An exploration of educational theories underpinning IPE initiatives at Higher Education Institutions in the UK

1. An exploration of educational theories underpinning IPE initiatives at Higher Education Institutions in the UK Deborah Craddock School of Health Professions and Rehabilitation Sciences

2. Philosophy behind Inter-professional Education [IPE] (Mandy et al 2004) IPE responds to the Government’s collaborative agenda (DOH, 1991; 1993; 1994; 1999a; 2000a; 2000b; 2000c; Miller, Ross and Freeman, 2001; Finch, 2000; Klein, 2000; Hale, 2003) Fashion in medical education or informed practice? (Campbell and Johnson, 1999) The effectiveness and impact of IPE initiatives remains unknown (McPherson et al., 2001; Mandy et al., 2004) IPE models span the continuum (Grahem and Wealthall, 1999; Roberts et al., 2000) Background

3. Background (continued) • 73% of undergraduate health professional programmes reviewed made no reference to any underlying educational theory (Cooper et al., 2001) • Reported educational theories used in IPE initiatives include Adult Learning Theory, Reflective Practitioner theory, social psychological studies of group behaviour and teamwork approaches (Parsell and Bligh, 1999)

4. Aim: To explore the theoretical underpinning of interprofessional education initiatives in Higher Education Institutions [HEIs] in the United Kingdom. Where educational theory was not explicitly identified the objectives were to: Explore the learning and teaching methods utilised and map to the related educational theoretical framework; Make recommendations as to the key elements for improving the curriculum development of IPE initiatives. Aim of Study

5. Ethics Approval Key informants were identified at the: University of Huddersfield, University of Brighton, University College Northampton, University of Plymouth, Glasgow Caledonian University, University of Salford, Queen Margaret University College and the University of Ulster Key informant interviews, using a purposive sampling technique, was carried out to qualitatively explore the different models of IPED within Higher Educational Institutions (Mays and Pope, 1995; Patton, 2002) Constructivist approach (Sarantakos, 2005; Polit and Beck, 2006) Methodology

6. Terminology associated with Inter-professional education [IPE]; Institutional vision of IPE; Institutional model of IPE in relation to their learning, teaching and assessment strategies; Theory/ theories guiding the development of their Institutional IPE initiative; Framework to evaluate the outcome of the IPE initiative; Perceived structural and attitudinal barriers to IPE and countering strategies adopted within that Institution. Transferability of Findings (Mays and Pope, 1995; Mason, 2002) Credibility of Findings (Barbour, 200; Polit and Beck, 2006) Pilot study [Honville et al., 1995; Patton, 2002] Data Analysis – grounded theory Interview Schedule (Britten, 1995; Lindlof, 1995; Patton, 2002; Bowling 2002)

7. Collaborative agenda[DOH 1999; DOH 2000; Miller Ross and Freeman, 2001] was perceived as the “official agenda” [HEI 7] “…I think that it is imperative that people are equipped to be able to work with each other, to understand other people’s roles as well as their own… there are more positive reasons for interprofessional collaboration that are to do with good teamwork, good professions, professional working… I don’t see there is a problem with changing the way in which we work… The patient is actually the most important person … therefore the service must actually meet [patients’] needs… professional groups have a responsibility to the client, to the service not just their own ends”. [HEI 6]. Several respondents conceived the Government’s agenda as being bipolar [HEI 1; HEI 6] Theme 1: Agenda behind IPE

8. Shape the future workforce by creating a flexible multi skilled workforce in which the blurring of role boundaries was considered an acceptable and positive development facilitating the cost effectiveness of patient/ client care [HEI 4; HEI 6] [DOH 1999; DOH 2000; Miller Ross and Freeman, 2001] “… there is less room for replication, so there is, you know there might be people doing things that are outside their normal role but it’s seen you know that’s done in a co-ordinated fashion rather than two people doing the same thing with an individual. So I think it is genuinely, to kind of streamline and make the best use of resources for client care” [HEI 1] Existing concerns regarding the generic agenda being aimed at weakening or breaking the power of the professions by eliminating professional hierarchies [HEI 3; HEI 4; HEI 5; HEI 7] and “deskilling of professions” [HEI 8] [Barr et al., 1999; Hale, 2003] Theme 1: Agenda behind IPE [continued]

9. Conversely several respondents perceived that this should be viewed as an ‘up-skilling’ of professionals. “But I think that can actually strengthen the professions. It makes the professional have to demonstrate why they are a professional, what does it mean to be a professional as opposed to a generic worker, what extra skills you have got. So I think its sort of an up-skilling if you like for professionals. Not necessarily you know too much of a concern that the generic worker can take over.“ [HEI 5] Distinguishing between the professional and generic worker would force professions to consider their professions and reflect on the need to develop specialist skills. Theme 1: Agenda behind IPE [continued]

10. Incorporation of key dates associated with IPE within the School calendar [HEI 3; HEI 1]; HEI 8]. Involvement of national key experts in IPE when developing their Institution’s IPE programme [HEI 3; HEI 7] Inter-Institutional collaboration [HEI 3; HEI 6]. Incorporating the IPE Initiative into the Institution’s Learning and Teaching Strategy [HEI 3] Nominating IPE champions to involve staff [HEI 3] Including IPE in a staff workload management planning model [HEI 1; HEI 3; HEI 4]. Introducing an evaluation strategy for IPE Theme 2: Commitment to the IPE Initiative

11. Undercurrent of doubt: Reluctance to implement any major changes to the current curriculum by proposing that “What [the Institution has] got to do is see whether we can combine the IPE agenda or insert it in such a way that it doesn’t compromise our ability to produce safe and competent practitioners…” [HEI 7]. The majority of respondents [HEI 2; HEI 3; HEI 4; HEI 6; HEI 8] revealed that minimal staff training had been provided despite Institutions having high expectations of staff to participate in IPE initiatives. Only one Institution incorporated a summative assessment to assess the learning outcomes associated with IPE across all programmes [HEI 1] Theme 2: Commitment to the IPE Initiative

12. Inconsistent approaches to learning and teaching and assessment methods [HEI 4; HEI 5; HEI 8], delivery times [HEI 4; HEI 5] and evaluation strategies [HEI 2; HEI 3] across programmes involved in the IPE initiative. Working practices - “… you’ll still find in [staffs’] own work within the University, they’re not working very inter-professionally, they’re still in their own profession in their own directorates, and often don’t go out and work with others. Interestingly the module leadership of some of the inter-professional modules has in the past been given to new members of staff...” [HEI 5] Theme 2: Commitment to the IPE Initiative

13. 3.1 Rational for adopting a ‘top down’ developmental approach to IPE senior managers needed to negotiate collaborative partnerships across the region, a number of HEIs and amongst the staff group [HEI 3; HEI 6]. Senior staff needed to ensure that staff, Faculty and University targets that were developed in line with QAA benchmark statements and other external bodies such as the Workforce Development Confederation and Government bodies in Scotland and England, were being addressed. [HEI 5; HEI 6; HEI 8] Needing to involve individuals who could make decisions quickly. [HEI 2; HEI 6; HEI 8] Influencing staff by showing commitment by senior managers [HEI 4] Controlling the IPE agenda [HEI 7] Theme 3: Developmental Approach to IPE

14. 3.2 Factors Influencing Curriculum Development Pragmatic approach to curriculum development influenced by the organisational requirements of the unit or module [HEI 1-8] “I think we probably played a fairly pragmatic, look we know we’ve got to do this folks, let’s get on with it sort of approach, rather than say with a missionary type zeal this has got to, this is working and this is what we believe in. I think we took a fairly independent view that said we pretty much know what we’ve got to do, that’s the agenda, let’s do it in a fairly pragmatic way…” [HEI 2] Literature on team working, principles of interprofessional working and an exploration of other models of IPE [HEI 3; HEI 4] Recognised need to underpin the educational strategy for IPE [HEI 6; HEI 8] yet no coherent educational theory was explained [HEI 1-8] Theme 3: Developmental Approach to IPE [continued]

15. “The Contact Theory was the most valuable one I think. Which was the theory about trying to get different ethnic groups or religious groups together. It’s based on work that was done over in the States, and the Blacks and Whites, the Jews and Arabs in Palestine and in Northern Ireland as well, the Catholics and Protestants. And you know how to get two communities of people together with quite differing views. And we had a load of… conditions that we were trying to bring to the fore so that we could promote the positive inter-group relations and there were various conditions that we were trying to push into the background because those were seen as inhibiting positive inter-group relationships”. [HEI 5] Contact theory – [Cooper et al, 2001; Barr et al., 2000; Goosey and Barr, 2002; Hean and Dickinson, 2005] Yet the contact theory was not used to inform IPE curriculum developments at this Institutions [HEI 5] Justification for Approach Lack of evaluative IPE research at the time of developments [HEI 2; HEI 8]; Belief that evaluative research would have had a negative impact on curriculum development [HEI 6; HEI 7]. Theme 3: Developmental Approach to IPE [continued]

16. 3.3 Curriculum Development Decisions Regarding IPE Models Use of generic issues across the professions in the content of IPE initiatives [HEI 3; HEI 7]. Utilisation of stimulus materials with professional relevancy developed from real issues [HEI 3; HEI 4; HEI 8]. Incorporation of interactive learning and teaching activities [HEI 3; HEI 4; HEI 5; HEI 6; HEI 8] – inherent use of Adult Learning Theory [Wood, 2003; Kaufman, 2003] Inclusion of placement based learning opportunities [HEIs 5-8] Theme 3: Developmental Approach to IPE [continued]

17. Inherent Use of Contact Theory [Cooper et al, 2001; Barr et al., 2000; Goosey and Barr, 2002; Hean and Dickinson, 2005] “… how the professional groups differ from each other. So I suppose in a way it’s much more in the sort of theory of how different professions develop and where they sit within health and social care. I mean the obvious one is around nurses and social workers, you know what is urgent to one isn’t urgent to another, based around the philosophy that social work is about people maintaining their independence whereas you know nursing care is actually about people maintaining their health. So, so we’re looking very much at why inter-professional, what benefits there can be from inter-professional learning and if there aren’t any benefits then well why are we doing it.” [HEI 4] Inherent Use of the Reflective Theory [Campion Smith and Wilcock, 2001; Romer, 2003] “… and around various models of reflection and so on, we’ll be using that to inform what we’re doing, to actually allow them to allow the students to reflect on how far stereotypes are still traded among the professions out there, and what are the implications for practice.. I think then when it comes to where they’re actually in the clinical environment, that’s where I think reflective practice is very important...”. [HEI 7] Theme 3: Developmental Approach to IPE [continued]

18. Undergraduate Level [HEI 1-8] [Miller, Ross and Freeman 2001; McPherson, Headrick and Moss 2001] “…having not had [IPE] in a pre-registration curriculum you know very strongly, I mean we’ve had problems when they become qualified because people are in their boxes already. So I do think… if we introduce it early enough then it will be the norm and people will see that working together you know with colleagues is the normal way of offering patient care really and it should make for a better client experience…” [HEI 3: 8] IPE is better at PG level compared with UG level [Barr, 2000; Koppel et al., 2001] “speculation” [HEI 1] Be aware of the limitations of IPE at UG level [HEI 7] Postpone IPE until the latter part of each programme [HEI 2; HEI 5; HEI 8]: “…wait until year three when they [students] are a bit more indoctrinated in their own way of looking at the world and then introduce that [IPE] to them. They’ll be able to argue from their perspective it’s too soon to do it back in level one.” [HEI 5: 15] Theme 3: Developmental Approach to IPE [continued] 3.4 Fundamental Consideration of Timing

19. 4.1 Structural Institutional Tensions Financial barriers [HEI 1-8] influencing curriculum development Large student numbers – timetabling, appropriateness of venues and monitoring attendance [HEI 1; HEI 3; HEI 4; HEI 8] Geographically getting students and staff together across different campuses [HEI 2; HEI 3; HEI 5; HEI 7] [Finch, 2000; McPherson, Headrick and Moss, 2001; Morrison et al., 2003] Concerns regarding medical students’ allegiance to IPE [HEI 7; 8] [Hammick, 2000] Different entry gates and requirements of students learning attributed to diverse academic ability [HEI 2; HEI 6] [Finch, 2000; McPherson, Headrick and Moss, 2001; Morrison et al., 2003] Inter-Institutional barriers- varying academic regulations, varying rates of programme development and communication problems [HEI 6] Varying duration of programmes and regulatory validation arrangements [HEI 2; HEI 4; HEI 6] [Finch, 2000; Morrison et al., 2003] Theme 4: Tensions Linked to the Development of IPE Initiatives

20. Limitations of campus based learning opportunities [HEI 4; HEI 6] Value of IPE placements Challenges “controlling” placement opportunities [HEI 2; HEI 4; HEI 8] “…you know there might be structural barriers in terms of the inter-professional rivalries that still exist out in the clinical environment… stereotypes are still traded among the professions out there, and what are the implications for practice”. [HEI 7] Different interpretations of IPE [Campbell and Johnson, 1999; Cooper et al., 2001; McPherson, Headrick and Moss, 2001] linked to: rapid expansion of IPE nationally [HEI 4] Presence of different views and approaches [HEI 6] Cause for concern [HEI 5] Debate regarding definitions of IPE – “red herrings” [HEI 4; HEI 6; HEI 7] Theme 4: Tensions Linked to the Development of IPE Initiatives

21. Staffs’ Resistance to IPE IPE initiatives imposed on staff without consultation [HEI 4] Staff reluctant to add to an already packed curriculum [HEI 2; HEI 7; HEI 8] [Atkins and Walsh, 1997] Lack of understanding as to the concept and relevance of IPE [HEI 2; HEI 3; HEI 5; HEI 8] [Miller, Ross and Freeman, 2001] Provision of minimal staff training [HEI 2; HEI 8] Lack of evidence to substantiate and justify changes imposed [HEI 5; HEI 7] Perceptions that IPE initiatives were irrelevant as they were not summatively assessed [HEI 3; HEI 4] Negative professional tribialism [Atkins, 1998; Hammick, 2000] with consequential professional resistance. “I think it’s seen as a financial saving and I think there will be some people who will embrace it because it is a good idea and I think there will be some people who will always reject it either because they see it as threatening to their own professional groups, and this is the start of the generic worker and they see it, feel threatened and actually it’s going to detract from their professional group”.; HEI 4 Theme 4: Tensions Linked to the Development of IPE Initiatives4.2 Attitudinal Tensions Towards IPE

22. Students’ Resistance to IPE Students struggling to see the relevance of IPE [HEI 2-5; HEI 6-8] Students unfamiliar with the educational approach to IPE [HEI 4] Students inexperienced about their own profession [HEI 2; HEI 4; HEI 8] Students perceiving IPE as irrelevant based on assessment or scheduling of the initiative [HEI 5; HEI 8] “If you didn’t assess it students didn’t value it. We had very poor attendance on some of our, early on some of our early inter-professional modules. Because our students, who were doing it formatively, it’s their first module in the first week and we still get them to do the assessment even though it’s a formative assessment. A lot of them still do it, some of them don’t. [HEI 5] “[students] felt that because it was put at that part of the timetable it didn’t matter, it didn’t matter to us because we were putting it in on a Friday afternoon, if it was a really important module it would be on a Wednesday morning.”. [HEI 8] Theme 4: Tensions Linked to the Development of IPE Initiatives4.2 Attitudinal Tensions Towards IPE

23. Positive attitudes towards IPE can be achieved through a commitment to the educational theories that underpin working collaboratively (Atkins, 1998). Consider the underlying educational theory/ theories [Cooper et al., 2001] of an IPE initiative before developing the programme Consider utilising and evaluating the use of multi theories within IPE initiatives [Zwarenstein and Reeves, 2000; Meads et al., 2003] Engage staff [HEI 6; HEI 7] and students [HEI 3] in discussions.[Plamping, Gordon and Pratt, 2000] enabling any problems to be ‘ironed out’ before they arise [HEI 1]. [Atkins and Walsh, 1997; Miller, Ross and Freeman, 2001] Recommendations:

24. Build in time for IPE initiatives to become embedded within respective programmes [HEI 1; HEI 2; HEI 7]. Incorporate e-learning activities as a means to overcome geographical and transportation barriers [Finch, 2000; McPherson, Headrick and Moss, 2001; Morrison et al., 2003] [HEI 7; HEI 6]. Consider the timing of IPE in students’ pre-registration programme [HEI 8].[Barr, 2000; Koppel et al., 2001; Miller, Ross and Freeman 2001; McPherson, Headrick and Moss 2001] Proactively identify staff’s professional development needs [HEI 5][Campbell and Johnson, 1999; Cooper et al., 2001; McPherson, Headrick and Moss, 2001] Consider nominating an IPE champion to inspire and motivate staff and students [HEI 8]. Recommendations: