ABSTRACT
Mouza Suwaileh and Nomthandazo S Gwele Introduction The world is continuously facing challenges, especially in health care. The increasing diversity of the population, and the complexity of health problems call for the revision of the delivery of health care and consequently of the education of health professionals. One of the innovative approaches in health professional education which has recently become popular in addressing these challenges, is interprofessional learning or IPL. Interprofessional learning is often used interchangeably with terms such as interdisciplinary education, shared learning, multiprofessional learning (MPL) and transprofessional education. The philosophical underpinning of this approach addresses collaboration, team work and learning together (Harden, 1998). Interprofessional learning is defined as an educational approach which includes at least two professions or disciplines, collaborating in the learning process with the goal of fostering interprofessional interactions. The ultimate goal is enhancing the practice of the disciplines involved. This approach has to be based on mutual understanding and respect for the actual and potential contributions of the disciplines (American Association of Colleges of Nursing, 2002). There is general agreement in the literature that the provision of effective health care demands collaboration and team work. These are the core values of IPL. Interprofessional education, therefore, involves the collaboration and interactive learning between learners from different professions. Its explicit aim is to examine each other’s roles for the purpose of improving collaborative practice. Characteristics of IPL IPL can be implemented in pre-registration and post-registration programmes. It usually encompasses only a part of the total programme, since all professions have to address their unique learning separately. Parsell and Bligh (1999) identified the following dimensions of IPL, which have to be considered when designing an IPL module. • The relationships among various professional groups: This dimension deals with values, attitudes and beliefs. It includes the professional identities, prejudices, stereotypical views of each other’s professions, the historical status and the knowledge base of each of the professions involved. • Collaboration and teamwork: This dimension focuses on the skills and knowledge needed to implement and engage in the collaborative learning successfully. These skills are centred on course design, teaching and learning strategies, resources, assessment and evaluation. • Roles and responsibilities: These refer to what people actually do or what roles they play in the provision of holistic care to address the problems of clients. They include the coordination of these roles through collaboration and teamwork. • The outcomes: The benefits to patients, professional practice and personal growth as a result of the IPL experience make up this dimension. Based on this framework, Parsell and Bligh (1999) developed an instrument to measure student readiness for IPL in all four dimensions, and called it the Readiness for Inter-
professional Learning Scale (RIPLS). When Horsburgh et al. (2001) used this scale to describe the attitude of medical, nursing and pharmacy students to shared learning, they found that attitudes were generally positive. Students believed that competence in team work skills and collaboration is important for holistic care. The perceptions about when the IPL should be implemented, however, showed greater variations. The rationale for IPL Rooted in the theoretical foundations of holistic care, IPL is aimed at providing patientor client-centred care from a variety of professionals, for maximizing patient and/or client outcomes. The basic premise is that most health problems are multidimensional in nature, encompassing economic, social, spiritual consequences and/or needs. Hence it is believed that it is not feasible for any one professional, irrespective of the quality of her/his education and training, to cater for all these dimensions (Cyphert and Cunningham, 2001). In the UK, IPL has a long history. The call for IPL has permeated the national health policy frameworks in the UK for over 30 years. It is envisaged that IPL has the potential to facilitate interprofessional collaboration in health care and thus reduce fragmentation, with resultant improvement in patient outcomes (Reeves and Mann, 2003). In 1988 the World Health Organization (WHO) issued a report that referred to IPL as one of the key initiatives to achieve the goal of ‘Health for All’. The report called for collaboration and team work amongst health professionals in primary, secondary and rehabilitative care settings. They made the point that working together would be enhanced by learning together. In response, a number of schools initiated IPL initiatives. There is general agreement in the literature that the benefits of IPL include: • increasing the understanding of each other’s expectations, roles and responsibilities • gaining knowledge and skills that are appropriate to the workplace • the exploration of various strategies to enhance collaboration and team work • improved communication within and between professional groups (Carpenter, 1995; Parr et al., 2000; Parsell and Bligh, 1999). Research on evaluation of IPL has, however, focused mainly on changes in attitudes, knowledge and skills, rather than the impact on quality of patient care and health outcomes. It is not easy to implement IPL programmes. The following challenges have been described in such projects, using the classification system of the American Association of Colleges of Nursing (AACN): • Philosophical and sociological: This group includes gender and class differences between professions, problems with commitment to the innovative approach and differences in the professions’ focus and mission. Parsell and Bligh (1999) saw the problem of changing the attitudes of professionals as the most crucial problem in this kind of programme. • Organizational and structural: Differences in scheduling and timing of each programme, variations in the levels of students, inadequate and insufficient clinical sites and/or facilities such as small group rooms, geographical distribution and budgeting constraints are included here. There are also differences in the size of student groups, and inconsistencies in teaching and assessment methods. • Academic and professional: Here the challenges include role reversal and overlap, risk to professional identity, lack of or a need for faculty preparation, identification and
selection of core courses and shared experiences, selection of various disciplines to be involved in the shared learning and identification and training of qualified mentors/preceptors (AACN, 2002; Horsburgh et al., 2001; Parsell and Bligh, 1999). The problems seem to be particularly severe in pre-registration programmes, with the result that less activity has been seen in this area than in post-registration programmes (Pirrie et al., 1998). Nevertheless, IPL does seem to be an endeavour worth the trouble. Models of IPL Although literature abounds on IPL, there seems to be paucity of literature dealing specifically with models of IPL. A few could be discerned from the literature, however. These include delivery mode models and those that focus on IPL as development. Whatever the model used, the key element is the coming together of different professions for the purpose of learning together. A stage-model of IPL The basic premise on which the stage model of IPL is based is that the development of interprofessional skills, such as collaborative team work, understanding and appreciation of the roles of the various members of the interprofessional team and managing conflict is a process and not an event. Harden (1998) described interprofessional education as a continuum with the following stages: going from isolation to awareness to consultation to nesting (small units work together) to temporal coordination to shared teaching to correlation to complementary teaching and then finally to interprofessional education and transprofessional education. Delivery mode-focused models Four types of delivery-focused models of IPL are identifiable in the literature. These are the seminar, conference, event and clinical models. These models are aimed at helping learners integrate theory and practice, develop interprofessional knowledge and skills, engage in interprofessional practice and develop a healthy sense of self. The seminar and conference models are largely classroom based models which use a variety of teaching strategies such as simulations, role plays, case studies and/or problemoriented learning (Jacobs, 2001). The strength of these models is that they provide students with a relatively safe environment in which to practise taking responsibility for patient management and treatment. Similarly, application of interprofessional skills, such as communication, collaboration, negotiation and conflict management within a simulation environment often do not change patient outcomes. Although inadvertent outcomes with colleagues are a possibility, the consequence of unplanned consequences of the learning experiences are not as threatening in a classroom setting as in a real clinical environment. The seminar model has its shortcomings. Application of theory to practice is not necessarily achieved, since environments are just that, simulated environments. The model does not really afford the learners with an opportunity to experience whether or not interprofessional work is feasible in the real world of healthcare practice. Once the students are placed in clinical settings, either as students or as beginning professionals, they soon learn that what seemed easy and manageable in the classroom, might not be so clear cut in the clinical world (Jacobs, 2001). Event-based IPL programmes are characterized by one-off workshops or a series of workshops or conferences which draw a number of participants from different professions to discuss on a similar theme or topics of interest to all participating
professions. An example of an event-focused IPL model would be an annual continuing education meeting of critical care practitioners involving nurses, doctors and emergency care practitioners. The real benefit of this model is that it offers an opportunity for the students to share their knowledge and skills whilst learning with and from each other without putting great demands for change in practice setting on participants. The following is an example of an event-based IPL. An example from Bahrain The College of Medicine and Medical Science, Arabian Gulf University, provides medical training in Bahrain, and the College of Health Sciences provides nursing training. Both of these institutions are situated in Manama and are leading higher education institutions in the Gulf region. Although both faculties believe in the importance of teamwork and the value of IPL, the fact is that the training takes place in two different institutions. This organizational factor has limited contact between both staff and students in the past. In 2003, however, the two schools initiated a series of IPL activities to bridge this gap. The first IPL project chosen was a problem-based learning workshop, during which groups of two medical and two nursing students each tackled problem scenarios around ethical issues. The objectives were to bring together medical students and nursing students in collaborative learning, to improve the understanding of the ethical issues facing the professions indicate how these are viewed by different professions, and to develop shared meanings and values. The day-long workshop was facilitated by one teacher from medicine and one from nursing. The results were positive, with students experiencing enhanced inter-professional communication and team work, and a greater appreciation for each other’s roles. This initiative was followed by another collaborative workshop along similar lines around the topic of complementary and alternative health care, held in October 2003. Both of these workshops fed into a third collaborative project students and faculty from the two professions presented papers together at two PHC conferences. Clearly, the IPL project has gained momentum, and has benefited both faculty and students. The clinical model is the most commonly used approach to interprofessional education in the health professions (Jacobs, 2001; Richardson et al., 1997). Clinical IPL involves placing a group of students from different professions in the same clinical learning setting, with a view to enhancing collaborative work among them. Expected learning objectives for the placement are developed jointly by the faculty from all participating professions. The strength of this model is the immediate application of theory to practice in real clinical situations. The concrete experience of working together in the provision of health care provides the learners with deeper understanding of the theory underpinning both interprofessional and uniprofessional education depending, of course, on the timing of the clinical learning experience. Furthermore, inaccuracies and entrenched stereotypes about other professions and clients and application of learned interprofessional skills are not only confronted through guided discussion and reflection in the case of the former, or practised within the protected laboratory environment in the case of the latter. Instead, the clinical model forces the learners to become aware of their preconceived ideas and stereotypes as well as to resolve them in order for any effective collaborative work to occur (Jacobs, 2001). The development of interprofessional skills in such a model,
therefore, seems to be more by intuition and trial and error on the part of the learners. Ideally, however, students should be guided by their facilitators during the early stages of placement to ensure that they gain confidence in themselves and their ability to assume their respective roles in the care of patients and/or clients. A mixed-mode model A mixed-mode model seems to be one of the frequently used approaches to IPL. A mixed-mode model combines classroom learning with clinical learning. Learners from different professions register for an interprofessional module. Such a module or course is planned so that students from all participating professions are able to participate meaningfully, both in the classroom and in the clinical learning setting. A number of authors caution that IPL should not be equated with students from different professions taking the same course. An IPL course should be designed with the aim of achieving the educational goals of IPL. It should create space for learners to interrogate theory and practice, get to know each profession’s roles in health care and identify uniprofessional strengths and limitations so as to be able to make informed judgements and insightful choices in shared and collaborative practice. Similarly, clinical learning should be guided by clearly defined learning outcomes that encourage collaborative work. Selected clinical learning environments should provide rich learning experiences to allow students from all participating professions an opportunity to engage fully with interprofessional practice. For instance, studies involving teams of nursing, social work, medical students and students from other health professions would be better placed in acute care or outpatient departments, rather than in clinics. There is very little that medical students do in primary healthcare settings in developing countries. Medical students might not find such a clinical learning experience interesting for them as members of an interprofessional team. Development and implementation There are few clear guidelines in the literature on how and when IPL should be implemented. The AACN (2002) indicated in a recent report that a limited number of nursing schools include some interprofessional activities either in the classroom or in the clinical setting. Key factors in developing and implementing IPL Reeves and Mann (2003) identify four key factors in the development of IPL. According to these authors conceptual, operational, educational and evaluative factors determine the success and effectiveness of IPL. Conceptual factors The multiplicity of conceptions of IPL demands that those planning to embark on this educational approach make a concerted effort to arrive at a common understanding of the phenomenon. Clarity on aims is just as important as clarity on terminology. In addition, issues surrounding the cost of IPL to the institution and the learners must be investigated and analysed. Operational factors Operational factors to be considered include decisions regarding recruitment of management group, inclusion of key staff and setting aside time for planning, including negotiations with professional regulatory bodies if necessary (Reeves and Mann, 2003). The role of the management team is that of facilitating the change process. Effective team-work is a function of facilitative leadership. Leadership in interprofessional
education, however, cannot be bestowed based on tradition, nor is it to be seen as independent of the context and constant. Leadership in collaborative teamwork is determined by the demands of the particular situation and the requisite knowledge and skills pertaining to what needs to be done. Hence, facilitative rather than authoritative leadership is recommended in IPL (Horder, 2000). Educational factors The significance of skilled facilitators in IPL cannot be over-emphasized. A true IPL experience cannot be neutral with regard to interprofessional issues. Facilitators need to be skilled in facilitating passionate discussions between professions. Unless skilfully managed, these debates might lead to conflict and/or silencing or marginalizing other voices. A facilitator who is skilled in questioning and probing as well as managing the process is invaluable in IPL classrooms and clinical learning settings. Recruiting and training facilitators who are willing to commit time and self to the process are key elements in developing an IPL curriculum. Barr describes the requisites for effective facilitation in IPL as: • in-depth understanding of interactive methods • commitment to IPL • knowledge of group dynamics • confidence and flexibility to creatively use professional differences within groups (cited in Reeves and Mann, 2003:312). The educational objectives of IPL demand interactive teaching/learning approaches, such as group discussions, case-based learning, problem-based learning, debates and inquirybased learning (Reeves and Mann, 2003; Richardson et al., 1997). It is important that the teaching/learning environment should create a platform for students to debate and discuss issues related to interprofessional learning. Such an environment should make it clear to the student that every voice counts and that it is not important that everyone agrees with everyone on all that is discussed but that it is essential that differences of opinion be acknowledged and respected. Evaluative factors A systematic review carried out by Zwarenstein et al. (2002) on the effects of IPL on interprofessional practice and healthcare outcomes yielded a total of 1042 studies, none of which met the requirements for rigorous scientific analysis on which evidence for best practice could be drawn. There is a need for planned systematic and scientific evaluation of IPL programmes in order for those adopting the model to justify the time, cost and the over-extension of clinical learning facilities resulting from a large number of students needing access to similar resources at the same time. Reeves and Mann (2003) recommend multi-method, longitudinal research studies for monitoring and evaluating IPL. Steps in the process of developing an IPL curriculum The steps in the process of curriculum development need a considerable degree of modification when IPL is being included. The context of the curriculum The faculty of all the professions involved needs to create an environment conducive to the successful implementation of change. They have to support an educational philosophy which encourages questioning, initiative, problemsolving and reflective approaches to teaching and learning, since these elements are inherent in the IPL experience. To
promote such an educational environment, teachers should be given opportunities for professional and personal growth. Visits to successful programmes, the exchange of success stories from their own teaching life and the sharing of problems they have experienced or are experiencing create a climate of supportive collegiality (Dockling, 1987). During the phase of curriculum development when the context is established and foundations are laid, the health professionals have to reach consensus about whether IPL is necessary and why they are doing it. It is often valuable to involve stakeholders such as students and clients in these discussions, since they might bring a stronger consumer orientation to the discussions. The group should clarify for themselves what they aim to achieve with the IPL for each group of students. Planning the macro-or micro-curriculum In terms of the macro-curriculum, the academics from all participating professions have to decide where the IPL would fit into their own programmes. It is ideal that students are more or less on the same level of their programmes when they learn together. If the IPL experience takes place early in the professional programme, it might have a positive influence on the learning in the rest of the programme. Immersing students in IPL early in their professional education is, however, not without its own problems. Interprofessional education is about different professions contributing equally, as demanded by the health status of the patient or situation involved. Students without the requisite knowledge and skills to provide competent uniprofessional care have very little to offer in an interprofessional experience. Professional identities and competencies need to be fully developed for meaningful collaborative work. A number of authors warn that early immersion may in fact result in the opposite of what IPL seeks to achieve. It might entrench feelings of inferiority, superiority and stereotypes about other professions. For this reason, it is recommended that students in the senior years of their professional programmes are best suited for IPL. It is hoped that at a later stage of their educational careers, students would be competent in their own professional roles and responsibilities so as to be able to participate and contribute meaningfully in collaborative patient care (Jacobs, 2001). Furthermore, it might be easier for students to learn together when they are more sure of their own roles and comfortable in these roles. Once the decision has been made about when the IPL will take place, and how long it will last, the setting has to be chosen. Students can share learning in the classroom, in a hospital, in a PHC setting or in a community. The content of the module(s) will be determined by both the level of the students, and the setting in which it takes place. The most successful topics or content are those that allow for distinct professional roles and which demand team-work (Harden, 1998). The teaching/learning approach also has to be chosen. Students can be given a community-based task, such as running a volunteer PHC clinic. The task may also be of an academic nature, for instance planning and doing a research project together, or organizing a faculty research day. The group must also identify how the teachers of all the professions will be involved. Shared learning ideally goes hand-in-hand with shared teaching. An IPL experience run by the faculty of one profession only loses much of its impact. Finally, decisions have to be made about the evaluation of the IPL experience. Students may be evaluated as individuals or as groups. The evaluation should be related to the
outcomes of the IPL learning experience, and should ideally involve teachers from all the professions involved. Providing for resources The planning group should identify what additional resources would be necessary for the IPL, and make sure these resources are made available. Resources might include small group classrooms for groups to meet, funding for transport to clinical sites or to another educational institution, computer systems that ‘talk’ to each other, or shared library resources. The early involvement of key decision-makers should prove valuable at this stage. Implementation Crucial to successful implementation is coordination between the different professional groups. It might be a good idea to pilot test the curricular outcomes, teaching approach and evaluation instruments on a small scale before general implementation (Harriet et al., 2003). It is important that the teaching team serve as role models for team work and cooperation for the students, and this demands frequent and open communication, regular scheduled and minuted meetings and adequate attention to detail. Conclusion Although much emphasis is currently being placed on IPL, it is essential that the outcomes of this approach be more thoroughly evaluated. Nevertheless the AACN recommended in 2002 that schools of nursing increase the cooperative learning of nursing students from different levels (undergraduate and postgraduate) as well as different fields of nursing, and also increase interprofessional learning. Such suggestions need to be tested in order to guide curriculum decisions about cooperative learning. Points for discussion 1. What do you see as the most problematic aspect of IPL in your own setting? 2. Why would IPL be a risk to professional identity, as the AACN says? References American Association of Colleges of Nursing (2002) Inter-disciplinary Education and Practice: Position Statements. Online. Available at: https://www.aacn.nche.edu/%20Publications/positions/interdisk.htm%20(accessed%20Ma y%202004). Carpenter, J. (1995) Interprofessional education for medical and nursing students: evaluation of a programme. Medical Education, 29:265-272. Cyphert, F.R. and Cunningham, L.L. (2001) Interprofessional education and practice: A future agenda. Theory into Practice, 24(2):153-156. Docking, S. (1987) Curriculum innovation. In: P.Allan and M.Jolley (eds) The Curriculum in Nursing Education. London: Croom Helm. Harden, R.M. (1998). AMEE Guide No. 12: Multiprofessional education: Part 1: Effective multiprofessional education: A three-dimensional perspective. Medical Teacher, 20(5):402-408. Harriet, B., Cummings, D.M. and Dreyfus, K.S. (2003) Evolution of an interdisciplinary curriculum. Journal of Allied Health, 32(4):285-292. Horder, J. (2000) Leadership in a multiprofessional context. Medical Education, 34: 203205.
