|Supporting Interprofessional Learning in Practice an Evaluation of a Pilot Project|
Page 1 of 2Authors: Kathleen Markey, University of Limerick & Charmagne Barnes, Middlesex University
Keywords: interprofessional education; practice; undergraduate programme; medical students; nursing students
This paper reports on the effectiveness of the learning and teaching approaches incorporated into a small scale interprofessional education pilot project, as evaluated by the participating students. The pilot brought together second-year nursing students and third-year medical students, for a period of four weeks of clinical practice, taught classroom sessions, self-directed study and facilitated reflective sessions.
The findings suggest that interprofessional learning in practice for undergraduate students on health care programmes is a highly valued experience, however, it requires extensive facilitation and structuring. Students involved in this pilot reported that they better understood the roles and remit of other healthcare professionals, including strengths and challenges that are present. The variety of learning and teaching approaches were evaluated positively although these elicited different views from student respondents.
Students highlighted the importance of structuring, focusing and facilitating such experiences to maximise the true interprofessional learning opportunities. Recommendations are made around the need for focussed and facilitated interprofessional learning opportunities in practice and the need for the incorporation of a variety of learning and teaching approaches. Although it is not within the scope of this article, these recommendations highlight the need for good interprofessional facilitation skills.
Introduction‘Interprofessional working requires complex interactions between two or more members of different professional disciplines, with the aim of achieving improved patient outcomes’ (Barrett et al, 2005, p.13). To assist in the preparation of professionals towards collaborative work, there has been an increase in the call for interprofessional education (IPE) (Barr and Ross, 2006). IPE occurs when two or more professions learn with, from and about one another, to facilitate collaboration in practice (CAIPE, 2002). This definition in itself suggests the potential complexity that may be associated with supporting sustainable and meaningful IPE for a diverse range of learners in undergraduate programmes. In particular, undergraduate professional programmes predominantly have larger numbers of students, with variances in the design and structure of curricula, which can result in challenges presented when considering developing sustainable IPE. This suggests the potential need for locally piloting IPE initiatives in undergraduate programmes, in an attempt to consider sustainable strategies that will support the development of IPE in individual institutions, to a diverse range of learners. This paper reports on an evaluation of a small scale IPE pilot project, with nursing and medical undergraduate students in a care of the older persons' clinical setting, in the United Kingdom (UK).
BackgroundResearch suggests that IPE is beneficial in attempting to enhance interprofessional collaboration and develop positive changes in attitudes, knowledge and skills (Cooper et al, 2001; Salmon and Jones, 2001; Freeth et al, 2002; Cullen et al, 2003). Although there has been much debate within the literature about the stage of professional development at which IPE has the greatest impact, the conventional wisdom that IPE is better left until after qualification has now been rejected, as the case for collaborative practice becomes ever stronger (Barr and Ross, 2006). Research literature supports the implementation of IPE in undergraduate as well as postgraduate programmes (Salmon and Jones, 2001; Cooper et al, 2001; Freeth et al, 2002; Barr, 2002), suggesting that early interprofessional learning experiences benefited later participation in interprofessional activities. Similarly, Hind et al (2003) found in their evaluation of inexperienced first year undergraduate students, from various disciplines, that there was a strong willingness to engage in interprofessional learning, suggesting that educators should capitalise on this potential. When considering strategies to support IPE to a diverse range of learners from different disciplines, it is important to plan appropriate learning and teaching approaches that will be most effective in achieving meaningful and sustainable IPE. Some research suggests that models of education that incorporate significant didactic, lecture-based elements may be less effective in promoting change, with attitudes towards interprofessional working remaining the same (Cooper et al, 2001; Tunstall - Pedoe et al, 2003). Nevertheless, didactic teaching methods remain a popular choice for IPE initiatives (Cooper et al, 2001; Freeth et al, 2002). Interestingly, O’Neill and Wyness (2004) in their qualitative evaluation of an interprofessional programme in Canada, report that students found experiential components of the programme more meaningful than theoretical components, and particularly valued practice-based learning experiences. Learning and teaching approaches and styles incorporated in IPE initiatives are predominantly influenced by the individual IPE facilitator. However, Freeth et al (2001) warn that the differing styles of facilitation can effect the team functioning and student satisfaction with the IPE experience. Similarly, Salmon and Jones (2001) and Camasooksai (2002) argue that IPE facilitators require appropriate IPE facilitation training and development, as poor IPE facilitation could further reinforce any prior hostilities. It is against this research that this small scale IPE pilot project is set in an attempt to consider ways of introducing IPE that is both sustainable and meaningful, across the undergraduate programmes delivered in two UK institutions.
IPE ModelThis IPE pilot was designed specifically for second-year nursing and third-year medical students, from two UK Higher Education Institutions (HEI). In an attempt to encourage meaningful learning, a variety of learning and teaching approaches in the classroom and practice settings were incorporated, over a four week period. These approaches consisted of: a) facilitated clinical learning experiences where nursing and medical students were paired together in a care of the older person setting; b) taught classroom sessions by specialist practitioners; c) self-directed study incorporating the use of a workbook and d) facilitated guided reflective sessions both as individuals and as a group. The decision to use a care of the older person setting was made, due to the coincidental, concurrent allocated clinical placement of medical and nursing students. Ethical approval was obtained. Those students that took part were in their second or third year of their respective programme and had been asked if they wanted to take part in this IPE initiative. Consideration was given to the need to protect the confidentiality of the participants and obtain their consent to the collection, recording and subsequent use of the data. Volunteers were informed that they were free to withdraw at any time, without detriment to their education.
SamplingA non-probability design to select the sample for this pilot was incorporated, using a purposeful sampling strategy. The criterion was based on the participant studying on the selected undergraduate programme, at the required level, and allocated to undertake a clinical placement in a care of the older person setting as part of their professional programme, during the time the pilot was due to run. Due to the complex nature of placement allocation for both of these disciplines, which were from two different universities, it was only possible to recruit four second-year nursing and four third-year medical students.
Methods of EvaluationData was collected from the participating students on completion of the four week experience using questionnaires and a focus group. It was envisaged that this would assist the gathering of data that had meaning and utility for both institutions, when considering the development of future IPE initiatives.
QuestionnaireAnonymous self-administered questionnaires were used to obtain opinions from the students concerning their experiences of participating in the pilot. The questionnaire combined the use of both open and closed questions. The findings from the questionnaire contributed to the devising of the prompt schedule for the focus group.
Focus groupA tape recorded focus group, using a flexible prompt schedule to enable probing of unanticipated issues emerging, was facilitated by a member of the project team. The interview schedule was devised in the light of issues that emerged from the questionnaire study e.g. views of the experience, how the learning had taken place and whether there were suggestions for improvement. The schedule was used flexibly to enable students and the facilitator to raise issues they considered relevant, while enabling differing perspectives to be explored and debated. However, the limitations of focus groups need to be highlighted in relation to validity.
Data AnalysisData collected through the questionnaires was analysed descriptively. The tape recording of the focus group was fully transcribed and analysed using a framework approach (Ritchie and Spencer, 1994). Guided by the framework approach our analysis comprised of a number of stages. An initial stage of familiarisation was achieved by listening to the tape recordings and reading the transcripts to establish a thematic framework of key concepts and themes; gaining an overview of the richness, depth and diversity of the data collected. During the process of indexing the data was systematically annotated according to the thematic framework and tabulated accordingly. Key characteristics of the data were interpreted as a whole by returning to the key objectives of the evaluation of the pilot project.
ResultsFour main themes emerged from the analysis of the data: a) structure of IPE initiatives; b) learning and teaching approaches; c) IPE opportunities in practice and d) professional identity.
Table 1: A summary of results presented in tabular form
Structure of IPE initiativesThe participants overall reported that the experience of participating in the pilot had improved their understanding of the value of team based methods of healthcare delivery.
“I now have a greater appreciation of the benefits of team working, for the individual and most importantly for the patient….” (Nursing student)
The students were in agreement that the structure of the IPE initiative met their needs, as it incorporated learning in the classroom and the practice setting.
“The biggest contributions towards our learning were the workshops in the classroom facilitated by the specialist practitioners, being able to meet professionals from other disciplines, and working with a student from another discipline.” (Medical student)
Similarly, another participant felt that the key to their development was the facilitation and support received during this pilot.
“…. In other circumstances it probably wouldn’t have been so focussed and so direct.” (Nursing student)
All of the participating students felt that it was important for students to be aware of the issues raised by this pilot project, however, some of the students felt that such learning should take place earlier in their professional undergraduate programmes.
“First year students would have benefited from this better.” (Medical student)
Some participating students felt that this learning later in their programme was not seen as a priority and would not be of benefit to their development. “…as our priority is developing the skills to carry out procedures....and enable us to pass our assessments.” (Medical student)
Learning and teaching approachesThere were however, mixed views with regards to the value of the different learning and teaching approaches incorporated in this IPE initiative. Some students felt that the most valuable component of the programme were the lectures from specialist practitioners.
“....it was really useful to meet specialist practitioners and learn about what they do in practice. I had never heard of a community matron.” (Medical student)
However, other students valued the structured experiences in practice, working with a student from a different discipline and being able to meet professionals in practice and discuss their role with them, while caring for a patient.
“It was really useful to meet other professionals and learn about their roles and remit but also to work with a student from another discipline as it enabled us to consider…….”(Nursing student)
Together with the difference in opinions of the most effective learning and teaching approach, participants reported obstacles to their learning during this pilot. Many students felt that there were differences in terminology, used by professionals on different undergraduate programmes and reported that this is one barrier to effective interprofessional communication and learning.
“The difference in terminology does not help, for example why use the term holistic?”(Medical student)
Participants identified further challenges with: a) learning to work collaboratively; b) demarcating responsibility and c) difficulties in maintaining and tracking accountability. Specifically, these challenges included how to keep open the many different lines of communication required by team working and also the challenge of benchmarking clinical work in a way that is understandable to other professionals.
“…there are challenges in separating responsibility and difficulties in maintaining and tracking accountability, depending on the professional group in question…..” (Medical student)
IPE opportunities in practiceStudents suggested that further insight into interprofessional working in practice could be developed, through being encouraged to become involved in IPE learning opportunities that are already available on the ward. However, it was reported that these IPE opportunities need to be made more specific and better structured.
“It would be useful to participate in clinical sessions on the wards with different healthcare professionals, and more exposure to multi-disciplinary communication such as multi-disciplinary team meetings. All of which do occur on the ward but are sometimes only made available for the select few students.”(Nursing student)
The participants agreed that whilst the learning they had achieved could have taken place in the practice setting over a long period of time, there is a possibility that many areas may have been missed and may not have occurred until after qualification.
“…..it would only have done so very sporadically and as a lengthy drawn out professional development on the job.” (Medical student)
However, it was acknowledged that any IPE opportunity in practice often depends on the teacher/facilitator.
“It would depend on who is teaching you.”(Nursing student)
Professional identityParticipants reported on examples of how they had developed a greater insight, and understanding, into their own professional identity, as a result of their participation in the pilot. The students reported that this pilot encouraged and provided them with an opportunity to consider and reflect upon their role and responsibilities, within the context of interprofessional working.
“I think by being aware of other people, it makes you aware of yourself and what your remit is and what you need to be doing when you go and see a patient…. (Medical student)
For the majority of students (N = 7/8) their understanding of the role and remit of other professions had also increased as a result of their participation in the pilot. Two participants spoke of their realisation
that different healthcare professionals were there for the same reason.
“I now have a greater appreciation of each other’s common humanity.” (Medical student)
The majority of students (N = 6/8) as above reported that other healthcare professionals now seemed much more approachable, as they gained a greater understanding into their roles and remit. The students in the focus group reported that they now felt far more able to interact with other healthcare professionals on the ward.
“I think we’re all much more aware of who is out there and who we’ll be able to get in touch with. Whereas before I wouldn’t have… but now having met these people and having come up to them…” (Medical student)
Their experiences had also prompted them to challenge the stereotypical ideas and beliefs they had previously harboured in respect to individual professions, activities on the ward, and patterns of interactions between professionals from different healthcare disciplines.
“The part that actually I felt changed was my stereotypical idea of what a doctor and a nurse did together.”(Medical student)
Just over half of the students (N = 5/8) as above reported that participation in the pilot project had enhanced their own professionals skills. These students also said that their confidence had increased.
“…before I was just here in the capacity as a student. But now I feel more than a student. I could do my own initial assessment and I could work my way through. I could assess as I go along. On my own, you know independently. I feel empowered. I felt I was doing something worthwhile.”(Nursing student)
Some students did consider IPE to be a worthwhile aim in order to improve communication between professionals and improve a team approach to complex health and social care problems. However, two students reported that IPE would not necessarily influence how they would practice in the future, as it is not seen to be a priority objective of their curriculum.
DiscussionPositive benefits of IPE
Overall, the students evaluated their IPE experiences positively. They agreed that IPE was an extremely valuable addition to their uniprofessional syllabus, as it enhanced understanding of their own roles, alongside the roles and remit of other healthcare professionals. Furthermore, students reported that it assisted them to further develop their insight into interprofessional working, including the strengths and challenges that this method of healthcare delivery presents. Similar benefits were highlighted by Lumague et al (2006), where students reported an increase in understanding of: a) their own professional role within the team; b) the value of team-working and c) viewing other professionals as more approachable. Students reported that the key to their developments with this IPE initiative was the intense facilitation and support received, particularly with the continuous presence of one member of the project team throughout the pilot. However, such intense presence and support would not be sustainable for future IPE initiatives to a larger number of students. Similarly, Salmon and Jones (2001), Cullen (2003) and Mendez et al (2008) highlight that IPE can be resource intensive and consideration needs to be given to devising IPE initiatives that are more flexible.
Structuring future IPE initiativesIn order to sustain IPE long-term in undergraduate programmes, the delivery model chosen needs to be sufficiently flexible, in order that a number of disciplines in a variety of learning settings, can participate. Freeth et al, (2001) discuss in their evaluation of an interprofessional training ward the value of contextualising IPE in the practice setting. It is evident that there are valuable interprofessional learning opportunities in practice as reported by the students in this pilot such as: clinical sessions on the wards with different healthcare professionals and more exposure to multi-disciplinary communication e.g. in multi-disciplinary team meetings. These IPE opportunities in practice should be capitalised on. However, much of the current literature appears to evaluate IPE initiatives that are classroom based, with fewer evaluations of IPE initiatives in the practice learning environment. D’Eon (2005) emphasises that IPE learning opportunities for a diverse range of learners should be approached from an experiential learning framework, incorporating planning, doing, observing and reflecting. Practitioners and academics need to work closely together to consider making such opportunities explicit and consider a variety of learning and teaching strategies that could be used to achieve such interprofessional objectives. Sustainability is also subject to the availability of facilitators to support students as they undertake the clinical activities.
IPE opportunities in practiceThe opportunities for undergraduate students from different professional backgrounds to work and learn together within a clinical context, are generally of an opportunistic nature. Students reported that there are such opportunities for interprofessional learning in practice but they are not perceived as a priority and certain opportunities may get missed. It is clear that to support successful interprofessional learning, in practice, interprofessional learning opportunities need to be clearly structured, facilitated and a variety of learning and teaching approaches incorporated. However, the challenge in organising and facilitating a variety of students with different backgrounds, and from different disciplines, to bring together in practice settings to learn with, from and about one another must not be under estimated. Salmon and Jones (2001) and Camasooksai (2002) argue that good facilitation skills and processes are necessary for facilitators of IPE, who should have links to both academic and practical settings if this method of education delivery is to be effective. However, anecdotal evidence from practice suggests that facilitators often feel ill-equipped for this education role. This suggests the need for interprofessional "champions" in both theory and practice, but this may require further professional development as many lecturers and practitioners may be products of an educational system whose perspective is limited to that of their own discipline and whose methods are uniprofessional rather than interprofessional.
Timing of IPE initiativesThere remains much debate about how early in the undergraduate programme IPE should be introduced. Many critics warn that premature introduction of IPE is not only inefficient but can be negative (Tunstall-Pedoe et al, 2003; Cullen et al, 2003; Mendez et al, 2008). However, this small scale study found that students felt that IPE initiatives should be introduced earlier in the programme and identified that developing key skills to carry out procedures were seen as more of a priority for more senior students. Finch (2000), suggests that it might be more effective to develop learning from an early stage in clinical settings, and further build on this throughout the programme, but acknowledge the organisational challenges for this are great.
Learning and teaching approachesA variety of learning and teaching approaches were incorporated into this small scale pilot in an attempt to address the learning needs of students from different disciplines and who were at different academic levels. This proved beneficial as the participating students had different preferences to learning and teaching approaches incorporated. The medical students appeared to prefer and get more from the didactic approaches, while the nursing students appeared to value the experimental approaches better. Further explorations into why this is the case is required where perhaps a mapping exercise of curriculum content and teaching strategies may reveal some anomalies.
IPE is grounded in adult learning theory (Barr, 2002) but to enable the learners to learn on a deeper and more permanent level, a variety of learning and teaching approaches are required and knowledge should have direct and early application to practice (Knowles, 1975). Hence, effective interprofessional learning has as its focus the relationship to the social situations in which it occurs; interprofessional learning takes place within a framework of social participation (Cable, 2000).
Although the literature identifies that there is a preference for interactive rather than didactic teaching and learning methods in IPE, arguably this small study identifies that didactic teaching may be effectively used to provide structured input and to complement and reinforce interactive learning (Barr, 2002). Similarly, Wakefield et al (2006), advocate combining learning and teaching approaches to ensure collaboration and interaction occur. The students were in agreement that the aspects of the programme that had made the largest contribution towards their learning were the lectures from the specialist practitioners, being able to meet professionals from other disciplines and working with a student from another discipline.
Challenges that presented as obstacles to the students learning were communication and different terminologies used by different professional groups. Students reported a variety of benefits gained from participation in this small scale pilot including: a) increased understanding of their own professional role within the team; b) the value of team-working and c) viewing other professionals as more approachable. Studies in Canada found that students involved in IPE initiatives in undergraduate programmes reported that their own professional identities were strengthened and their understanding of the roles of other professions had also increased (O’Neill and Wyness, 2004; Lumague et al, 2006).
In addition, students in this pilot identified where their roles were distinct and where they overlapped, which is consistent with findings from a larger IPE study carried out by Wakefield et al, (2006). It is evident from the results that a variety of teaching and learning approaches was beneficial, as no single approach met all individual learning needs. Didactic approaches were reinforced by interactive and experiential learning, fostering reflection on other perspectives. Both individual and group reflection were encouraged and facilitated throughout the pilot. This reflection contributed to what had been learned about interprofessional issues as it provided an opportunity for learners to become aware of what they have experienced, in an attempt to consolidate learning that is meaningful. Emphasis on promoting teamwork, reflection and meaningful interaction amongst students from different professional backgrounds relies on the IPE facilitation skills of the facilitator. Specific IPE facilitation training should be provided to ensure consistent IPE teaching and learning approaches are incorporated in IPE initiatives. Camsooksai (2002) identifies good facilitation and strong practice-academic links as crucial in achieving successful IPE. However, Freeth et al (2001) highlight that IPE facilitators in practice are at risk of “burn out” due to the long-term effects of maintaining such IPE activities in practice.
ConclusionFacilitated interprofessional learning in practice for undergraduate students on health care programmes is a highly valued experience, but has many complexities. It is a useful way to challenge interprofessional boundaries, to develop understanding of ones’ own role alongside that of other professionals within health and social care provision. There is a need for further research to explore the effectiveness of IPE in changing long-term attitudes and behaviour, and its impact on improving interprofessional working and patient care. This was a small scale pilot study, incorporating small numbers of students from two disciplines. This pilot has, however, reiterated for us the need for quality IPE experiences within our undergraduate programmes, alongside the strengths and challenges inherent in its implementation. It has allowed us to take small steps in the direction of furthering the IPE agenda within our curriculum, whilst allowing us good insight into how we might progress this within our undergraduate health and social care programmes in the near future. It is clear that investment in the development of practice placements and the staff that support learning in practice is key to enhancing interprofessional learning. Further research is required to evaluate interprofessional interventions that: a) provide longer periods of time in practice; b) incorporate students from other health and social care professional groups and c) utilise evaluation strategies that explore longer-term follow-up of outcomes.
AcknowledgementsAcknowledgements and thanks go to: The Project Team: Charmagne Barnes; Kathleen Markey; Kay Caldwell; Madeline Brett-Richards; Kathy Wilson; Lisa Smith; Katrina Myrdal; Sheena Mitchell; Clarissa Murdoch; Caroline Sargisson; Marcia Fernandes and Kate Coleman. The Project Team is very grateful to the students who gave so generously of their time to participate in the interprofessional learning in practice experiences and contributed towards the evaluation of this project. We are grateful to the North Central London Strategic Health Authority for funding this project.