The participants answered questionnaires that were distributed daily (n = 66), to all participants, during the fourteen weeks course. A total of 2,376 questionnaires were distributed via mobile phone technology. In addition, the participants were asked to score their attitudes about interprofessional teamwork (IPT) by using the Interdisciplinary Education Perception scale (IEPS) questionaries before and after the course. In the IEPS questionaries interprofessional cooperation are used as IPT synonymous.

The questionnaires

Every day’s questionnaire consisted of ten questions, (Table 1) regarding ongoing activity and in what way the participants experienced, e.g., cooperation in the group of the course, academic emotions, flow, and stress. At the end of each day, Monday to Friday, the participants received a reminder in their mobile phones about complete their daily CASS questionnaire.

Table 1 Daily CASS questions asked to be answered related to reported learning activities

The CASS methodology enables moment by moment reports from the respondents. The methodology was developed to gather on-going experiences instead retrospective memories [27]. The CASS-methodology was inspired by the Experience-Sampling Method (ESM) [30]. In this study the participants were asked to respond on one CASS-questionnaire each day during the course. The number of questionnaires completed ranged from zero to 58.

To be included in the analysis, the participants had to respond to the two provided IEPS questionnaires, before and after the course. In addition, the participants had to have completed a minimum of three CASS-questionnaires during the 14-week course. Nine of the participants completed less than three questionnaires and thus were excluded from the analysis. This resulted in the inclusion of 27 participants whereof 24 also answered the requested IEPS-questionnaires, before and after the course.

Procedure using Contextual Activity Sampling System.

By using the the Contextual Activity Sampling System (CASS) methodology, [25,26,27], for data collection the participants accessed the CASS questionnaires online. Each participant was asked to respond to a total of 66 questionnaires via CASS, each including ten questions (Table 1). The response times were 3 – 5 min for each questionnaire and the questions were repeated daily so they would become familiar to the participants. The questionnaires were returned to the database server automatically after completion. Data were stored and then made available to the group of researchers. This methodology enabled investigators to follow participants’ ongoing activities and experiences concerning, e.g., academic emotions, longitudinally. The focus was on collecting the participants’ experiences of collaboration, academic emotions, flow, and stress during a fourteen-week course, by using the CASS methodology. The study participants, physicians from countries outside Europe, were asked to work together in various activities, such as seminars, clinical practice and groupwork with, and without, supervision.


The four-channel model [8, 10, 11] (Fig. 1) was used to describe the participants’ experience of flow in relation to ongoing activities.

Fig. 1
figure 1

The four-channel model of flow inspired by Csikszentmihalyi [8]

Flow has been defined as a situation when a person carrying out a task experiences it as challenging, meaningful and has a feeling of having adequate competence to manage it [8,9,10,11]. Pekrun et al. [5], and Adar [6] have both stated that positive experiences stimulate people and help them appreciate the actual situation.

Academic emotions

The participants rated their experience of academic emotions connected to daily course activities on a Likert scale graded from one to seven. One indicates very low and seven very much. The positive emotions rated were: determination, enthusiasm, and interest, and the negative emotions: irritation, nervousness, and being afraid. The participants were asked to rate their experience of both positive (determination, enthusiasm, and interest) and negative emotions (irritation, nervousness, and fear), together known as academic emotions [31]. The Cronbach´s alpha coefficient for the questions about positive emotions were 0.78 and negative emotions 0.79 [32].


Experience of stress was measured by one-single question [33], on a Lickert-scale 1–7, with 1 indicating “Not at all” and 7 “maximum”. The question asked was: Stress refers to situations in which people feel tense, anxious, nervous, or crowded, or when they have sleeping difficulties because they are constantly thinking of things. Do you feel that kind of stress currently. The single-item measure of stress symptoms has been tested for validity by Elo et al. [33] and has been found to be satisfactory.

Interdisciplinary Education Perception Scale

Using the Swedish version [34] of the Interdisciplinary Education Perception Scale (IEPS) [19], the participants’ attitudes and perceptions concerning the need of interprofessional teamwork were assessed. The IEPS [19, 34] consists of 12 questions with a six-point, Likert scale (one = strongly disagree and six = strongly agree) and was used to investigate if the course impacted on their perceptions. It has been divided into three categories, which are Competency and autonomy (scale 1–30), Perceived need for cooperation (scale 1–12), and Perception of actual cooperation (scale 1–30). The Cronbach´s alpha coefficient for the subscales were 0.89, 0.88 and 0.66 [19, 34].


Descriptive statistics were used to analyse demographic data, academic emotions, stress and FLOW. Group data are presented as mean value (± SD), numbers, and proportions of numbers (%). Since each participant answered the CASS-questions, i.e., stress, experience of flow, academic emotions, positive and negative emotions, between 3 – 58 times, a Z-score was calculated on an individual level: first, the mean and standard deviation for each question and each participant. The scores were then standardized for each question and for each participant by setting the mean to zero and the SD to one to reduce effects of variances related to individual answering tendencies [35]. Flow, apathy, anxiety, and boredom are presented with numbers and proportion of numbers in relation with learning activities. The experience of flow occurs when competence is rated > 0 and challenge > 0; anxiety when competence is rated < 0 and challenge > 0; apathy when competence is rated < 0 and challenge < 0; and boredom when competence is rated > 0 and challenge < 0 [8,9,10, 36]. The relation between stress and reported activities was also calculated, as well as positive and negative emotions connected to reported learning activities with descriptive statistics. IEPS was analysed by paired sample T-test.

All statistical analyses were performed using a database application (Excel) and the software The Statistical Package for Social Science, SPSS version 27 [37]. A p-value < 0.05 was considered as statistical significance.


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