An evaluation of using champions to enhance inter-professional learning in the practice setting
Article Outline
Abstract
The promotion of interprofessional working is a key government target for healthcare professionals. This article outlines one approach to establish inter-professional learning in the practice setting using systems based on current clinical placement allocation of students from a variety of health and social care professions. By utilising current unprofessional support systems for developing the learning environment, inter-professional learning opportunities were created for students. Interprofessional ‘champions’ in a targeted number of placements self selected themselves to participate in a new innovation. These healthcare professionals were given preparation, support and facilitator training. Interprofessional learning opportunities were developed using a variety of formats. Evaluations of the innovation demonstrated the usefulness of this approach for qualified staff as well as for students. A key target of sustainability was achieved and expansion of the initiative has been guaranteed through further funding.
Keywords: Practice Learning Teams, Interprofessional Learning, Practice Learning, Champions, Facilitated Student Led, Patient Centred Learning
Introduction
The aim of this paper is to introduce how it has been possible to establish Interprofessional learning in practice using existing structures of Practice Learning Teams that support practice learning for nursing students.
Multiprofessional treatment is the philosophy of modern shared care (Irvine, 1997) with failure to achieve this being deemed to be responsible for resulting in Victoria Climbie’s tragic death (Laming, 2003). Lack of effective interprofessional teamwork was also identified as a factor in Wayne Jowett’s death (Toft, 2001), with the Bristol enquiry (Bristol Royal Infirmary Inquiry, 2001) making similar conclusions. The government’s response has been to encourage inter-professional learning for all healthcare professionals to improve multiprofessional working, with InterProfessional Learning (IPL) being recognised as an effective way to develop quality patient care (Finch, 2000). To develop this concept in healthcare professional students, the concept of shared learning has been suggested. Horsburgh et al. (2001) describes shared learning as an educational process that uses structured learning opportunities for students and practitioners from different professional backgrounds. This is very different from shared teaching where students are present at the same teaching sessions but interaction may not necessarily occur. Parsell and Bligh (1998) suggest that large taught classes where students from some health professions vastly outnumber other students may even reinforce stereotypes and harbour resentment. However, shared learning, particularly if it occurs in practice, can help to overcome stereotypical views and engender understanding of each other’s roles leading to better communication between those involved in healthcare situations. Nurses, in particular, believe they are central to effective interprofessional collaboration (Miers and Pollard, 2009) with the timing of inter-professional learning being most effective when experienced in clinical practice whilst working together (Horsburgh et al., 2001).
The overall aim of inter-professional learning is to ensure that the health professionals have the ability to perform their roles as part of a team to provide effective patient care, and should be achieved through a structured programme of shared learning opportunities. D’eon (2004) suggests that these opportunities may involve simply shadowing other health professionals but can be more complex as individuals develop both clinical and interactive skills to provide patient care with other health and social professionals. D’eon (2004) goes on to suggest two models of learning that will allow students to develop the more complex interprofessional working; co operative and experiential learning. Co operative learning uses small groups to develop such skills as purposeful discussion, joint decision making, interpersonal and team working skills; it also encourages team working. Experiential learning takes place as a result of an encounter with an experience that is planned by a teacher/mentor/clinical educator. However utilising a service user as a focus for clinical practice is arguably one of the best ways of learning interprofessionally. It needs effective planning, implementing and evaluation followed by reflection on the whole experience; the latter being multiprofessional and a facilitated experience for the students. It was felt that the type of shared learning described by Horsburgh et al. (2001) could be used to develop student learning alongside other health professionals, and our project was based on this approach. The model we developed allowed the students to develop their learning around a client whose care the students were participating in. The model followed a student led, patient focused; facilitated approach to encourage shared interprofessional practice learning.
Reeves and Freeth (2002) describe setting up training wards to achieve IPL in the clinical area using pre-registration medical, nursing, occupational therapy and physiotherapy students which was an idea based on work by Sanden and Wahlstrom (1996) in Sweden. A decision was made that our project would not follow such a formal pattern as Reeves and Freeth. These can be expensive and time consuming to develop, as well as difficult to sustain in the long-term. Instead it was decided to use structures already in place in the University of Nottingham Division of Nursing that supported and developed learning in the clinical area i.e. Practice Learning Teams (PLTs). The rich learning environment is already in place wherever client care takes place. What was necessary, however, was to develop and support champions within these placements to develop sustainable inter-professional learning models.
Practice learning teams
The concept of taking a team approach to practice learning support arose out of an English National Board funded project which explored the role of the teacher and lecturer in the practice setting (Day et al., 1998). This project identified that the link teacher role was highly variable in effectiveness, leaving both practitioners and teaching staff dissatisfied with the support offered by educationalists for practice learning (Aston et al., 2000). As a result, at the University of Nottingham, an innovative partnership approach was advocated for the support of students and mentors, as well as to develop learning opportunities within the practice environment. After much negotiation with local Trusts and the Strategic Health Authority in, Practice Learning Teams were established in 2000. Practice Learning Teams (PLTs) consist of nurse lecturing staff and designated practice staff in a collection of areas such as Healthcare of the Older Person, or surgical placements. Their remit is to develop the learning opportunities in the placement learning environment and provide support for both students and mentors. The development of PLTs is described by Chapple and Aston (2004); this article describes how these collaborative teams are responsible for developing the practice learning environment for nursing students (4).
Over time, the PLTs have evolved and become an accepted and established system for developing practice learning but only on a unprofessional basis for nursing. During this time the recommendation that all health professionals experience inter-professional learning became a pressing target as a result of learning from untoward incidents (Laming, 2003, Toft, 2001, Bristol Royal Infirmary Inquiry, 2001). We recognised the need to develop inter-professional learning opportunities, and the successful PLT approach seemed to be a logical way to develop interprofessional opportunities for our healthcare students as the teams were already responsible for the clinical learning environment.
Through the Strategic Health Authority Learning in Practice Unit and the University of Nottingham, some funding was allocated to provide time for a lecturer for one day per week to develop PLTs on an interprofessional basis. It was decided to supervise and develop the project over 2 years in order to identify the viability and effectiveness of this approach to inter-professional learning.
Developing the innovation
An education leader was appointed and four well established practice learning teams were identified for the innovation. The teams chosen provided specialist study programmes, student workbooks, student discussion forums, and already received positive student evaluations of the practice experience from nursing students. It was important to commence the project with teams that were well established, as change can be threatening; we did not want to disrupt teams that were still in the process of establishing effective practice learning opportunities. We also wanted to reflect different branches of nursing as well as different types of healthcare settings. The areas chosen were: an orthopaedic and emergency care setting; cancer services, which included a charitable hospice and NHS hospice; community with an intermediate care team; and mental health for residential clients.
Once the PLTs were chosen the first aim was to introduce and discuss with each PLT the concept of inter-professional learning and obtain both the team’s permission and the placement manager’s agreement to take part in the project. Once agreement was obtained, a priority was to map which healthcare students accessed these placements so that their clinical mentors/educators could be invited to join the PLT.
Gaining commitment and motivation of all practitioners was essential. Various methods were utilised to do this; for example, away days, working lunches, extra meetings and visiting the wards to ensure that there were no misunderstandings about the project from staff involved. This was a slow process but it was important that all of the team understood the project aims, and was motivated to take part. The practitioners themselves needed to champion the project and the interprofessional approach was embedded so that the culture of the team started to change, and an Interprofessional Practice Learning Team (IPLT) was formed. Table 1 gives an indication of membership of the pilot teams.
Table 1. IPLT membership.
| IPLT | Community Hospital PLT | Trauma and Orthopaedic PLT | Cancer services PLT | Residential mental health PLT |
|---|---|---|---|---|
| Membership | •Nurses •Medical Student Tutor •Physiotherapists •Occupational Therapist •Dietitian | •Nurses •Physiotherapists •Occupational Therapist •Dietitian | •Nurses •Physiotherapists •Occupational Therapist •Dietitian •Radiotherapist | •Nurses •Occupational Therapist •Clinical Psychologist •Housing Association |
Implementation
It was important to develop individual aims for the IPLTs, as to how they would support inter-professional learning experiences for students in order to help staff to feel focused in their Interprofessional activities.
Mapping when the placements of the different health professional students occurred helped to clarify the mix of students that could take part in the experiences and allowed the IPLT to identify when and what opportunities could be facilitated for students as numbers and student mix were variable (see Table 2).
Table 2. Student experiences.
Specific activities used for IPL ■Case Conferences ■Procedures ■Assessment processes of each profession ■Patient assessments/the use specific forms of record keeping ■Moving and handling ■Discharge planning ■Examination of health professional roles and how they integrate in the clinical area ■A mock case conference regarding one of the patients on the ward, ■Risk assessments |
After reviewing the literature regarding approaches to inter-professional learning, the University of Teesside, (2004) was considered to be the most appropriate model to use. This model has a 3 Track approach:
This flexible approach should allow all students in placement to have some exposure to inter-professional learning experiences. Within this intervention, track two and three were most frequently used (see Table 3).
Table 3. Structure of IPL as experienced by the students.
■80% took part in a session with students facilitated by a Practitioner ■76% worked alongside a student from another profession ■60% shadowed a registered practitioner from another profession ■52% participated in a session facilitated by another student |
Preparing facilitators
The next stage was to help the mentors/clinical educators/facilitators to identify and facilitate learning opportunities within their IPLT and to prepare the facilitators for this role, as the learning experience can often depend on the quality of facilitation. Howkins, (2004) suggests anecdotal evidence from other projects shows that clinical facilitators can find the process difficult and often feel ill prepared. It was therefore important to prepare our first facilitators carefully for the task. PIPE (Promoting Interprofessional Education Unit) (Howkins, 2004) identified 5 qualities for a facilitator:
A training session was developed based on these qualities for the different health professionals involved. The Inter-professional learning experiences also needed to be patient centred and student led. The groups discussed and identified areas that could be used to facilitate this. The final part of the session used a real patient scenario where the group role-played students to explore the type of learning that could arise from it. This also triggered questions that could be used when facilitating IPL, and ways of helping the students to reflect.
Ideas and experiences were shared between IPLTs through the project lead.
Evaluation
Overall 52 participants took part in the project including physiotherapy, nursing, dietetics, radiography, radiotherapy, medicine, social work and complementary therapy students. Demographic data was obtained on the evaluation form and the aspects of the IP experience that were are evaluated are listed in Table 4. The evaluations from students demonstrated a range of meaningful experiences from understanding other health professional roles to interprofessional organisation of patient care (Table 4, Table 5, Table 6). Negative comments from those not allocated alongside students from other healthcare professions included that students would have liked to work with a wider range of professionals. They also felt that clearer information would be useful and suggested a page in the placement orientation pack with numbers to telephone in order to arrange inter-professional learning opportunities. In addition, outline of things that can be focused on whilst spending time in various departments e.g. complex discharge planning were suggested by students.
Table 4.
Aspects of Interprofessional learning included on the evaluation form •A list of interprofessional opportunities the student accessed •Interprofessional activities focused on in the placement •How Interprofessional activities enhanced understanding of other health professional’s roles •How Interprofessional experiences contributed to the student’s personal development •How Interprofessional opportunities could be further developed in the placement •How Inter-professional learning contributed to the effectiveness/quality of patient care |
Table 5. How Interprofessional activities/experiences enhanced understanding of other professional roles.
■Realisation of how closely these teams have to work together and how each profession is directly dependent on the other to provide a good and effective treatment for the patient concerned (medical student) ■I realise now that the best way to treat a patient is by considering how everybody else plans to treat this specific patient and how your plan fits in with this (radiotherapy student) ■Useful to discuss patients care with other healthcare professional students and formulate plans based on a teams input as they will (hopefully) be part of my everyday job (nursing student) ■It made me realise the sheer volume of work involved in caring for a ward of full patients (dietetic student) ■I have been made more aware of the importance of good communication between members of the MDT. I have gained a good insight into the amount of factors which need to be taken into consideration in ward rounds, case conferences, family meetings and home visits to ensure an appropriate and timely discharge is achieved (medical student)(7) |
Table 6. Perceptions on Interprofessional learning contributing to the effectiveness/quality of patient care.
Student comments ■It allows better communication between the different professions and better understanding of each others roles. This can only contribute to better quality of care for patients, more effective working and quicker/better discharge (nursing student) ■Inter-professional learning allows practitioners to develop their own knowledge and understanding in other disciplines that impact upon their own practice area. Patient care will therefore be more fluid and continuous in working towards set goals (physiotherapy student) ■I will now make more appropriate and informed referrals; I have a greater understanding of the skills available within the MDT (physiotherapy student) ■It helped me to build a better relationship with people(social work student) |
Clinical Facilitators comments ■One example was when my student corrected me when I issued a wheel chair cushion to a patient and clinically reasoned out why the patient must be given a different cushion with a better pressure reducing capacity. I later realised my student has been discussing tissue viability with a final year nursing student during an IPL experience (Senior Physiotherapist). ■It’s all about ideas and problem solving, to try and make a difference to patients health and well being whilst in hospital and once discharged (senior nursing manager). |
A comparative analysis of the evaluations was undertaken to identify the key themes that emerged from the student evaluations. Four key themes that emerged from the evaluations; the importance of teamwork, collaborative working practices, communication between disciplines, and the importance of understanding each other’s roles.
Discussion
Shared learning between professions can sometimes reinforce stereotypes and foster resentment (Arkesog, 1988) whereas interactive learning has potential to increase respect for each other and dispel myths and stereotypes. IPL in the practice setting can provide structured learning to enable students to acquire knowledge, skills and professional attitudes within the clinical arena. Through working alongside each other in an actual care setting, the student’s understanding of the complexities of working in a multiprofessional team is enhanced. This type of experience also helps the student to be adaptable, flexible, collaborative team workers who understand the contribution each person makes to the patient and health outcomes (Horsburgh et al., 2001). The student’s experience in the IPLT’s identified that better understanding of other’s roles within the multiprofessional team contributes to more effective patient care through effective communication and collaborative working. It also had a positive impact on the student’s learning and professional practice. In addition, the interprofessional facilitators learned from the process (see Table 5) and this impacted on the care they delivered to patients. Reeves et al. (2002) identify the value of clinical realism but found that it can cause stress for students. However, this was not an issue identified by participating students in the IPLT. It is, however, an aspect to be aware of and needs to be incorporated into the evaluation process in the future. It could be argued by maximising existing learning experiences rather than creating a unique interprofressional training ward (Reeves et al., 2002) that stress is minimised for those involved. It is also sustainable as it uses areas that students from a variety of healthcare professions are already allocated to; it does not require additional resources apart from mapping of when interprofessional opportunities can be facilitated.
The student evaluations were not the only positive outcomes from the project. Firstly using champions within the placements proved a real advantage and gave sustainability to IPL in those areas. However, it could be argued that by using champions, the initiative could falter if the champion left the placement. Our experience has been that, even if individual champions leave, other health professionals have taken on the role. Taking care to involve all professionals in the team has helped to change the culture of the placements. Team members have also developed shared ownership of the interprofessional experience allowing the project lead to reduce their input to the IPLT, and the IPLT to survive the loss of a champion. This enhances the sustainability of the inter-professional learning experience. Sustainability has been further enhanced, as other placements have wanted to share experiences and develop IPL for themselves as they become aware of the benefits.
In addition, the clinical facilitators working in their own specialities with a good knowledge base gave them confidence when facilitating learning with the different type of students. By sharing facilitation across professions, this meant that no one facilitator would be overloaded with work and helps to prevent facilitator burnout, whilst joint training of facilitators helps to reduce variation in facilitator styles that can complicate student learning (Reeves et al., 2002). Opportunistic learning also decreased the workload as, once the students had been introduced during an IPL experience, they continued to share experiences, work and learn together.
Learning in the clinical area was a very positive experience. Koppel et al. (2001) state that the idea of using opportunities in the work place improves the quality of patient care more than college based learning. Evaluations from students and qualified practitioners supported this in our project (Table 5). The qualified practitioners were used to consulting with each other and thus supported each other in providing effective experiences. Many felt it was a good opportunity to develop on a personal level as well as to enhance their teaching and facilitation skills.
There are challenges to extend this programme, the main one being the need to dispel the myths around inter-professional learning and working. There is a history of strong professional boundaries in the Health System (Gilbert et al., 2000) and staff can be very resistant to change (Reeves and Freeth, 2002). Our approach of introducing the concept slowly to the teams, giving them time to assimilate the idea and develop their own ideas, before agreeing to join the project dispelled worries within the IPLT. In addition, it can appear to be a vast amount of work, but our experience is that by using naturally occurring experiences, workload can be minimised.
Outcomes from the project
From consultation with the students and facilitators about their experiences, it was agreed to develop a “how to” booklet (Kelley and Aston, 2009) to engage other PLTs in this interprofessional initiative and this is work that is proving invaluable in helping to disseminate how to establish inter-professional learning in the practice setting. The booklet has been developed using the experiences and evaluations from the project to demonstrate the interprofessional experiences that are readily available in the learning environment and how, with a commitment to inter-professional learning, existing resources can be utilised to enhance learning.
The way forward
Establishing four IPLTs has been time consuming for the project lead in terms of establishing within the teams what inter-professional learning is, developing commitment from the team, identifying a champion to take the initiative forward, mapping all healthcare professionals placements, providing facilitator training, and developing the actual learning opportunities for students. However, in terms of sustainability, this time has been well spent. Since the project has been completed, we have continued with student evaluations and the number of evaluations received have increased since project completion. This demonstrates both sustainability and growth. Whilst the “how to” booklet can offer guidance to other PLTs, it is still felt necessary to have an interprofessional lead who can dedicate time to disseminating the findings and helping staff within PLTs to develop their understanding of inter-professional learning. In addition, support can be provided to help staff identify interprofessional opportunities within their PLTs.
Recently, the East Midlands Healthcare Workforce Deanery (EMHWD) has agreed to fund expansion of the project, which has demonstrated such positive benefits for both students and qualified healthcare professionals alike. This will involve expansion within our own University as well as introducing the initiative into another University within the East Midlands region.
Acknowledgments
We would like to thank the ‘ champions’ within the participating IPLTs for their continued support and enthusiasm and Maggie Mallik, Nottingham Practice Learning Unit (2004–2007) for initial partnership funding, ongoing support and critical commentary on this article. Also Wendy Percy, Learning in Practice Manager (2004–2007) for invaluable support of the project in the clinical areas.
References
- . The need for multi professional health education in undergraduate studies. Medical Education. 1988;22:251–252
- . An exploration of the teacher/lecturer in practice – findings from a case study in adult nursing. Nurse Education Today. 2000;17(3):175–182
- . Learning from Bristol: the report of the public enquiry into children’s heart surgery of the Bristol Royal Infirmary 1984–1995. London: Stationary Office; 2001;www.bristol-inquiry.org.uk/(accessed 09.02)
- . Practice Learning teams: a partnership approach to supporting students’ clinical learning. Nurse Education in Practice. 2004;4:143–149
- . The role of the nurse teacher/lecturer in clinical practice. Researching Professional Education. 1998;8:[London, ENB]
- . A blueprint for interprofessional learning. Medical Teacher. 2004;26(7):604–608
- . Preparing students for interprofessional teamwork in health care. Journal of Interprofessional Care. 2000;14(3):223–234
- . Interprofessional education and team working: a view from the education providers. BMJ. 2000;321:1138–1140
- . Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning. Medical Education. 2001;35:876–883
- . Interprofessional Learning in the work place: are current facilitators prepared for the job?. CAIPE Bulletin. 2004;24:9–11winter
- . The performance of doctors: professionalism and self regulation in a changing world. BMJ. 1997;314:1540–1544
- Kelley, A., Aston, L., 2009. Interprofessional Learning; how to Develop an Interpofessional learning team, www.nottingham.ac.uk/nursing/practice/plt/IPL_teaching_booklet.pdf.
- . Establishing a systematic approach to evaluating the effectiveness of interprofessional education. Issues in Interdisciplinary Care. 2001;3(1):41–50
- . The Victoria Climbie Inquiry: report of an inquiry. London: Stationary Office; 2003;
- . The role of nurses in interprofessional health and social care teams. Nursing Management. 2009;15(9):30–35
- . Educational principles underpinning successful shared learning. Medical Teacher. 1998;20(6):522–529
- . The London Training Ward: an innovative interprofessional learning initiative. Journal of Interprofessional Care. 2002;16(1):41–52
- . Training Ward 30. Sweden: Linköping University; 1996;
- . External Inquiry into the Adverse incident that occurred at Queen’s medical Centre Nottingham. London: Department of Health; 2001;
- . “It teaches you what to expect in the future…”: interprofessional learning on a training ward for medical, nursing, occupational therapy and physiotherapy students. Medical Education. 2002;36(4):337–334
- . A multi-dimensional framework for clinical/practice placements. Published by the University of Newcastle Upon Tyne; 2004;[Common learning Programme]
PII: S1471-5953(10)00092-2
doi:10.1016/j.nepr.2010.06.003
© 2010 Elsevier Ltd. All rights reserved.
