1 Introduction
The power of a health profession is based on an organized body of knowledge; clear disciplinary boundaries that define scope of practice and relationships with other professions (Hammick, 1998). For students, the incongruity is in learning to be an individual practitioner but being expected to practice as a team member. Hence, originators of interprofessional education (IPE) advocated that working as a team comes from learning as a team (Barr, 1998; Hammick, 1998). Interprofessional education is defined as learning with, from, and about the diverse representations of health students or practitioners on the team who all strive for the goal of quality care in health or education contexts (Centre for Advancement of Interprofessional Education [CAIPE], 2017). Learning to become interprofessional, both an outcome and a process, requires pedagogical design that facilitates the transformation (Goldman, Zwarenstein, Bhattacharyya, & Reeves, 2009).
The threshold concept (Meyer & Land, 2003) that transforms the way students interpret teamwork is interprofessionality, marked by the ways of thinking, practicing and experiencing the interprofessional community. Health education should facilitate the change on that threshold and allow
students to experience that ‘A-ha!’ moment, after which they cannot imagine the provision of health care from any perspective other than one of interprofessionality.
(Royeen et al., 2010, p. 252)
The aim of this study was to describe the health profession student learning experience of crossing the threshold to interprofessionality.
2
The transformation into becoming a member of the health profession is the liminal experience which Turner (1969) described as the transition from separation, over the threshold, to reaggregation where the liminal stage at the threshold is often chaotic and has no attributes of the previous nor future structure. Understanding the tacit knowledge of a profession, found beyond the liminal threshold, shapes how students learn to relate to community members (Davies, 2006).
Limited research exists describing the healthcare student liminal stages in relation to patients and none were found in relation to IPE. Case studies of two students described the chaos of professional learning and identity development that was dependent on educator critique and student assertiveness (Barlow et al., 2006; Hurlock et al., 2008). Holland (1999) found a hierarchy of care for nursing students that started with technical skills but showed how nursing promoted the caring relationship with patients and families. In contrast, Fuzzard (2017) collected the experience of students during service-learning placements while the students were in the liminal phase. The final article on liminality that was identified was in regard to an international student exchange where social work students had a transformative experience related to culture and community (Parker, Ashencaen Crabtree, bin Baba, Carlo, & Azman, 2012). The research on liminality characterized the challenging of perceptions, mostly about the gap between education and practice. All research reviewed on liminality was conducted during the final clinical practicum where the sense of professional identity was expected to have been strongest.
In the delineated time of this study, no research was found on threshold concepts in IPE but one study did suggest implications to threshold concept attainment when the learning was patient co-facilitated (Stacey et al., 2015). Threshold concepts with profession-specific application or that assist students to think like a professional are difficult, transformative, and more relevant to identity development (Martindale, 2015; Nicola-Richmond et al., 2016). Researchers began their studies by determining troublesome knowledge which was often characterized by the cognitive or emotional impact of that difficulty. Leidl (2016) found that tacit knowledge about mental health care was most difficult and counterintuitive until students were in clinical settings and Fortune et al. (2014) found that occupational therapy students were frustrated at being held back in clinical until they could apply theory. Hill (2020) compared required learning content in a health profession program to the change in thinking that occurs in threshold concepts, noting that understanding numerical equations was reversible, such as calculating physics of
3 Method
3.1 Methodology
This was a phenomenographic study to determine four hierarchical categories, from superficial to deep learning, of becoming interprofessional through the lens of social constructionist epistemology (Berger & Luckman, 1966). The aim of this study was to describe the health profession student learning experience of crossing the threshold to interprofessionality.
Two frameworks outline the interprofessional nature of working and learning for health profession students. First, the interprofessional education for collaborative patient centred practice (IECPCP) framework conceptualizes interprofessionality where the focal point of patient engagement is the interface between the systems of education and health (D’Amour & Oandason, 2005). Second, Canada’s national competency framework is six-fold: role clarification; collaborative leadership; interprofessional communication; interprofessional conflict resolution; team functioning; and patient, client-, family-, & community-centred care (Canadian Interprofessional Health Collaborative [CIHC], 2010). Frameworks provide a structure to begin proving how IPE can impact the patient experience.
Phenomenography was employed to explore how students think, learn, and understand the phenomenon of interprofessionality (Marton, 1981). Phenomenography seeks the variety of experiences and student learning is described as categories of description which are the aggregate of multiple experiences. Phenomenographic research collects second-order perspectives about the meaning of learning (Marton & Booth, 1997). Interprofessionality is experienced uniquely by each student, but is presented in aggregate in parsimonius,
3.1.1 Bracketing
Phenomenological reduction was employed, as described by Marton and Booth (1997) – employing judgment to consciously step back and listen for how the students were experiencing the learning rather than evaluating mastery from an educator perspective. Bracketing was achieved by engaging empathetically (Ashworth & Lucas, 2000) as the student shared their experience.
3.1.2 Positionality
Bracketing requires an etic stance of reducing my role as an IPE coordinator. However, an emic stance has been built into the research procedures because the results are co-constructed with the participants. Therefore, I employed a dynamic positioning, negotiated with the participants during discussions.
3.2 Participants
Variation in perspectives was a focus for phenomenographic work. The population is all health profession students currently enrolled in one of the more than 30 programs across the three main educational institutions in one Canadian province. Potential participants were contacted by a variety of digital means: bulletins, emails, posters, and social media.
Ten students, as noted in Table 27.1, gave perspectives of working with students in 15 other health profession programs. All students were undergraduates except for one PhD student. His interview was retained because he requested an interview, provided a unique perspective, and was the only male. Health profession programs are often female-dominated and therefore gender imbalance was not a concern.
Students describing threshold moments
| Profession | Primary interview | Learning context | Follow-up interview |
|---|---|---|---|
| Nursing | Y | Student run clinic | Y |
| Psychiatric nursing | Y | Long-term care, then community | Y |
| Dental hygiene | Y | Educational, then practice | Y |
| Nursing | Y | Educational | Y |
| Dental hygiene | Y | Educational | N |
| Nursing | Y | Acute care | Y |
| Public health | Y | Educational and research | Y |
| Nursing | Y | Acute mental health | Y |
| Nursing | Y | Acute mental health | N |
| Addictions counseling | Y | Educational, then community practice | Y |
3.3 Data Collection
Primary interviews ranged from 45 to 85 minutes and were digitally recorded then transcribed. The interview was guided by situated questions about what was learned and in what context, followed by probing questions to expand on variable learning (Marton & Booth, 1997). Often, the student told or referred to their threshold a-ha! moment only once, then proceeded to discuss the meaning of their learning in relation to shared experiences, collaboration, and healthcare education.
3.4 Data Analysis
Phenomenographers approach analysis in different ways (Bowden, 2000). The purpose was to find variation between experiences but it was difficult for me to keep the whole of the data in my mind. Transcript data were collective and individual experiences. In general, analysis began by determining one category of description until all learning steps had been described for one individual, then as analysis proceeded, individual experiences were compared to the aggregate.
Through analysis and for each follow-up interview, it was important to depict pictorially each set of categories of description for each individual in comparison to each learning step for the aggregate learning experience of crossing the threshold. This tool, simplified in Figure 27.1, assisted in the conversation for the follow-up interview and maintained my awareness on both individual and aggregate data – parts and the whole.
3.4.1 Rigor
Trustworthiness was judged through the criteria outlined by Lincoln and Guba (1986). Credibility was ensured through multiple interactions with participants through member-checking, triangulation between data sources, and debriefing to confirm analysis and interpretation. Transferability was supported by rich discussions that were long enough to attain depth and description. Dependability was ensured by the creation of a series of steps for analysis and subsequent diarizing of the process. Confirmability was employed through bracketing and confirmation interviews with student participants.
3.4.2 Ethical Considerations
Ethical approval was obtained in a harmonized process from the Behavioural Research Ethics board of record.
4 Results
Students described and named their threshold moments. There were troublesome experiences of skill attainment, navigating relationships, and determining how to share knowledge and clinical decisions. Threshold moments were bounded in profession-specific knowledge such as contexts where patient rounds occurred. After the threshold crossing, students turned frustration into action. The transformation was changing communication to an interprofessional focus and gaining confidence. Change was irreversible as noted by the students actioning their threshold moment to further team prospects like advocacy, health promotion, and team building. From these individual threshold moments, the aggregated experiences of crossing the threshold in four learning steps is described.
The learning steps through the threshold concept of interprofessionality
4.1 Community Vision
The first learnings were about building a team able to achieve goals of patient care. Meeting that outcome meant gaining awareness of the needs of others on the team in relation to their own skills. The first aggregate statement described the superficial learning required:
Growing a community & finding a common vision takes more than hard work – it includes initiative in preparing to be ready to begin appreciating others & awareness of what you will contribute to the team while in the same sense anticipating what other members need to know to make a difference for patients.
Students acted on building or becoming part of a team and understanding the patient needs within their particular experiential context.
This learning step was marked by being challenged and hard work. Students related their limited experience communicating with diverse others and being wary of what to expect or feeling like robots as they tested therapeutic skills. One student shared that:
The patient trusted me. They told me about their life experience and what they felt the afterlife would be and why they had chosen palliative care. That night, I said to myself, OK, it was not comfortable, it was outside of my comfort zone. I had to use therapeutic use of touch and I don’t like to be touched very much. I had to put my hand on the patient when the patient was crying.
Working through discomfort successfully meant impacting patient care and the beginning of creating community. Relationships required the ability to articulate. Students talked about gaining autonomy and the resultant responsibility during interprofessional communication:
You have to build that trust before they can allow you to go do those skills on your own. You have to prove yourself in the early years. Later you just have more responsibility, but they also make sure you know your stuff and drill you hard on it.
These interactions with team members were part of the challenge of ‘becoming’ in the practice community. Students became discerning on what information other professionals required to make decisions toward patient care:
I have this information and it’s all the same, it’s all ranked on the same level. But now it’s easier to pinpoint which information is helpful.
The ability to articulate knowledge useful for other professions meant communicating toward a common practice community vision.
4.2 Leadership from Expectations and Obligations
This learning step was often an emotional response to the conflict that occurred between internal and external obligations required in striving for more than a standard of interprofessional care. The statement describing the learning step was:
Leadership arises from respecting commitment to patients and team & appreciating contributions rather than focusing on singular approach to care; internal expectations and external obligations.
A realisation arose that for interprofessional teams to succeed, leadership was required. Students moved from being in a professional silo to being a bridge to a shared perspective of care.
I was really surprised, it actually worked better. It is good to have that support. Like a teamwork kind of thing. I really appreciated learning about the different types of knowledge that they have to offer.
After witnessing effective teamwork, students were able to navigate a place for themselves in providing care, essentially being a bridge to further interprofessional learning and working.
Students reported seeking out others to gather personal feedback, asking for professional assistance to achieve patient interventions, sharing unique knowledge, or to thank others for their work.
But when you actually have people come to your face, or when they do those rounds as a group it’s like an amazing thing, I’m so pro that. That really is so beneficial for the patient.
The action of becoming a presence is intentional, not just for patient care, but for sharing leadership of team functioning. Internal expectations were professional goals or seeking assistance while external expectations were described as the team taking shared responsibility for safe patient care.
4.3 Trust and Value
The third learning step was weighted in relationship building that included the patient and family which required the effort of building trust and acknowledging the value of others. The aggregate statement of learning from students was:
Trust and retaining value as a professional come from reciprocity in learning about and building upon professional strengths to safely interact, not disappoint, & link patients to the best efficient care.
Student narratives in this learning step were reflective of how they could learn. Disrespect and conflict were frustrating because of the impact to teamwork or team goals;
Every team has some kind of conflict. Because everyone has some kind of self-esteem that is a silo and to me the walls are too high, so sometimes
they don’t put in the teamwork. Put the legacy of the work there. Don’t put the legacy of yourself.
Students worked through conflicts in an attempt to not be reactive, but to create safety and opportunity for learning.
A story of participating in psychiatric rounds revealed the variations in how health profession students experience their clinical. Despite her effort, team members always went to the staff member for information. During rounds, the psychiatrist gave up leadership and asked all the interprofessional students to report.
It was one of the first times where my experience and my knowledge was like really valued and being listened to. It was interesting too, my value in that room was way different than when I closed the door and walked back out to the floor.
The experience in this narrative was an oscillation of value and trust in a short span of time, demarcated by the door to a room. Being able to show knowledge and experience that could contribute to patient care by seeking belonging, was an action toward gaining the trust of others.
Learning from profession-specific expertise for the value of increasing the therapeutic skills of interprofessional teammates was in an effort to improve the patient experience;
Most people have probably judged them. That’s the harm reduction part. We understand that addiction is not easy. How can we make this safer? How can I be a support for them without forcing them? Because they probably don’t trust anybody from their past experience. How do we show unconditional positive regard?
Students focused on learning that could change the patient experience, such as maintaining patient independence by improving mouth care mobility aides eg gluing a hockey puck to jar lids so patients could have a better grip.
4.4 Connect the Threads
As the deepest learning step, students revealed problem-solving, communication skills, and attaining an interprofessional worldview by employing empathic care. The aggregated statement for this step was,
Education fosters a responsibility and accountability to connect the threads of ethical or humane issues from individual and systemic worldviews when adjusting team care.
Students may be on the cusp of transformation in this step, potentially having greater awareness and understanding.
Now, having had a personal experience of interprofessional work, students could associate uniprofessional notes in static communication tools such as the patient chart with interprofessional discussions and context:
In the discussion you can see all the threads connecting, but in the chart, it says, we’ll trial this, based on my info, not the teams. They don’t write notes from the team’s plan – comprehensive. It’s each discipline by themselves – together but separately towards the goal.
Progress notes no longer captured the dyadic relationship between professional and patient. Students realized that notes were reflective of the patient interacting with the entire team. This was a moment where students articulated the awareness that problem-solving happened elsewhere and the chart only documented the results of those decisions:
Preceptors know what they are looking for in particular and generally where it goes. Where students don’t. You never ever see it related anywhere else unless you are in those rounds.
The significance for students was the opportunity to critically judge their own assessments and decisions as compared to professional counterparts. Silo walls began dismantling as students learned what knowledge and skills were required for efficient patient care.
A student shared her new conceptualizations of herself on the team, including how she processed information and contributed to coordinating plans. While she talked, she literally drew connecting lines in the air as if she was drawing a concept map or following ley lines:
When I look in a chart, to draw the lines myself, because they are not in there. I kind of see everybody sitting around a table having a discussion and I just wasn’t in on it. I can see the goals plotted along the lines. So that is very valuable for understanding the progress notes. But knowing that
they all round someplace without me, that they are all working and how I can contribute to that. Now I kind of pretend that I can sit at rounds with my goals.
This particular quote was an exemplar narrative of how an interprofessional worldview or perspective could have a communication structure and a relationship process. The team standpoint became the lens through which most students talked, including the rationale for their decisions.
Empathy was a required skill to show respect for patients and colleagues because it decreased judgment. The perspective of interprofessional care was that patients could receive so much more than the capacity of one individual.
We have to go back to the basics. Even just talking about brushing your teeth. Learning how to do that, you wouldn’t see so many cavities and you wouldn’t see kids end up in the emergency room with a heart infection. Not everyone learns those simple skills in life and to me it all goes back to education and preventative measures.
Students saw interprofessional learning and working as impacting upstream health prevention; improving the lives of individuals and the community.
4.5 Ontological Shift
An ontological shift is more profound than a conceptual shift, is required for health profession students (Land, Neve, & Martindale, 2018), and highlights transformation which is revealed as ways of practicing or thinking like professionals (Timmermans & Meyer, 2019). The experience of transformation is about meaning-making (Timmermans, 2010). Students shared the emotional impact of changing perspectives. The telling signs of shift were the rationales for modifying their learning or care plans to magnify the patient voice for an interprofessional perspective.
Students felt empowered with respect and encouragement from the interprofessional team. These experiences were ways to become autonomous and create networks of team members. A student who did her follow-up interview after graduation shared the experience of working in practice with an intraprofessional team,
I’ve learned they are completely juggling people all the time and trying to prioritize to keep track of things. They push me kind of like to my line basically. I definitely gained a lot more, I don’t want to call it respect,
because I always had respect, but it’s been a real eye opener for what they do.
She was challenged and tested to build her role on the team, but never out of her scope. She modified how she interacted with patients to fit the team approach to care for their context.
The patient perspective was apparent in shifts in thinking. One student witnessed a team struggling to work with a new immigrant speaking a different language. They ultimately found a translator which changed the patient experience:
Finally, we brought in the translator. The lady was so receptive! The way they teach in her country is little bit different than the way you teach a pure Canadian. I told the truth from growing up in my country. I told the staff, let’s approach it from this way.
The student had advocated, provided a cultural perspective, and led the team to resolution. She had become part of the team, providing clinical and cultural expertise.
All students had an emotional response along with their perspectives changing during the ontological shift. They gained confidence and self-assessed competence in relation to the interprofessional team, as well as a reflection of how they empowered the patient.
5 Discussion
The findings reflected the complexity between education and health for student learning. Students should be provided with authentic structured IPE, grounded in IPE frameworks and competencies, with diverse health profession students and patients as partners. Aiming to support authentic, epistemic and ontologic learning with a lack of instructional design results in mimicry and a decreased rationalization of patient-centred practice interventions for new graduates (Barradell & Fortune, 2020).
Interprofessionality is troublesome because of its variation in contexts of learning, patient acuity, student capacity across professions, and accessibility to others. Students with previous experience, like the community health nurse, paramedic, or continuing care assistant, may traverse the threshold more easily (Hill, 2020). This may translate to transferability of the conceptualization
The experience shared by students was troublesome and they exhibited anxiety with a change to confidence once the threshold was crossed. Martindale (2015) researched a similar experience of nursing students articulating anxiety to confidence in a research course about evidence-based practice. Students in my study had a strong response to relationship development with patients and interprofessional team members, contrary to research where students could not reconcile patient behaviour to theory (Leidl, 2016). For the most part, students were on the same trajectory to an ontological shift. The research showed the first learning step of students socially constructing team knowledge similar to a study with medical students (Neve et al., 2017). In step two, students developed communication skills to navigate expectations, including conflict resolution similar to students in mental health nursing research (Leidl, 2016). Step three was the beginning identity shift to being a professional, similar to occupational therapy students (Fortune et al., 2014). And finally, in step four, the outcome of interprofessionality was connecting the threads between professionals to ensure empathic care.
The non-linearity of the threshold concept framework (Land et al., 2010) was a well-suited guide. Seeking, and finding, all five threshold criteria in each interview grounded my understanding of the a-ha! moment ensuring I could differentiate between student experiences. I agree that transformation was a required criteria to meet and I would argue that it is not possible without integration and irreversibility. Boundedness was a tricky criterion for this study because Meyer and Land (2003) stated it was a boundary of disciplinary knowledge, yet healthcare, education and interprofessionality are full of complexity. Barradell and Fortune (2020) suggested that boundedness is a required criteria because of the mindset required; it assists students to provide clear and patient-centred contributions to an interprofessional team that required a profession-specific rationalization for quality care. The depth of narrative with which students described their threshold learning validated prioritizing the threshold concept framework (Meyer & Land, 2003) over the practice framework (CIHC, 2010). The students narrated their ways of thinking and practicing as becoming professionals both hierarchically through learning steps through progression to new graduates and in their hierarchical learning as interprofessional team members. This was confirmation that acquiring a
Scholars have long argued that interprofessionality is a process and an outcome. This is a wicked problem that this study begins to address because interprofessionality is a way of functioning for professionals and a bounded threshold concept (Barradell & Fortune, 2020). Future research shall determine whether “threshold concepts are the jewels in the curriculum, [while] WTP [ways of thinking and practicing] are what hold those jewels together in formation” (Barradell & Fortune, 2020, p. 302). Proponents may maintain that interprofessionality is a threshold concept jewel, a process and outcome of teamwork for quality patient care that is required of each profession to enact. Educators may maintain that interprofessionality is a key function of being a professional in healthcare and education for students and patients. These diverging and converging contextual priorities add to the complexity of future research crossing education and health boundaries. The benefit of the constructionist approach in partnership with health students was the member-checking process for each of their threshold concept a-ha! moments, learning steps, and shifts in ways of thinking and practicing.
From a practice framework perspective, students shared they were frequently invited to contribute their professional expertise. Being interprofessional enhanced their ability to contribute to care and decision-making for their patients. The argument existed that students earlier in their program have less professional identity development to be able to contribute competently. This was somewhat apparent in junior students providing more descriptive narratives about their threshold moments. However, students were adamant that interprofessionality could occur earlier if opportunities were offered. As noted, participants in this study were providing serendipitous a-ha! moments rather than the more authentic experiences of structured IPE in clinical settings which are more prevalent in the literature and notedly lacking in this provincial health education system. Confidence to contribute according to the interprofessional competencies (CIHC, 2010) came with, not just knowledge, but application in patient-centred care.
This was the patient paradox present in this study. Students and faculty need to be responsible for patient-centred care, not gleaning what they can from tokenistic patient contributions to interprofessional learning. Interprofessionality equitably prioritizes student learning along with patient outcomes (D’Amour & Oandason, 2005). The IECPCP framework links education and
6 Conclusion
A limitation of this study was the convenience sample despite a large population of health profession students available. However, this suggested that students self-selected because they understood the experience of the threshold moment as laid out in recruitment information. Further, there were no structured IPE in clinical acute contexts for health profession students in the province. Structured IPE has been considered the most authentic for learning as it facilitates the threshold moment. Therefore, this study relied on student experiences of serendipitous a-ha! moments.
Interprofessional education is diverse health profession students learning with, from and about each other to improve teamwork and provide quality care (CAIPE, 2017). The study purpose was to describe the threshold learning experiences of interprofessionality for health profession students. Ten students agreed to conversational interviews regarding their threshold a-ha! moment on an interprofessional team with patients and peers. Phenomenographical method guided the co-constructed learning steps leading to the ontological shift of the threshold crossing of interprofessionality. Student participants described both their individual and interprofessional experience, contributing to the aggregate. The short names for the learning steps with increasing depth were (1) community vision, (2) leadership expectations and obligations, (3) trust and value, and (4) connect the threads. The process of completing these steps was the liminal experience from separation, through crossing the threshold, to reaggregating as an interprofessional team member.
Interprofessionality begins with building community that shares the reciprocity of teamwork. There is a component of leadership that entails reconciling the obligations and expectations of being a professional in healthcare. Trust and valuing others are required for learning with, from, and about team members, patients, and families. Interprofessionality is taking those moments and connecting the threads to contribute to quality care.
Ashworth, P., & Lucas, U. (2000). Achieving empathy and engagement: A practical approach to the design, conduct and reporting of phenomenographic research. Studies in Higher Education, 25(3), 295–308. https://doi.org/10.1080/713696153
Barlow, C. A., Phelan, A., Hurlock, D., Sawa, R., Rogers, G., & Myrick, F. (2006). Virginia: A story of conflict in social work field education. Affilia: Journal of Women & Social Work, 21(4), 380–390. https://doi.org/10.1177/0886109906292175
Barr, H. (1998). Competent to collaborate: Towards a competency-based model for interprofessional education. Journal of Interprofessional Care, 12(2), 181–187. https://doi.org/10.3109/13561829809014104
Barradell, S., & Fortune, T. (2020). Bounded – The neglected threshold concept characteristic. Innovations in Education & Teaching International, 57(3), 296–304. https://doi.org/10.1080/14703297.2019.1657034
Berger, P. L., & Luckman, T. (1966). The social construction of reality: A treatise in the sociology of knowledge. Penguin Books.
Bowden, J. A. (2000). The nature of phenomenographic research. In J. A. Bowden & E. Walsh (Eds.), Phenomenography (pp. 1–18). RMIT University Press.
Canadian Interprofessional Health Collaborative. (2010). A national interprofessional competency framework. https://health.ubc.ca/sites/health.ubc.ca/files/documents/CIHC_IPCompetencies_Feb1210.pdf
Centre for Advancement in Interprofessional Education. (2017). Interprofessional education guidelines. https://www.caipe.org/download/caipe-2017-interprofessional-education-guidelines-2/?tmstv=1705326852
D’Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 10(Suppl. 1), 8–20. https://doi.org/10.1080/13561820500081604
Davies, P. (2006). Threshold concepts: how can we recognize them? In J. H. F. Meyer & R. Land (Eds.), Overcoming barriers to student understanding: Threshold concepts and troublesome knowledge (pp. 70–84).
Fortune, T., Ennals, P., & Kennedy-Jones, M. (2014). The hero’s journey: Uncovering threshold barriers, dispositions and practices among occupational therapy students. Paper presented at the Sixth Annual Conference and the Fourth Biennial Threshold Concepts Conference, Dublin, Ireland. https://files.eric.ed.gov/fulltext/ED558533.pdf
Fuzzard, R. (2017). Yes but no but yes – students straddling the change process in community service work. Practice and Evidence of Scholarship of Teaching and Learning in Higher Education, 12(2), 116–124.
Goldman, J., Zwarenstein, M., Bhattacharyya, O., & Reeves, S. (2009). Improving the clarity of the interprofessional field: Implications for research and continuing interprofessional education. Journal of Continuing Education in the Health Professions, 29(3), 151–156. https://doi.org/10.1002/chp.20028
Hammick, M. (1998). Interprofessional education: Concept, theory and application. Journal of Interprofessional Care, 12(3), 323–332. https://doi.org/10.3109/13561829809014123
Hill, S. (2020). The difference between troublesome knowledge and threshold concepts. Studies in Higher Education, 45(3), 665–676. https://doi.org/10.1080/03075079.2019.1619679
Holland, K. (1999). A journey to becoming: The student in transition. Journal of Advanced Nursing, 29(1), 229–236. https://doi.org/10.1046/j.1365-2648.1999.00883.x
Hurlock, D., Barlow, C., Phelan, A., Myrick, F., Sawa, R., & Rogers, G. (2008). Falls the shadow and the light: Liminality and natality in social work field education. Teaching in Higher Education, 13(3), 291–301. https://doi.org/10.1080/13562510802045311
Kolar, C. (2017). Across the patient care practitioner threshold: Identifying threshold concepts and evaluating the teaching of the pharmacists’ patient care process [Doctoral dissertation]. University of Minnesota. https://conservancy.umn.edu/handle/11299/188949
Land, R., Neve, H., & Martindale, L. (2018). Threshold concepts, action poetry and the health professions: An interview with Ray Land. International Journal of Practice-based Learning in Health and Social Care, 6(1), 45–52. https://doi.org/10.18552/ijpblhsc.v6i1.517
Leidl, D. M. (2016). Troublesome mental health knowledge in a western Canadian undergraduate nursing education program: Student and faculty perspectives [Doctoral dissertation]. University of Liverpool. https://livrepository.liverpool.ac.uk/3000872/1/200874683_April2016.pdf
Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Directions for Program Evaluation, 30, 73–84. https://doi.org/10.1002/ev.1427
Martindale, L. (2015). Threshold concepts in research and evidence-based practice: Investigating troublesome learning for undergraduate nursing students [Doctoral dissertation]. Durham University. http://etheses.dur.ac.uk/10998/
Marton, F. (1981). Phenomenography – Describing conceptions of the world around us. Instructional Science, 10, 177–200. https://doi.org/10.1007/BF00132516
Marton, F. (2000). The structure of awareness. In J. A. Bowden & E. Walsh (Eds.), Phenomenography (pp. 102–116). RMIT University Press.
Marton, F., & Booth, S. (1997). Learning and awareness. Lawrence Erlbaum Associates.
Meyer, J., & Land, R. (2003). Threshold concepts and troublesome knowledge: Linkages to ways of thinking and practising within the disciplines. Universities of Edinburgh.
Neve, H., Lloyd, H., & Collett, T. (2017). Understanding students’ experiences of professionalism learning: A ‘threshold’ approach. Teaching in Higher Education, 22(1), 92–108. https://doi.org/10.1080/13562517.2016.1221810
Nicola-Richmond, K. M., Pepin, G., & Larkin, H. (2016). Transformation from student to occupational therapist: Using Delphi technique to identify the threshold concepts of occupational therapy. Australian Occupational Therapy Journal, 63(2), 95–104. https://doi.org/10.1111/1440-1630.12252
Parker, J., Ashencaen Crabtree, S., bin Baba, I., Carlo, D. P., & Azman, A. (2012). Liminality and learning: International placements as a rite of passage. Asia Pacific Journal of Social Work & Development (Routledge), 22(3), 146–158. https://doi.org/10.1080/02185385.2012.691715
Royeen, C. B., Jensen, G. M., Chapman, T. A., & Ciccone, T. (2010). Is interprofessionality a threshold concept for education and health care practice? Journal of Allied Health, 39(3 pt 2), 251–252.
Springfield, E. A., Rodger, S., & Gustafsson, L. (2017). Threshold concepts and authentic assessment: Learning to think like an occupational therapist. Practice and Evidence of Scholarship of Teaching and Learning in Higher Education, 12(2), 125–156.
Stacey, G., Oxley, R., & Aubeeluck, A. (2015). Combining lived experience with the facilitation of enquiry-based learning: A ‘trigger’ for transformative learning. Journal of Psychiatric and Mental Health Nursing, 22(7), 522–528. https://doi.org/10.1111/jpm.12228
Timmermans, J. A. (2010). Changing our minds: The developmental potential of threshold concepts. In J. H. F. Meyer, R. Land, & C. Baillie (Eds.), Threshold concepts and transformational learning (pp. 3–19). Sense. https://doi.org/10.1163/9789460912078_002
Timmermans, J. A., & Meyer, J. H. F. (2019). A framework for working with university teachers to create and embed ‘Integrated Threshold Concept Knowledge’ (ITCK) in their practice. International Journal for Academic Development, 24(4), 354–368. https://doi.org/10.1080/1360144X.2017.1388241
Turner, V. W. (1969). The ritual process: Structure and anti-structure. Aldine Publishing Company.