Health students' perceptions of collaborative interprofessional practice in caring for patients with chronic diseases

Abstract

Treating patients with chronic diseases is challenging for public health due to their multicausality. This study sought to understand students' perceptions of the care provided to patients with chronic diseases. This is an exploratory and qualitative field study with an exploratory approach. Students from the final year of the Nursing, Physiotherapy, Psychology, Physical Education, and Medicine courses at a private university in the interior of São Paulo, Brazil, were included. Those absent on the day of the invitation and the day scheduled for interviews were excluded. Data was collected using a script constructed by the authors with guiding questions from September to November 2023. The interview audio was recorded and later transcribed using IRAMUTEQ software. The interview was then analyzed considering references to collaborative interprofessional practice and chronic non-communicable diseases. The results indicate that some students identified social determinants of these pathologies, their challenges, their treatment, and the need for interprofessional work, which remains in the theoretical and practical training scenario.

Keywords:
Chronic Disease; Interprofessional Relations; Interprofessional Education

Resumo

O tratamento de usuários portadores de doenças crônicas é um desafio para a saúde pública devido à multicausalidade. O objetivo desta pesquisa foi compreender as percepções dos estudantes sobre os cuidados prestados aos portadores de doenças crônicas. Trata-se de uma pesquisa de campo com abordagem exploratória e qualitativa. Foram incluídos estudantes do último ano dos cursos de Enfermagem, Fisioterapia, Psicologia, Educação Física e Medicina de uma universidade privada do interior do estado de São Paulo, Brasil. Foram excluídos os que não estavam presentes no dia do convite, assim como no dia agendado para as entrevistas. A coleta de dados ocorreu por meio de um roteiro construído pelas próprias autoras com perguntas norteadoras durante o período de setembro a novembro de 2023. O áudio da entrevista gravado e posteriormente transcrito foi tratado no software IRAMUTEQ e analisado à luz dos referenciais da prática interprofissional colaborativa e doenças crônicas não transmissíveis. Os resultados apontam que alguns estudantes identificaram alguns determinantes sociais dessas patologias, seus desafios, tratamento e a necessidade de um trabalho interprofissional que permanece incipiente no seu cenário de formação teórica e prática.

Palavras-chave:
Doença crônica; Relações interprofissionais; Educação Interprofissional

Introduction

Chronic non-communicable diseases (NCDs) represent one of the leading public health problems in the world, causing around 35 million deaths annually. They are related to deprivation of well-being, work limitations, and worsening economic, social, and family concerns (WHO, 2018; Draeger et al., 2022). Among these diseases, there are four leading causes of premature death: cardiovascular diseases, neoplasms, diabetes, and chronic lung diseases. Tackling this epidemiological profile depends on effective public policies and adequate training for health professionals (WHO, 2019; Draeger et al., 2022).

This condition is complex because it involves various factors in the process of becoming ill, such as accelerated urbanization, stress, social inequality, low levels of education, and misinformation. It also includes obesity, sedentary lifestyles, smoking, alcohol consumption, physical inactivity, and poor diet. These are modifiable risk factors, which means that professional strategies and appropriate public policies can reduce the occurrence of pathologies and their consequences (Haikal et al., 2023).

Collaborative Interprofessional Health Practice (CIP) can be an alternative for dealing with the various modifiable factors involved in treating NCDs, as this condition requires working with different perspectives. CIP is a partnership between a team of health professionals from other fields of knowledge. For interprofessional collaboration to happen, there is the premise that professionals want to work together to provide better care (D'Amour et al., 2008).

Collaboration refers to partnerships established in everyday work, strengthening and improving what is already produced in teamwork. Using PIC, the team shares objectives, presents well-defined goals about the care provided, shares decision-making, and looks at the user as the center of care. So, the focus is not on the professional but on the user or family (Peduzzi et al., 2020; Agreli), 2017).

Patient-centered care (PCC) is established by assigning all care to the user or family and their needs during follow-up. Focusing attention on the user is a way of valuing the different professional perspectives and approaches to that need for care and not restricting oneself solely to one's specialty (Agreli, 2017).

Therefore, fragmented, disease-centered professional health training is part of a past that must be overcome to deal with contemporary health challenges. Contextualized professional training, problematized with the interprofessional model, seeks to overcome the hegemonic model and produce comprehensive care based on the needs of users and families (Sousa et al., 2023).

Thus, the guiding question of this research is: How can students' perceptions of the care of people with NCDs help to build more assertive and collaborative care? The aim was to understand the perceptions of final-year undergraduate nursing, physiotherapy, psychology, medicine, and physical education students about the care provided to people with NCDs.

Materials and Methods

This is qualitative, exploratory research that answers questions and, in the social sciences, is concerned with a level of reality that cannot be quantified. Exploratory qualitative research works with the universe of meanings, motives, aspirations, beliefs, values, and attitudes, corresponding to a deeper space of relationships, processes, and phenomena that cannot be reduced to operationalization. Therefore, to understand perceptions, it is essential to take an approach that values their meanings and aspirations (Minayo, 2001).

Students from a private university in the interior of the state of São Paulo, in their final year of undergraduate studies in Nursing, Physiotherapy, Psychology, Physical Education, and Medicine, took part in the survey. These courses were chosen because they are the closest to the subject under study. The invitation was made to students in their final year because, during this period, there is more experience in the internship fields; in other words, the students are closer to professional practice, as well as being a period in which they have already taken most of the curricular subjects.

Data collection involved a random sample; interviews were scheduled with students who agreed to participate in the research after the researchers had invited them verbally in the classroom. The number of interviewees per course followed the logic of data saturation; in other words, interviews were scheduled until the data began to repeat itself. A day and time were scheduled for the interview at the university or in the internship fields. The research objectives were presented, with any doubts clarified, and the free and informed consent form (FICF) signed, with one copy remaining with the researchers and the other with the participant.

The inclusion criteria were being a final-year student in the Nursing, Physiotherapy, Psychology, Physical Education, or Medicine courses. Students absent on the day of the invitation and on the day scheduled for the interviews were excluded.

One of the researchers conducted the interviews individually outside class time. The interviews were audio-recorded and later transcribed by the researchers into a Word document, which was double-checked: one researcher did the transcription, and the other checked it against the audio. Data collection took place from September to November 2023, and the average duration of each interview was approximately thirty minutes.

Participants answered the following trigger questions: What do you understand about NCDs? Do you believe that a multi-professional approach focused on user needs could contribute to NCDs care? How could it be worthwhile? Did you experience taking care of people with NCDs during your undergraduate internships or any theoretical-practical moment (simulation)? Do you know if this care was shared? What role does your profession play for people with NCDs? What are the challenges in approaching and treating people with NCDs?

The interview data was transcribed and submitted to lexicographic textual analysis with the R interface software by Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ), which was developed using Open-Source logic. It categorizes textual data by assessing the similarity of their vocabularies, indicating elements of the object studied (Camargo; Justo, 2013; Costa et al., 2021). Descending Hierarchical Classification (DHC) was used to identify the frequency of each word and its connection to others, contributing to the analysis of the textual corpus.

The program can build matrices with these lexicons and organize this data into a dendrogram that allows the relationships between the classes to be visualized (Camargo; Justo, 2013). This lexical analysis associates the most common vocabulary between the text segments with each class in the original corpus, contributing to the qualitative analysis (Camargo; Justo, 2013). After processing the data, interpretation and analysis were carried out based on the literature pertinent to NCD care and CIP. The intersection between these approaches provided the data for analyzing the material.¹

All stages of the research followed the Research Ethics guidelines contained in national and international documents for this purpose. The research was carried out after approval by the Human Research Ethics Committee in compliance with Resolution 466/2012. Opinion: 6.258.226 accepted in 2023, with Certificate of Submission for Ethical Appraisal (CAAE, in Portuguese) code n. 70905723.7.0000.5383.

Results

Forty-three students, 26 (60.46%) female and 17 (39.53%) males, aged between 20 and 50, participated in the study. The corpus of the interviews consisted of 348 text segments (TS). 271 TS (77.87% of the TS) were used to elucidate the classes working with Iramuteq in CHD.

Figure 1
Dendogram: Chronic diseases and their challenges.

The corpus comprises six classes, of which classes 4 and 5 are related to class 1, while classes 3 and 6 are related to class 2.

Class 1: Social determinants of NCDs and their challenges

The most representative words and elementary context units in class 1 allowed the factors related to NCDs to be contextualized. The words “acquire”, “affect”, “social”, “family”, “heredity," and "cure" represent the various factors involved in the onset and coexistence with NCDs, as can be seen in the following speech:

Chronic non-communicable diseases are diseases that have no cure. Unfortunately, they can be caused by genetic problems or family history and often also by risk factors such as smoking and obesity... (student/Nursing).

Some patients have a good idea... they will have to treat it, but some do not understand it so well. Every professional must explain to the patient how they will live with this disease and its difficulties and limitations. You must always have a good conversation and explain how it works because of some pathologies, like diabetes. For example, if the person does not have good treatment and care, it will disrupt the rest of their life. (student/Physiotherapy).

I understand that NCDs generate a particular demand in society and require time for treatment, expenditure on the public network, prolonged assistance, and more care from various professionals. For example, diabetes, a disease that by the time it is diagnosed, the patient has already had diabetes for at least 10 years. So, it is a disease that is already characterizing some secondary disease such as a cardiological disease that has more of a pre-existing heart attack or stroke, and this makes the patient less productive for society. (student/Medicine).

Well, NCDs are behavioral diseases acquired through the habits of individuals, so if they sometimes do not seek a quality of life, they run a greater risk of being susceptible to these diseases. This is a very alarming problem because they are one of the classes of diseases that kill the most people in the world (student/Physical Education).

Class 2: NCDs and interprofessional care

The words representing this class are doctor, nurse, fundamental, help, and nutritionist. This need for different perspectives can be seen in the following statements:

I believe it does contribute because each person will act in a specific role. For example, a nutritionist can act around nutrition, being able to draw up a diet that is suitable for each case, the doctor can act in prescribing, can analyze the situation of the disease and the nurse can act in the altered human responses of this patient, collaborating in this area. We have many professionals who will collaborate at a certain point, so I think it is important to have this multidisciplinary treatment. (student/Nursing).

For example, a doctor gives a diagnosis to a patient, referring to physiotherapy, which many do not do, primarily COPD. They take it, they give the diagnosis, they say ...stop smoking. Then, the patient sometimes cannot even breathe, dependent on oxygen, so that is where it starts. There are also situations in which they sometimes need a psychologist because they smoke due to emotional factors, in short, psychosocial factors. (student/Physiotherapy).

For example, in the internship we did in the clinic, in geriatrics, there were often elderly patients whose drug management was not enough, so they had to be adjusted with food. Everything else referred to nutrition or psychology, one complementing the other" (student/Medicine).

Yes, the gaze of these different areas is critical in integrating the whole patient because the patient is not just the disease; they are an integral being. So, you need to look at it from the point of view of what is observed and what is diagnosed by each area. Psychology also looks at the professional and how the professional perceives this whole situation with the patient. (student/Psychology).

In my opinion, everyone must understand where they will be working to approach a patient directly. For example, medicine will focus on the clinical picture of the disease. We can also take this approach to the clinical picture and improve it through physical exercise, so I think this interprofessional approach is fundamental. (student/Physical Education).

Class 3: Experiences in caring for people with NCDs

The words that represent this class are attending, nursing, hospital, consultation, look, share. These experiences during the training process with NCD patients are demonstrated in the following statements:

I experienced it during my supervised internship in a hospital... A patient who was hospitalized discovered diabetes at an advanced stage, going into diabetic ketoacidosis. He had complications because he did not know he had diabetes. So, at the time he was hospitalized, there was a multi-team nutritionist and a psychologist because his life was going to change. He was going to have to take care of himself differently from the way he used to, both in terms of food and medication. There is a social factor, the nursing team who explained the disease and how he will manage it from now on. (student/Nursing)

I shared this experience at the hospital. I had patients who were COPD, and I was always in contact with nurses, doctors, physiotherapists, this whole range of professionals helping these patients. So, I could see that he felt safer, trusted more in the work of the professionals, and felt more welcome. We noticed that the improvement was evident. The nurses were always there doing everything, the physio performed the maneuvers, and the doctors constantly monitored, always offering the best medication for the patient. (student/Physiotherapy).

Yes, we always went to the clinic or even to the hospital. We asked for inter-consultation with other professionals to see how the treatment progressed. We even referred diabetic patients to the nutritionist and, occasionally, the psychologist. (student/Medicine).

Class 4: Professional challenges for treatment

The representative words in this class are challenge, difficulty, adhere, understand, explain, approach. The following statements highlight these points:

First, make the patient understand their relationship with their body and the activities they do with their body, which are nothing more than the exercises we do with them in physiotherapy. They bring quality of life to him in the smallest detail, whether getting out of bed, running, walking, or acting, more in rehabilitation than prevention because we get this patient through rehabilitation. Then, we try to prevent other issues so that he has a good quality of life. (student/Physiotherapy)

First, make the patient understand their relationship with their body and the activities they do with their body, which are nothing more than the exercises we do with them in physiotherapy. They bring quality of life to him in the smallest detail, whether getting out of bed, running, walking, or acting, more in rehabilitation than prevention because we get this patient through rehabilitation. Then, we try to prevent other issues so that he has a good quality of life. (student/Physiotherapy)

Class 5: Patient challenges for the treatment of NCDs

This class included the words: difficult, adherence, acceptance, treatment, guidance, continue. The following statements represent the challenges:

I believe It´s the lack of communication, the nurse, or the team having the patience to explain, approach it calmly, and look at it correctly. To understand the patient's needs, the bond, where they live, who they live with, the patient's routine. It is not easy because nowadays, people want to get through it, and that is it. In the treatment, sometimes it is not self-explanatory for the patient, or sometimes they stop taking care of themselves because they do not want to, or even because the nurse has just said whatever. This ends up interfering with the patient's self-care. (student/Nursing).

Patients do not want to change their lives, and many do not give up their bad habits. They come to physiotherapy and stay there for one hour. They want one hour to be efficient for a whole week. Twice a day, they come here and spend an hour. They think it should be enough that they do not have to do anything at home. The treatment is the same. We cannot get results because they do not follow the home exercises. (student/Physiotherapy).

The challenge in bringing in patients with chronic non-communicable diseases is the lack of knowledge of the sensations they have with the disease. The challenge in treatment is the lack of understanding of what they have, and I, as a professional, do not understand what they feel. (student/Psychology)

These patients do not see the need to practice or come to us because they often lack information. As I said, if they had adequate information, if they had been warned and had been exposed to the benefits of activity, of physical exercise, they would typically value it more. They would not be able to reach such a stage. (student/Physical Education).

Class 6: Treatment of NCDs

Represented by the words "physical exercise", "psychologist", "medication", "nutritional", "diabetes", and "start". The following statements represent this class:

A quality-of-life treatment, not just with medication, but with changes in eating habits, for example smoking, reducing the number of cigarettes, drinks, reducing the amount of consumption, and thus quality of life. (student/Nursing).

In general, knowing how to deal with pain, how to resignify this illness, and how to live with it, with the pain, with the symptoms.I think it's reframing and knowing how to deal with the situation (student/Psychology).

I think our role is fundamental through physical exercise, for example, diabetics we can have glycemic control through increased insulin sensitivity. For a patient with arterial hypertension, we can also have an improvement in the clinical condition after exercise. (student/Physical Education).

Discussion

The social determinants of NCDs include social inequalities, differences in access to goods and services, low levels of education, and inequalities in access to information. These factors encompass a range of adversities that hinder the diagnosis and treatment of patients with NCDs. Therefore, when these determinants are present in patients' lives, they previously affected the entire health process (Melo et al., 2019).

In the first class, according to the students, some determinants of the pathology are related to hereditary factors and lifestyle habits such as smoking or a sedentary lifestyle. According to the students, the challenges relate to disease control throughout life. It is worth noting that, in this first class, while the nursing student emphasizes the determinants of the disease, the Physiotherapy student points out the challenge of living with the pathology throughout life; the Medicine student points out the challenges for the health system and, finally, the Physical Education student reports the challenge of quality of life. It is important to emphasize how each profession has a complementary view according to its training field.

NCDs are referred to as behavioral pathologies, but they are defined as long-term conditions resulting from genetic, physiological, environmental, and behavioral factors. It is significant to note that NCDs are influenced by behavior; however, the combination of causes can occur throughout the user's life. Heredity is a factor that can trigger the disease independently of your behavior and lifestyle habits (Borges et al., 2023).

The findings of class 2 mention the importance of shared care between different professionals. All the students discussed the need for other professionals to provide care. However, these statements reflect a view of care that is still fragmented, in which each professional does their work in a complementary but not integrated way.

CIP uses a team of health professionals from different fields of knowledge to work with a participatory and collaborative approach. This approach shares problems and makes decisions involving user-centered care, including the patient, family, and community in taking responsibility for their health (Peduzzi et al., 2020).

Multidisciplinary treatment reflects fragmented care in which each professional assesses the patient. However, they do not work together to provide care focused on the user's needs; the examples mentioned are different types of care but not interconnected. The idea presented is of multiprofessional work, in other words, with other professionals working, where each specialist makes their assessment and offers contributions according to their specialty, but with little interaction (WHO, 2010).

The students' experiences in class 3 reflect this definition of fragmented work, where each professional contributes to their expertise but does not share knowledge, planning, and actions demonstrating common objectives and goals. At the same time, as the students defend the benefits and need for integrated teamwork, their internship experiences reflect work in the traditional model with little integration.

The results show the importance of working with interprofessional education (IPE) around health. This type of education is linked to debates based on the National Health Promotion Policy (PNPS) since it is in this context that social conditioning factors and determinants are incorporated into the concept of health. Using a broader perspective, they value strategies that seek to articulate actions with social protection networks (Freire et al., 2019; Brasil, 2018).

IPE advocates learning between students from two or more professions to integrate actions to improve the quality of care in health services. To this end, it is essential to learn together interactively to enhance collaboration and healthcare quality (Reeves; Xyrichis; Zwarenstein, 2018; Freire et al., 2019).

NCDs are pathologies that require a series of factors for their proper treatment, from social factors that favor self-care to factors that favor lifestyle change. These different facets of pathologies require professionals to identify the best approach to conduct each case, require interaction between these professionals and user-centered care (Costa et al., 2021).

The statements in class 4 reflect the view of the physiotherapy student, who mentions the challenge of working more on rehabilitation than preventing problems in patients with NCDs. The medical student emphasizes the challenge of drug treatment, which is indeed an essential part of treatment, but difficulties in stimulating behavior change are not one of his main concerns.

Concerns about treatment from a professional perspective reflect the history of healthcare, which has developed a practice that is excessively medicalizing, more assistance-oriented, and often not very sensitive to users' uniqueness. This may be due to the social context, which does not provide favorable factors for their treatment, such as access to health services, healthy eating, adequate sleep, and encouragement to exercise (Torres-Cruz; Dias, 2022).

Due to their complexity, adherence to treatment for these diseases is not limited to access to information, the disease itself, its symptoms, the necessary change in lifestyle, and the permanent use of medication. Even institutional issues of access to health services are part of the factors that directly influence the outcome of user follow-up (Costa et al., 2021; Silva; Crepaldi; Bousfild, 2021).

According to the findings in class 5, which mention the challenge from the patient's perspective, communication is again mentioned as an important factor for effective treatment. The nursing student talks about the importance of the bond with the professional and mentions the relevance of the user's understanding of their state of health and their treatment, as does the psychology student. These statements highlight the need for proper understanding for treatment to be effective.

One of the policies of the Unified Health System (SUS), the National Primary Care Policy (PNAB) has as one of its objectives the development of a relationship of bonding and accountability between the team and the population. According to this Policy, the bond is the affective construction between users and health professionals, allowing the deepening of the process of co-responsibility for health; however, this is built over time and is part of the therapeutic process (Brasil, 2017; Barbosa; Bossi, 2017).

The Physiotherapy and Physical Education students, on the other hand, mention a point of discussion: in their speeches there are the expressions “...patients do not want to change their lives...” in another speech, the expression “...they do not see the need to practice, to come to us...”. Most difficult patients are labeled this way when care is centered on the professional, so the bond of trust is not built. In this way, the professional does not listen to the patient, and the relationship becomes paternalistic and authoritarian, with a strict biomedical focus (Cruvinel; Grosseman, 2023).

Person-centered care requires consideration of the person's biopsychosocial dimension and their active participation in treatment. It is essential to explore the social context and the illness's situation and value experiences, perspectives, complications, needs, and expectations. Sharing information must ensure that the patient understands it and feels free to ask questions to be clarified, in addition to their participation in the therapeutic plan (Benedetti, 2013; Cruvinel; Grosseman, 2023).

When the user is blamed for their state of health and the difficulty adhering to treatment, there is a greater appreciation of the disease. This includes the person who has fallen ill, their process of becoming ill, and their autonomy (Cruvinel; Grosseman, 2023).

In class 6, Nursing and Physiotherapy students present a broader view of the treatment of people with NCDs, focusing on lifestyle changes and the process of giving new meaning to illness, learning to live with the disease.

National and global initiatives are proposed to prevent and control NCDs. The United Nations has included targets for reducing NCDs and their risk factors by 2030 in the Sustainable Development Goals (SDGs). Health professionals must, therefore, be involved in planning strategies to ensure access to health care with national and local counseling for patients with NCDs and their families. It is important to move towards stricter measures with tobacco, alcohol, and unhealthy eating and to promote and encourage self-care to live with and control the pathology (Malta et al., 2021; WHO, 2016).

The scenario in which students follow individualized care, focusing on their specialty, is the opposite of the scenario advocated by the World Health Organization (WHO). The WHO has come to consider interprofessional work an innovative strategy in the training and work of health professionals. It aims to offer improved treatment in all areas of health, with their complexities (WHO, 2010).The scenario in which students follow individualized care, focusing on their specialty, is the opposite of the scenario advocated by the World Health Organization (WHO). The WHO has come to consider interprofessional work an innovative strategy in the training and work of health professionals. It aims to offer improved treatment in all areas of health, with their complexities (WHO, 2010).

Interdisciplinary health courses aim to overcome the tendency towards the fragmentation of knowledge by integrating disciplines in the same professional field. However, what is currently happening in health courses is an attempt to build an interdisciplinary approach without the prior construction of interprofessional education. To construct this education, the faculty needs to support the implementation of courses and programs that include interprofessional education. The interprofessional experience must be incorporated into the context of current practice in the various internship scenarios for effective and meaningful learning (Peduzzi et al., 2020; Reevis et al., 2016; Benevides; Miranda; Pereira, 2023).

Thus, educational institutions should incorporate the principles and guidelines of the SUS and guide students on the importance and form of how the service network should be integrated. Emphasizing health policies, such as the Humanization Policy, aims for comprehensive care. In addition, the pedagogical projects of the courses guided by the national curricular guidelines should contribute to an education capable of acting in the analysis, monitoring, and evaluation of health situations. This strengthens resolutive ness, one of the organizing principles of the system. This can also be favored by interprofessionalism (Brasil, 2017).

Therefore, offering training that values and works with PIC can favor caring for people with NCDs by increasing how we look at and care for the complexity of these pathologies and their social determinants. Articulating the care of different professionals favors teamwork and problem-solving that leads to the construction of dialogued knowledge, respecting and valuing the contributions of each professional with a focus on care and changing the user's lifestyle (Araújo et al., 2017).

Final considerations

It was possible to identify no significant difference between the courses; some presented a broader perspective and others a narrower one. However, they were complementary perceptions of care for patients with NCDs. The courses identified social determinants and treatment challenges from the users' and professionals' perspectives.

The findings show that the students mention the involvement of various professionals in caring for patients with NCDs, but the experiences reported show that care is still fragmented.

The study's limitation is that it portrays a local reality; therefore, the results should be understood from this perspective. However, this challenge in professional training and caring for people with NCDs may be similar in other academic environments.

Therefore, it is of the utmost importance to emphasize and deepen these themes in undergraduate courses so that more is studied and known about CIP, as well as research and create approaches that can promote integrated care. To this end, internship scenarios can be used for integration and simulation actions, among other activities.

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• 1
  All research data are available in this text.

• Editor:
  Fernanda Mattioni

Data availability

All research data are available in this text.

Publication Dates

• Publication in this collection
  15 Sept 2025
• Date of issue
  2025

History

• Received
  27 Feb 2024
• Reviewed
  01 Oct 2024
• Accepted
  02 Nov 2024