Effects of interprofessional education on teamwork and on knowledge chronic conditions management*

Objective: Evaluate the effect of interprofessional education on the climate of Primary Health Care teams and on the acquisition of knowledge about management of chronic non-communicable diseases. Method: Quasi-experimental study of interprofessional education intervention. Seventeen Primary Health Care teams (95 professionals) participated in the study, of which nine teams (50 professionals) composed the intervention group and eight teams (45 participants) composed the control group. The team climate inventory scale and a questionnaire on knowledge about management of chronic conditions in Primary Health Care were applied before and after intervention. Type I error was fixed as statistically significant (p<0.05). Results: In the analysis of knowledge about management of chronic conditions, the teams that participated in the interprofessional education intervention presented higher mean post-intervention increase than the teams of the control group (p < 0.001). However, in the analysis of both groups, there was no significant variation in the teamwork climate scores (0.061). Conclusion: The short interprofessional education intervention carried out during team meetings resulted in improved apprehension of specific knowledge on chronic conditions. However, the short intervention presented no significant impacts on teamwork climate.


Introduction
According to the World Health Organization (1) , Chronic Non-Communicable Diseases (CNCDs) are responsible for 41 million deaths annually. The most frequent include cardiovascular diseases (17.9 million), cancers (9 million), and Diabetes Mellitus (1.6 million). This is a global problem, in which only 25% of people with CNCDs are provided care and among them only about half reach the desired goals of clinical treatment.
This result is mainly due to insufficient access to health care and inadequate management of CNCDs (1) . As a way of addressing this, the ten priority recommendations of the Pan American Health Organization (2) to improve the quality of care for CNCDs feature the reorganization of health workers into teams, ensuring interprofessional education and continuous training on the management of CNCDs.
Teamwork and collaborative practice are highlighted when considering their potential for change in light of the fragmented care and also as a means for establishing integrated health systems, which are characterized by collaboration-based forms of action (3) . In recent decades, the literature and the public policies for implementation of teamwork have conducted a broader discussion, which associates teamwork with interprofessional practice and education (IPE) (4) .

IPE is understood as an educational intervention
or action aiming to improve collaboration in the care provided to users, in which members of more than one health profession learn together interactively, with the explicit purpose of improving the quality of care. This interaction in the IPE requires active participation and exchange of knowledge between different professional areas (5) . The subject gains prominence from 2010, with international publications that point to IPE as a component of a wide reform in the vocational training and health care model, aimed to work in health care networks and training for person-centered collaborative practice (3,6) .
Cochrane literature review on the effects of IPE on professional practice and health outcomes (5) found fifteen studies that met the inclusion criteria, The authors suggest the need for studies that enable understanding the processes of changes in health care practices related to IPE (5) .
Studies of IPE interventions in the context of health care, including in the care of chronic conditions, report positive impact of IPE on satisfaction with care (5,7) and on team collaboration (8) .
Considering the growing trend of health care based on collaborative teamwork and the necessary professional enhancement to provide integrated care for CNCDs, it is necessary to understand how IPE can contribute to effective teamwork, interprofessional collaboration and specific professional knowledge on the management of CNCDs in Primary Health Care (PHC). However, studies on the subject are mostly found in the international literature, from developed countries such as Australia, Belgium, Sweden, the United Kingdom and the USA (9) and little is known about the impact of IPE interventions in developing countries such as Brazil (10) .

Method
Quasi-experimental study (11)  practice in the management of chronic conditions in PHC" and were devised based on the techniques of experiential learning theory (14) . Experiential learning consists in an approach on adult development, in particular, professional development. Professional practice is a permanent course of experiential learning, based on the following principle that all prospective professional development stems from current learning, as well as the already constituted development is indispensable for learning (14) .
The first workshop had the following objectives:  previous study in the teams in the same municipality, a significant relation was found between time in the team and team climate scores (9) .
The data were entered into Windows Excel spreadsheets and analyzed by the Statistical Package for Social Sciences® 22 software. In all statistical tests, the significance level adopted was 5%.
Internal consistency was checked through Cronbach's

Results
The results related to the characterization of health professionals who participated in the IPE workshops in the BHUs are presented in Table 1    Comparison between the groups shows that the intervention group presented a higher increase in mean knowledge than the control group as seen in the p-value of the interaction.
In the evaluation of teamwork climate, the interaction effect measures whether the difference in pre and post means is equal in both groups, which effectively evaluates the impact of the IPE intervention (  The results suggest that the adopted IPE intervention produced no effect on teamwork climate.

Discussion
This study aimed to examine the effect of IPE on the climate of PHC teams and on the acquisition of knowledge on the management of CNCDs. The results confirmed, partially, the initial hypothesis that IPE is associated with improved knowledge on the management of chronic conditions and improved teamwork climate.
The hypothesis is confirmed partially because the teams participating in IPE intervention showed significant improvement only in scores related to knowledge on management of CNCDs, but not in teamwork climate.
The results are consistent with a systematic review that describes a trend in IPE studies: the existence of evidence on the positive impact of IPE on acquisition of specific knowledge, but not on changes in attitudes and perceptions of professionals (8) , as measured by the TCI.
The literature (9) presents evidence of positive impact of IPE on interprofessional attitudes/perceptions and specific knowledge, but little is known about the impact of IPE on professional behaviors, patient outcomes and interprofessional practice.
In order to understand the impact of IPE on professional practice, there are quasi-experimental and practical intervention studies aimed at improving interprofessional work and quality in health care.
Evidence from quasi-experimental studies shows positive impact of IPE interventions on the improvement of interprofessional work (15)(16) . However, the systematic review on the effect of interprofessional interventions on practice presents methodological weaknesses and lack of conclusive findings regarding the impact of such interventions on the improvement of interprofessional work and health care (17) .
The results of this study corroborate the findings of other studies that aimed to evaluate the impact of short IPE intervention on the acquisition of specific knowledge. On the subject of management of CNCDs and interprofessional work, we highlight the controlled experimental study for evaluation of IPE intervention (18) .
According to the authors, a short intervention (11 hours) on specific content can positively impact both the self-perception of the capacity to manage CNCDs and the attitudes related to interprofessional work.
The potential of short IPE intervention can positively influence the attitude towards interprofessional work (19) . However, short IPE interventions (less than 2 hours and a half) show no potential for change in professional knowledge (20) .
The findings related to teamwork climate differ from those of a previous study related to IPE (21) in which increased TCI scores were found after IPE intervention.
The main differences between this study and the aforementioned study on IPE (21) consist in the duration of the IPE intervention, the interval between pre and post test, and the existence of a control group. In an initial sample of 79 participants, the authors performed an IPE intervention with 12 hours of duration, with post test at four and eight months after intervention and did not include control group. Although the aforementioned study (21) suggests that 12-hour interventions over eight months of duration are capable of positively impacting the teamwork climate, the implementation of an IPE intervention involving professionals in the context of clinical practice may pose challenges (17) , especially in the context of shortage of staff, which may compromise the participation in professional education activities.
As for the team climate scores, it is worth noting that the only aspect that showed significantly decreased scores, both for the control group and intervention group, www.eerp.usp.br/rlae 7 Agreli HF, Peduzzi M, Silva MC, Mascarelle RCV, Espinoza P.
was the task orientation factor. This involves reflection as a key element for the existence of interprofessional negotiations, clarity about the responsibilities and roles of each professional in the team (22) .
The significantly decreased scores in the task orientation factor suggests that when answering the questionnaire the second time the professionals presented a more negative perception exactly in the factor that translates the team's capacity to reflect on their work in pursuit of excellence.
The time working in the team was not related to the teams' knowledge about the management of CNCDs, and showed no effect on teamwork climate scores. The time of experience in the same team is described in the literature as "team stability," this is an attribute that stimulates shared work and joint decision-making (23) .
Finally, if on the one hand short IPE interventions showed to be effective to improve knowledge about the management of CNCDs, on the other hand they did not contribute to improve the teamwork climate.
This result refers to a reflection on the characteristics of teamwork climate, which receives contributions from social interactions, relationships between professionals from different areas, and influence of organizational culture (24) , complex aspects that are less sensitive to a short intervention restricted to the scope of the teams.
Collaborative practice and teamwork climate (25) involve relational, organizational, contextual aspects and some tensions, for example, the development of collaborative competencies versus autonomy of each profession. IPE interventions aimed at improving team climate should consider such tensions, which can be challenging, especially in a short period of time.
The tensions that exist in practice do not necessarily need to be "solved," but they need to be confronted in order to allow the advance of the movement in favor of collaborative practice. Accordingly, the very complexity of interprofessional work and its tensions help to understand the possible reasons for the lack of impact on team climate of a short IPE intervention in an isolated way (24) .
One of the limitations of the study was the composition of the intervention and control groups.  interventions with duration of more than 6 hours and monitoring the results at an interval exceeding 60 days between pre and post test.
Although presenting limitations, this study was the first approach to advance in the discussion about the effect of IPE interventions on teamwork in the FHS. This is a relevant study to understand which characteristics of IPE are capable of producing positive effect on the knowledge of PHC professionals and on the improvement of teamwork. To date, little is known about which interventions should be adopted in the daily work to prepare teams for better management of CNCDs.