Coexisting of interprofessional education and organizational culture

Increasing knowledge, technological advances, growing elderly and disabled population, and the need to provide safe and quality patient care over the world have made the healthcare systems more complex. In the last 30 years, the need for interprofessional education has increased. The training and participation of more than two disciplines is defined as interprofessional education. The aim of interprofessional education is to learn how students should work in an interprofessional team and to apply the knowledge, skills and attitudes that they have learned to future health service delivery. Most of the competencies for interprofessional education are related to teamwork. Communication, leadership and collaboration skills need to be achieved for teamwork. There are many barriers on the basis of the training program and the organization. In addition to the structural change, cultural changes are needed to initiate a reform movement in the interprofessional education in the healthcare system. Critically important interprofessional education should be defended in the framework of how to act and approach all employees of the institution in the same belief, common values and the same way of working together for optimum success.


Introduction
There is uncertainty in Turkey about the definition of interprofessional education (IPE). In the field of health sciences, education conducted with the participation and collaboration of more than two disciplines is defined as interprofessional education. Horizontal and vertical integration should be applied throughout the entire curriculum in IPE [1]. The aim of IPE is to teach how students should work in an interprofessional team and apply the knowledge, skills and attitudes they have learned to future healthcare system practice. This article will start with the definition and value of IPE. Important barriers for its implementation will be discussed followed by constructive suggestions for an institutional environment where the organizational culture supports IPE.

What is/is not IPE?
IPE is expected to focus on patient-centered care as part of a collaborative team in patient recovery in the environment of interprofessional practice. In line with a common goal of the team, learners should work in concert with their individual expertise to ensure patient-centered practice. For safe, efficient and qualified patient care, the team members must cooperate, decide collectively when necessary, communicate with other team members and lead their observations in line with their occupational expertise [1,2]. The roles of team members should be well defined and their responsibilities should be determined in IPE. Most of the competencies for IPE are related to teamwork. Characteristics of teamwork are [1,3]; -Communication is the key skill in IPE. Communication skills are required to increase teamwork, to understand team members, to define the task well in the team, to transfer the task to other team members, to evaluate team performance and to develop a solution and/or suggestions. It enables students to understand different disciplines, develop empathy and communication skills. It also enables the development of problemsolving and reasoning skills of both the individual and the team. -Leadership in IPE is an important skill required for team meetings to be carried out effectively, conflict resolution and team members to reach consensus. With the leadership skills, the problems of the team members can be identified and solutions can be developed. -Collaboration is an important skill in patient-centered care practice.
'What IPE is not' should also be noted to better understand the definition [1]: -It is not the learning of different health sciences without interaction. -It is not the case where trainers from different departments come together and lead the learning experience. -It is not when different disciplines are involved in patient management without sharing responsibility. -It is not the situation when even there are more than one health professional in patient management, but these people can't be accepted as a team.

Why IPE is needed?
In the last 30 years, the need for IPE has increased. Because of increasing knowledge and technological advances all over the world, health has also become an increasingly complex area. Thus, IPE is needed to improve interdependent healthcare system [2]. With the growing elderly and disabled population, the professional burdens of social services and health care providers have increased. In parallel with the increase in the information load, the complexity and increasing costs in the healthcare system necessitated IPE. IPE along with working on reflection aims to have patient-centered solutions: improvements in patient care quality and quality of life, reductions in hospital stay, treatment and maintenance costs, and medical errors. Thus, IPE ensures that health services and social services work together in a way that community benefits [2][3][4].
The medical education literature reports that it is possible to provide safe and quality patient care and to gain the necessary knowledge, skill and attitude to work as a team by IPE [1,3,4].

What are the barriers to IPE?
There are some barriers to the IPE [1,2] and these can be grouped as personal, institutional, cultural etc.
Some of the barriers can be listed as below: -Shortage of time for participation of faculty members and students from different disciplines in IPE. -Intensive education program content.
-The lack of a clear framework for IPE, the disconnection between theoretical knowledge and practical applications. An important issue in order to overcome the barriers encountered in IPE is the change in the organizational culture. Organizational culture is defined as the relationship patterns that affect the common values and beliefs of individuals who share the same environment and shape their behaviors [5,6]. Organizational culture is created informally by individuals who make up the institution. In order to change the organizational culture, the individual needs a catalytic converter to review the culture he created with his beliefs, values and behaviors, and to perform a transformational change by reflection [7]. There are thousands of people in every institution and at every level. Therefore, the change in the culture of the organization is possible by accepting the change of individuals of all levels. The variety of the individuals involved in the development of IPE makes this change difficult. With simple behavioral changes of individuals and organizational culture, it is impossible to create a change in challenging processes such as IPE. Defining the theory of transformational learning Mezirow argued that in difficult processes such as education, it is necessary to change one's own beliefs, experiences, assumptions and perspective [8]. This change, also called a perspective transformation requires the individual to think critically about his/her own ideas and actions. The act of reflection is defined as a skill that healthcare professionals need to successfully implement IPE [7,9].
It is a challenge to think and discuss what can be done to improve the service delivery of health care professionals. The lack of cooperation between health institutions is similar to the lack of cooperation between individuals providing healthcare. Strategies to improve cooperation between institutions are similar to those required for the IPE of health professionals. The change required for individuals is the change needed to change the organizational culture. It is only possible for the individual to initiate the change through reflection if the individual needs it [7].
To overcome the barriers encountered in IPE, the following points should be noted [1,2,4]: -In many disciplines, management, training programs and physical settings should be changed to prepare for IPE. Training institutions should make physical spaces capable of providing IPE. -It is necessary to perceive whether IPE is beneficial and whether a new change is necessary. As health care systems change, managers and faculty members need to understand the need to improve their professional education, motivate and support each other.
-In order to establish a clear framework for IPE, the task descriptions of the individuals in the training and working environments should be made clear. The implementation of the IPE development programs, the formation of a pool of professionals who received interprofessional training and the administrative structure of the educational institutions should be made suitable for IPE. For this innovative approach, intensive cooperation and cultural change are required in educational institutions. -IPE programs to develop institutional support for having a positive attitude to this training program is very important for students and faculty members.
To cope with these difficulties, the first change should start from the organizational culture. It is necessary to determine the interprofessional common competence areas related to general health. Secondly, continuous professional development trainings on the planning, facilitation and evaluation of interprofessional activities should be organized for the faculty members. Providing trainings to managers and faculty members in health education institutions accelerate the transformation of individuals via reflection. Thirdly, it is necessary to coordinate the programs of all health education institutions in order to ensure participation, to allocate time and to allocate a special area to carry out interprofessional practise. In the end, it is necessary to motivate individuals to disseminate their experiences related to IPE through presentations and publications. Health institutions are conducive to promoting cooperation between students and faculty members. Moreover, the measurement of the impact of IPE initiatives is the best evidence that these efforts are not meaningless in terms of health care [2,7].

Results
In healthcare institutions, it will be appropriate for learners to receive the right education to reflect the real life in order to improve the quality of health care and to ensure patient safety. In this way, it would be inevitable for the professional groups who can assimilate each other's duties and responsibilities in their education lives, in the professional life, and they will be the employees who can provide the most effective health service as a team.
The fact that being a team is important in terms of saving time and work and that the service offered directly affects the health of patients, training of the learners together with the IPE standards directly increases the quality of the service provided.
The most important obstacle to IPE is the organizational culture. Strategies are needed to promote organizational culture change. The organizational culture can be changed by providing the opportunity to create a common vision together in the process of transformational change by reflection of the individuals in health and social service delivery and to design a forward plan together. Thus, the most important obstacle to IPE can be overcome by motivating individuals with a change in organizational culture, finding solutions to uncertainties, and especially by adopting an implicit organizational culture.