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Interprofessional Learning in a Blended Learning Environment: Rhetoric, Reality and Opportunity
Margeurite Bramble School of Nursing & Midwifery, University of Tasmania, Australia
Ellen Ennever School of Medicine, Faculty of Health Science, University of Tasmania, Australia
Rosalind Bull School of Nursing & Midwifery, University of Tasmania, Australia
Justin Walls Faculty of Health Science, University of Tasmania, Australia
Craig Zimitat School of Medicine, University of Tasmania, Australia
Abstract
Interprofessional education (IPE) is an important goal in undergraduate health professional education because of its potential for improved patient care and health care reform. This paper explores the IP dimension of a unit from the perspective of medical students enrolled with other health professional students in a unit delivered face to face and online to a large cohort across multiple campuses. There was alignment between the rhetoric of the unit description and the reality of course delivery. Their experiences illustrated how small issues can undermine the philosophy and goals of a curriculum and highlighted the challenges of connecting students in a unit delivered face to face and online across disciplines and campuses. Opportunities for improvement include a broader faculty vision for IPE, permeation of the IP philosophy across all teaching and learning activities and consideration of new technologies to enrich online social interaction
KEYWORDS: IP education, medical education, undergraduates, online learning
Introduction
Interprofessional (IP) education (IPE) is a priority area in health professional education. The drivers for IPE include the need for workforce flexibility and reform, changes in the demographics of ill health and an aging population with chronic disease, improved patient safety and health outcomes (WHO, 2010). “IPE occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care" (Barr, 2002). IPE involves learning to collaborate, learning from others, learning from experience and learning together to improve health care. IPL goes beyond multidisciplinary team work because it aims to achieve broad system reform to achieve better patient outcomes. The implementation of IPE activities in the workplace has led to improvements in culture, fewer errors and better management of patient care (Hammick, Freeth, Koppel, Reeves, & Barr, 2007; Reeves et al., 2009; Zwarenstein et al., 2000). There is scope for more work evaluating workplace change and health outcomes brought about by IPE over the short and longer term (Thistlethwaite & Nisbet, 2007). Whilst the positive impact of IPE continues to emerge, government health policies continue to drive IPE partnerships and collaborative practice.
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The last decade has seen a significant amount of national and state based policy development around IPE. The Framework for Action (WHO, 2010) has identified stakeholders, processes, enablers and actions for policy makers to advance IPE in their own jurisdictions. Creating an IP workforce: An education and training framework for Health and Social Care in England (Department of Health, 2007) is a comprehensive example of the translation of the WHO framework to a national context. It defines essential processes and roles and responsibilities of key stakeholders in shaping culture to positively influence the formation of an inter-professional health workforce, and highlights the importance of partnerships between key agencies and universities. In Australia, uptake of IPE at the state level has been uneven. However, sophisticated examples exist in West Australia (Reid, M., Laungoulant, Saffioti, & Cloghan, 2004) and ACT (ACT Health, 2006) where a large scale collaborative projects have developed IPL from a system wide perspective involving all key stakeholders to identify key success strategies for state-wide health reform.
The distillation of principles and philosophies to guide IPE curriculum development is emerging from the literature. CAIPE (2002) has elaborated a combination of outcomes and principles to guide and underpin the development and implementation of IPE that has been shown to work well. IP competencies have been developed to define the necessary knowledge, skills and values necessary for students to act effectively as members of an IP collaborative health team focused on improving patient outcomes (Barr, Koppel, Reeves, Hammick, & Freeth, 2005). Oandasan & Reeves (2005a) review the territory of IPE, salient definitions and key issues to be considered in the design and implementation of IPE curricula highlighting a need to focus on appropriate pedagogy. In addition to appropriate learning theory to guide curriculum development (Freeth, 2007; Sargeant, 2009), the elements necessary for quality curriculum design to effect IPE are largely in place.
The level of support within universities for IPE is reflected in the range and quality of IPE curricula that have been developed. Langton (2009) describes five different models in the literature including individual modules added to a curriculum, common modules developed for health professional students and clinical or work-based approaches. Barr et al (2005) describes detailed examples of integrated models where a combination of cross discipline teaching and learning activities extend vertically into the postgraduate domain. An overview of different levels of IPE drawn from Oandasan & Reeves (2005b), Zwarenstein et al (2000) and Reeves et al (2009) is shown in Table 1. Despite many IPE initiatives in the literature, to date much curriculum development for IPE has been fragmented and lacking an integrated, theory-based, whole of curriculum approach (Thistlethwaite, 2012). Several IPE initiates stand out as exemplars of holistic design and planning. Over 20 years, Linkoping University (Areskog, 2009) has developed a faculty level framework defining core IP values and competencies, as well as profession specific competencies. At Memorial University a well developed model of early exposure to IPE (e.g. students from five health professions study public health cases together face to face and online using case studies) and ongoing reinforcement with learning activities and projects throughout their respective courses (Curran & Sharpe, 2007). These successful integrated IPE curricula reflect a strategic vision enacted at a whole of faculty/school level.
Table 1: IPE Matrix. Sophistication of IPE model, learning activities and possible outcomes.
Level Teaching and Learning Activities Pedagogy IPL Outcomes
0 There are no planned interactions between learners from different professional groups, subject matter is not interdisciplinary.
Lectures Case studies presented
Awareness of need for IP health care teams. .
1 Learners from different professional orientations cohabitate and study same unit – interactions between learners are unplanned; subject matter may be multidisciplinary, exposure to professionals as part of study.
Low level IPL outcomes:
Basic understanding of professional place in health care system.
Development of professional identity.
Vicarious learning.
2 Learners from different professional orientations study together, and collaborate or work together in teams on understanding subject matter from different personal and role perspectives, and learning about different roles in the healthcare system. Teamwork may be modelled by a multidisciplinary/IPL teaching team.
IPL outcomes relate to:
Development of professional identity.
Learning about each other as preparation for teamwork.
Understanding role in the health care system.
IP supervision.
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3 Learners from different professional orientations collaborate in a clinical/authentic context to understand different roles and responsibilities in care of patients.
IP ward rounds Case audits Outreach clinics
IPL outcomes relate to:
Development of professional identity.
Learning about each other as preparation for teamwork.
Understanding role in the health care system.
Focus on patient care.
4 Learners from different professions collaborate in a clinical context to understand different roles and responsibilities for care of patients, with the explicit goals of improving working relationships for the ultimate benefit of patient care.
IP ward rounds Case audits Outreach clinics
IPL outcomes relate to:
Development of professional identity.
Experience of teamwork in a clinical setting.
Learning with, about and from each other.
Improvement of patient care, workforce skill mix, system.
The paucity of integrated IPL initiatives reflects the challenges of designing and implementing multi-professional activities in complex institutions. Some barriers to IPE include the difficulty in aligning student timetables, capacity of infrastructure, developing the IPE capacities of teaching staff, and the availability and capacity of health care partners and settings for IPE (Curran, Sharpe, & Forristall, 2007; Thistlethwaite & Nisbet, 2007). Thistlethwaite & Moran (2010) also note a fundamental lack of clearly defined course outcomes and poor alignment of outcomes with activities and assessment (Biggs, 2003) as key factors that impact upon quality IPE curriculum design. This may reflect a lack of consensus over terminology and about the detail of desired outcomes (e.g. what does “collaborative practice” look like?). Sargeant (2009) proposes a suite of appropriate philosophies to inform choice of learning activities that ideally should actively engage and challenge learners whilst Luke et al (2007) makes similar proposals for the online environment. Where small scale IPE activities have been successful, developers have not always been able to apply the philosophy (e.g. problem-based learning) and efficiently upscale teaching practices to larger class sizes (Gordon et al, 2010)(Author). At the end of the day, logistical issues often prevent developers from attending to critical pedagogical matters.
The context of this study
IPE was identified as a University of Tasmania, Faculty of Health Science priority area in 2007. The focus on IPE at this time led to the revision of an existing unit delivered by the School of Nursing and Midwifery as a cross Faculty unit. Perspectives on Ageing (POA) was originally designed to ensure students had an understanding of contemporary and IP issues related to ageing and ageism and aged care delivery in Australia:
Knowledge of demographic changes in Australian society and the implications for the development of aged care policy and service provision
Insight into ageing and the experience of being an elderly person in Australian society, including capacity to critically reflect on understandings and attitudes towards older people,
Also identify and describe;
Key aged care services in Australia and the range of multidisciplinary supports available to older people both in community and institutional settings;
Major health issues related to older people and apply this knowledge to analyse case studies as they unfold from different professional perspectives;
What is meant by the term dementia and how this condition becomes manifest. Apply this knowledge to issues that impact on the management of people with dementia in Australian society; and for students to:
Skilfully engage with peers in a respectful inter professional dialogue on health professional practice in aged care.
POA was chosen as a vehicle for IPE because of the broad application of the subject matter and outcomes to all health professional students at UTAS. Subsequently, learning and teaching strategies were revised and enrolments opened up to include nursing, medical, paramedic and pharmacy students. Lectures and panel sessions about the elderly, aging and aged care were delivered face to face in Hobart to nursing, medical and paramedic students, and videoconference to three other sites to nursing students. Online tutorial groups included a mix of students from different courses.
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Assessment tasks included (i) interviewing an older person as a basis for writing an essay that incorporated a narrative, commentary and reflection upon the interview, 30%; a written exam at the end of the semester (40%) and online activities (30%). Online assessment tasks included completion a pre and post survey of readiness for IPE, discussion posts to allow each student to introduce themselves to their tutor and group, case study analysis and a final post reflecting on their experience in POA. The case study analysis involved students discussing the role of a health care provider different from the role they were enrolled to study. For example, medical students might be asked to imagine they were a social worker, a nurse or an occupational therapist. These roles were assigned by the lecturing staff of POA so that students had different roles for the two discussions that employed this approach.
In this study we sought to explore the IP dimension within POA from the perspective of medical students. Specifically, how does the IP philosophy manifest in the POA curriculum and reconcile with the students’ experience of the course. We sought to align rhetoric and reality, and to identify opportunities for enhancing the IPE dimension of this unit.
Methodology
A collaborative approach to designing this study was undertaken with key staff from Schools of Nursing & Midwifery and Medicine meeting to define, develop and refine the research approach and questions. Development of the research questions was informed by historical evaluative data including SETL, assessment data and student focus groups. In addressing the research questions, this study triangulated information obtained from (i) unit documentation, (ii) observation of face-to-face and online teaching and learning activities and (iii) student feedback. The class overall was informed of the study. Specifically, medical students and their group members consented to observation and review of their online discussions and interviews/focus groups. This study was approved by the Social Sciences Research Ethics Committee.
Unit documentation The Unit outline was obtained from the relevant Unit coordinators in the respective Schools. This material included unit aims, graduate outcomes, learning outcomes, subject content, references and other information, which were analysed with reference to the research questions. Implied or overt IPE aims were considered in the coding of this material, so that a picture of both the stated and the aspirational aims of POA was distilled from the documentation.
Observations of face to face and online teaching Observations of IPL dimensions of teaching and learning activities were undertaken using an ethnographic approach where the primary researcher was embedded within the teaching environment and experienced POA along with medical students. The observer sat openly as a non-participant /observer in lectures for POA over the 13 teaching weeks; taking care not to interact with lecturers or students. In face to face lectures, the lecturing team asked students to identify the course in which they were enrolled so that that overall attendance could be calculated. The observer mapped out the seating positions of students in the lecture theatre to assess possible interactions amongst student groups over time. Longhand field notes (observations of teachers and students, and subject matter) were taken for every lecture and transcribed (and checked against original notes) before a second, reflective consideration of the topics and themes they raised were addressed in a diary.
Observation of IPL dimensions of online interactions in POA consisted of logging into the online learning system (MyLO) at a minimum every two days during teaching weeks. Unit content online, surveys and asynchronous discussion areas were accessed over the semester. The observer read the posts of the consenting medical students and associated student groups to gain an unobtrusive appreciation of how medical students interacted with their peers in the online environment. Field notes captured immediate impressions of the online environment and were transcribed as per face to face notes.
Student experience Interviews and focus groups were held with students by invitation. A focus group was run at the end of semester to explore issues raised by the observer’s observations and documents. Issues arising from the focus group were used to inform focus groups with students who had completed POA the previous year to test confirmatory or divergent interpretations of the issues and themes emerging from the research to date. Interview and focus group sessions were recorded and later transcribed, with the observer taking notes to indicate topics the students emphasised, or where there was a lack of correlation between what had been said and what had been observed or commented upon previously.
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Results & Discussion
Approximately one third of the medical student cohort in POA consented to participate in this study. In+ the first week of teaching, all students were informed of the research and asked for their consent for the primary researcher to observe lectures. In addition, medical students were asked to consent to the observation and analysis of their online discussions and their individual contributions to IPL case discussion. Forty of 122 medical students (33%) consented to have their online posts observed which equated to medical students in seven of 70 IPL online role discussion groups. The observer had access to all teaching and learning documentation relating to POA, which included all lectures, assessment tasks, unit detail and outline documents, and consented student materials.
Course documentation
The POA unit outline comprises stated learning outcomes and graduate outcomes, teaching activities, assessment and available resources to support learning. Face to face teaching in the unit comprised a series of lectures delivered by a sequence of health professionals each discussing a particular professional perspective on the elderly (e.g. Ageism), aging (e.g. Healthy aging, Biology of aging) and aged care, e.g. Multicultural care). A case-based panel session involved a range of health professionals was also held providing opportunity for interaction amongst the professions. Online discussion groups of case studies involved students from different disciplines were used to facilitate IP interactions across the disciplines and campuses. There were a plethora of readings available for students to explore further issues raised in the lectures and tutorials; most readings presented perspectives of single health professions. The Medical School and the School of Nursing and Midwifery also uncovered instances of variant versions of POA’s learning outcomes had been communicated to the medical students.
Observation of teaching
Among the first lectures, there was a significant amount of attention from teaching staff drawn to the IPL aspects of the unit. Some of this related to the logistics of online organisation, but much was about the need for IP care for older people. Lectures by visiting staff were of 1hr duration, often with an introduction and wrap up by a key member of the teaching team. Lecturers frequently referenced the content in each others’ lectures, but rarely made comments of an IP nature. A case study (Vincent Brody) provided a narrative that ran across the whole unit and served as the basis for the IP panel session (in the last week of teaching). A few videoclips highlighted discussions and commentary by elderly people, but did not focus directly on IP care.
The first week of POA 175 students attended the lecture for the initial introductory and overview lectures. The medical students formed the largest proportion of the group attending (120 enrolled) even though there were also 120 nursing students and 35 paramedic students enrolled for POA. Another 300 students were enrolled by distance. By the second week of lectures numbers in attendance had reduced to 83 and thereafter maintained this level. Students appeared to sit in disciplinary groupings, and tended to arrive and leave the lecture theatre without much interaction with others.
Online. The students’ reflective pieces at the end of POA also reinforced that they found the unit very good in addressing perspectives on ageing in Australia, but found the IPL building elements of the content problematic, particularly the online interaction:
‘Online tutorials are no substitute for face-to-face interaction….I did not feel as though the IP learning aspect of the course particularly improved my attitudes towards teamwork and collaboration in the clinical environment.’ (2
nd year MBBS POA1b )
‘I don’t think the interdisciplinary part of the course was particularly effective. I…think I learnt a lot in the discussions and was forced to think about the different roles of the people I was assigned, I just don’t think the interactions were particularly helpful in that regard. I think I learnt more from the interactive panel about the first case than in either discussion group.’ (2
nd
year MBBS POA1b)
Student interviews
Students commented favourably on the commitment of staff teaching in POA and how the POA lecturing staff had value added to content in the unit. This was particularly evident from comments about the panel discussion on a hypothetical case scenario modelled multidisciplinary practice “It was a great idea and very valuable to hear the different perspectives on the situation.’
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In the interviews medical students were asked how well POA achieved its IP outcomes. Students commented that the pre and post survey and introductory lectures signalled what attitudes to IPL were expected of them:
‘I don’t need to hear it 30 or 40 times. Instead of saying the same thing 30 or 40 times, it would be interesting to go into it a bit behind it or something.’ (2
nd year MBBS interview)
Further comments about the IP goals of the unit from students revealed that they saw the IP dimensions of aged care, but that the potential for the unit was not fully realised.
‘in general, if it’s about studying different professions….it doesn’t seem like that component of it, us all coming together, seems to be being utilised at all.’ (2
nd year MBBS interviews)
‘I think the understanding and learning and what is happening is that people are getting a feel for the need to have inter-professional relationships and working as a team.’ (2
nd year MBBS
interviews).
Medical students stated that they were unclear of what was expected of them in terms of the IPL outcomes of the unit. They indicated that this tended to demotivate them and reinforce some negativity over construction of their role in multiprofessional teams.
The drop in attendance and the observer’s impressions of valuing POA were discussed with interviewed students and the second year focus group. The students were asked if they thought that the small numbers of nursing and paramedic at the lectures was a surprise to them or not:
‘Personally, I feel a little bit rude not turning up…..I don’t think it’s very good professionalism I suppose. … With a lot of other courses you do have a lot more online components .. maybe they’re more used to that kind of aspect and learn better that way.’ (2
nd year MBBS interview )
When asked to expand upon the professionalism and value aspects of POA to clarify how they viewed nursing and paramedic students as partners in IPL and whether it was a valuable learning aim the medical students did value the experience but thought the unit had more scope to learn from IPL interactions. Medical students in focus groups revealed isolation and disconnection; they had little interaction with students from the other cohorts enrolled in POA. Average responses were:
‘You sort of go in, sit down, listen, walk out and go home.’ (2nd
year MBBS interview )
‘It’s an opportunity for us to come together and it seems to be squandered a bit, us all coming together and not having any [face to face tutorials]…. Perhaps it would be difficult, logistically, to organise tutorial groups.’ (2
nd year MBBS Interview)
Online observations
The online assessment tasks were generally received well by the medical students and the opportunity to learn together was seen as worthwhile by many:
‘I’ve been able to gain some insight about the problems that can arise with the organisation of the complex cases that we faced in our online discussion….I have realised there is much overlap between roles, but this ensures appropriate treatment of patients, which is the primary goal of medical care.’ (2
nd year MBBS POA1b)
‘The online conversations that were completed did highlight that there were essential things that all of us, as upcoming health professionals, need to be aware of … our different roles….and how best to maximise care for the patient through our inter-professional relationships.’ (2
nd year MBBS POA1b )
MBBS student impressions of the online environment as a mediator/medium for IPL were less enthusiastic:
‘I think it is extremely important that POA integrates multi-disciplinary learning into teaching, but I do not think that an impersonal forum is the best way of fostering a genuine understanding of the perspectives of other professions….possibly a wasted opportunity..’ (2
nd
year MBBS POA1b )
‘Though I found the case based scenarios somewhat useful I don’t think I gained much out of “role-playing”. It was a very good experience learning with different students however I feel the interaction was highly superficial due to the nature of the online
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The students did appreciate that the geographical separation of the campuses made live face to face personal interaction difficult to achieve, but a consistent theme emerged from interviews and from the online reflections of students at the conclusion of POA that face to face interactions would promote social connection, and a better understanding of the roles, attitudes and ideas of the nursing and paramedic students.
Discussion
This review has highlighted some of the challenges involved in building an IP unit that enrols a large number of students from several health professions across several campuses. The perspective presented here is from medical students who report a lack of connection to other health professional students, even though they attended lectures and interacted online.
The intended outcomes, activities and assessment in POA are aligned. Reviewing the documentation clearly shows the primary emphasis on aging and aged care and IP development as a secondary outcome. The use of a multiprofessional lecturing team, IP panel, longitudinal case study and assessment are consistent with the level of stated IP outcomes. Greater clarity needs to be provided as to the interpretation of learning outcomes in terms of learning activities (e.g. how many case studies should be used and analysed) and assessment (e.g. assessing skilful engagement in respectful IP dialogue). Some activities introduced confusion: an early spoken emphasis on interprofessionalism exceeds the expected learning outcomes, an early survey focuses overtly on interprofessionalism and historical anecdotes from older students who provide informal commentary about previous deliveries of POA.
The greatest opportunity at the Faculty level is development of an IPE strategy. It appears that over time teaching staff have projected IPE outcomes onto POA beyond those in the unit outline. This is perhaps a consequence of the historical promotion of POA as a “flagship” IPE unit in the faculty. Just like a lighthouse without a light, POA never fully achieves its goal because it exists in the absence of an IPE framework to support and position the unit and IP outcomes within broader graduate outcomes. In addition, the faculty possesses simulation infrastructure and offers units and activities (e.g. Trauma weekends) with multiprofessional enrolments (e.g. nursing and paramedic, paramedic and medicine) that would also benefit and be strengthened by better positioning within a larger IPE purpose and enterprise. There is an argument in the literature as to whether multiprofessionalism is a transition point on the pathway to IPE (AUTHOR), an issue that the faculty might also consider.
Opportunities for in-class interprofessional interactions in POA could be exploited for greater benefit. Students bemoan the lack of in-class interactions in the lecture theatre which stands in stark contrast to the IP philosophy of the course and early IPE commentary in lectures. At the simplest level, some initial class room seating engineering and ensuring that students introduce themselves to people on either side of them would facilitate social and academic interaction. The use of videoclips and more case studies could model skills of critical analysis and also provide opportunities for “snowball” discussions within lectures that could work to overcome the “silos” in the lecture theatre. It is possible that these interactions could undermine the online discussions, but it is unlikely that students adjacent to each other in lectures would be allocated to the same group (across courses and campuses)
Online collaboration for the analysis of an aged care case study involved students across the professional groups and across campuses. Students reported the experience raised their awareness of IP issues, but did not support richer, quality IP conversations. Managing this online collaboration with so many students is a major logistical effort that may indeed limit the possibility of improving conversations. Luke (Luke, et al., 2007) and Bluteau (REF) recommend more sophisticated use of technologies to support interactions. The introduction of a new learning management system enabled with Web 2.0 technologies that afford more opportunities for social interaction may facilitate deeper, quality conversations in the online environment.
This exploration of the IP dimension of POA revealed good alignment between the rhetoric of the unit description and the reality of course delivery, and demonstrated how relatively small issues can undermine the philosophy and goals of a curriculum and highlighted challenges for connecting students in a unit delivered face to face and online. This study is limited by its restriction to medical student experiences and a parallel study is exploring the experiences of other students. Opportunities for improvement include a broader faculty vision for IPE, permeation of the IP philosophy across all teaching and learning activities and consideration of new technologies to enrich online social interaction.
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