness and IPC atmosphere. Respectful relationship helps making a comfortable atmosphere, that plays a significant role in service quality. In this regard, a participant stated: “Team members are human beings not Keshmiri F., et al. 9 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. robots, and we need a peaceful workplace to do our best, to provide best services, which is not achievable without good relationships and respectful interactions”. [Participant No. 6] Regarding the interaction with team members, a participant stated: "When attending physicians enquire residents’ opinion, they are respecting the residents and they feel valuable and appreciated, which in row affect their behavior and push them towards excellent outcomes”. [Participant No. 10] Discussion This study explored theme of "Reciprocal accountability in IPP”. Present findings confirm the accountability in IP team function as a facilitator, and weakness in accountability to the team-based values as a barrier to IPC; weakness in accountability to respect team-based values, including respectful communication, empathy, altruism, and not adhering to human and professional values among team members, were barriers to IPC in OR. The participants complained about the weaknesses of team members in respecting altruism and commitment to professional values. Moreover, situational abuses of team members based on feeling superior in terms of several factors (e.g., education level, age group, or social class) make the abusers self-gormandize, show off, or seek less suffering and hardship at work, thereby leading to unfavorable relationships among team members. The feeling of being abused by the exercise of power by the abusers, as well as disrespecting the personality and professional values of other team members, were major obstacles in IP activities. Value-contradictory behaviors of some members towards their colleagues to conceal their mistakes or negligence, or showing their abilities and highlighting incapacity of others, may cause a deviation of the team's attitude towards others and even other professions. Such behaviors may disrupt cooperative relationships and effective communication among different professions. The dominance of individualism and the priority of self- interest can adversely affect IP relationships and IPC (8). According to a Cohort study conducted at Asian universities, altruism and empathy were two attributes that the students disregard as professional behaviors (9) that may be due to the individualistic attitude in their cultural context. In the category of team-based challenges, defections in team responsibility, disruption in IPC, and IP discrimination were highlighted. Accountability in healthcare team involves accepting responsibilities and diverse roles as well as meeting requirements and activities affecting Interprofessional professionalism as a motivating force in interprofessional collaboration J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. 10 patients, team outcomes, and community’s health needs (10). Participants regarded role ambiguity as an excuse for some colleagues’ failure to do their responsibilities and delegate their duties to others due to conflicts and superiority. Ambiguity of roles, lack of accountability, as well as creation of IP challenges and conflicts may lead to personal and professional abuse and disrupt IP relations. Moreover, disorder and disorganization disrupted IPC in teamwork and stressful environments such as ORs. Deficiency of work discipline among team members, such as physicians' unpunctuality, lack of coordination for the timely presence of all members, and non-compliance with the organizational rules in individuals, especially in physicians, were among individual problems disrupting IPC. The lack of planning for service management and the large number of patients causes chaos and increases the workload for some employees, especially new employees. Furthermore, lack of empathy, altruism, and discrimination frustrate team members. Participants believed that lack of evaluation system and constant monitoring of the performance on compliance with organizational rules and professional principles creates challenges in IPC. According to Schot et al., IPC should be implemented through bridging professional and social gaps and removing the slacks among the professional duties, negotiating overlapping roles and responsibilities, and creating opportunities to understand members' professional duties and roles (11). The present findings showed that IP discrimination is perceived as unfair behavior and prevents the formation of cooperative relationships among healthcare team members. The paramedic personnel highlighted class antagonisms in the teams, resulting in various payment levels for equal effort of the healthcare team members. These differences make physicians underestimate other professions. Such feeling of superiority has rendered administrative and decision-making positions extending and making everything in favor of physicians. Therefore, in personal, professional and legal disputes, everything is in favor of physicians, that weakens the rights of other professions, as well as leads to inappropriate conduct and professional judgments and reduces the motivation of other professions for IPC. Moreover, physicians believe that they deserve higher salaries, and lack of motivation in other professions is because of their incapacities and indolence. Feeling superior makes the physicians forget that they are members of teams and consider themselves the team head. This attitude poses a Keshmiri F., et al. 11 J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. significant challenge in collaborative relationships. The class-income antagonisms and professional discriminations lead to negatively competitive surroundings among team members and prevent cooperative relationships. In the targeted context, discrimination, the culture of physician dominance, and the hierarchy system among different professions deepen the boundaries and fail to realize team-based services (8). Consistent with the present findings, Shohani's results showed that the experience and perception of the discrimination in the organization is an essential factor influencing how individuals work together, the lack of motivation to cooperate and work in the clinic, and even the decision to leave the service (12). Observing discrimination leads to the team member's disobedience to the leader, failure to perform assigned responsibilities for the member, and failure to cooperate in requested tasks (13). In line with the present findings, discrimination is an important factor leading to irresponsibility and lack of obligation in accepting and fulfilling professional, personal, IPC and IP roles (13). Tsou et al. emphasized on the need for integrity and maintaining justice as well as the need to include IP framework. The adherence to integrity and maintaining justice among team members prevents unprofessional actions such as discriminating, undermining, and disabling colleagues (10). Consistent with the present findings, in another study on understanding IPC mechanisms, the "support and value" mechanism, as an underlying mechanism, highlighted team members’ support of each other and respect for their skills, capabilities, and values (14). In the second category, “responsibility of maintaining empathetic relationship within IP team” as a facilitator of IPC was explained. Respectful interactions and exchanging ideas among team members make them feel relieved and not ignored. Empathy and mutual understanding among team members disrupt the boundaries among different professions and create closeness among them. Altruism, helping others, and teamwork spirit were explained as significant ways to initiate IPC. Similar to the present findings, in a grounded theory study by Sur, empathy in IPC is considered a critical component in team making, IPC, and IP interactions. In the category of empathy as a collaborative engagement, mutual respect, understanding and assisting others, and team communication are facilitators of IPC (15). Adamson et al. introduced IP empathy as a factor affecting the well-being of IP team members, leading to team cohesion and IPC (16), inconsistent with the present results. According to the present Interprofessional professionalism as a motivating force in interprofessional collaboration J. Med. Ethics. Hist. Med. 2022 (Oct); 15: 8. 12 findings, accountability to the team responsibilities facilitates cooperation among team members. When members accept team responsibility and team membership, they need to be able to respond to other team members' requests, help them, teach them, as well as strive for individual and team excellence. Hewitt et al. introduced efficient, open, and equitable communication, shared responsibility, and team behavioral norms as team members’ accountability approaches for IPC (17), consistent with the present findings. Respectful relationships, empathy, and accountability to team roles are essential elements to improve IPC, in line with other studies’ findings (18, 19). Stephenson and Bliss suggested that IP learning provides situations for understanding, practicing professional values, and IPP improvement among learners and staff (20). Considering that the present study is qualitative, generalizing the results to other contexts with different cultures involves limitations. Implementation details cannot be controlled by the researchers. Conclusion The present study explored "reciprocal accountability in IPP" as a theme, and two categories, "weakness in accountability to team- based values" and "responsibility of maintaining empathetic relationship within IP team", were considered. The development of IPP and professional values such as altruism, empathetic communication, and accountability to individual and team roles can facilitate collaborative processes among diverse professions. Lack of commitment to IP values leads to ineffective communication, unprofessional practice, and IPC challenges. Moreover, the rejection of team-based values and responsibilities disrupts the realization of IPC. Therefore, educational and practical opportunities in IP teams should be created and culture of team-based service should be launched in the target context. Funding This project was funded by the National Agency for Strategic Research in Medical Education. Tehran. Iran. Grant No. 992000. 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