engaging students to learn in practice: lessons learnt ......messages from pietroni “to encourage...
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Engaging students to learn inpractice: Lessons learnt through
interprofessional placements
Professor Elizabeth Anderson
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University of Leicester - Centre for Medicine 2016
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AimsConsider the added value of interprofessionallearning (IPL) in practice
• Context
– Our challenges for Practice-based IPL
• Analyse your clinical area
– Are you ready?
• Models that work
– Steps to follow with examples
• Take home messages
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Context
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Your Vision
‘To have a health and social care workforce inwhich individual practitioners fully understandthe value of education for learners, patients,carers and other health care practitioners’
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Interprofessional Education
World Health Organisation 2010
To prepare you to be ‘workforce ready’
‘Occurs when two or more professions learnabout, from and with each other to enableeffective collaboration and improve health
outcomes’The World Health Organisation (2010). Framework for Action on Interprofessional Education &Collaborative Practice. WHO, Geneva. p13.
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Your Challenges
• How IPE is perceived and understood
– Working culture
– We train for professional examinations
• Focus uni professional competence
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http://www.parliamentlive.tv/Main/Player.aspx?meetingId=12578
Personal responsibility versus culture
Working Culture
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Being Interprofessional:Interprofessional education
not directly implied
Francis ReportSolutions to culture change: Where IPE?
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Newton, J (2014). Group Conformity: The legacy continues. MedicalEducation, 48, 842-848.Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, MonashUniversity Australia
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Concerns raised by Newton
• Hierarchy there is a pressure to conform toauthority
• Power relationships between medicine andnursing
– Why: Task and finish (don’t rock the boat)
• Patient safety is about poor communication,ineffective team working and inappropriatemanagement
• Workplace cultural shift is required
– Students under power to conform
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Newton: Our response as educators
“..the interprofessional conflict that hasdominated, particularly between medicine and
nursing, must abate. Promoting a culture ofrespect and collaboration needs to begin at
undergraduate level through the developmentof sensitive, interprofessional curricular
activities that are mindful of the knowledge andexpertise that each health profession has to
contribute to care delivery”
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Anderson E & Bennett S. Are we serious about changing culture. Blog. BMJ 6th December 2016http://blogs.bmj.com/bmj/2016/12/05/elizabeth-anderson-and-simon-bennett-are-we-serious-about-changing-culture/
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Stories from medical students
• ‘No one welcomes me and no one even says
hello’
• Story of the nursing sister with medical
students… ‘who gave you permission to…’
• Foundation doctor: ‘….take it from another
ward’
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The ‘doves’ appear to be more accepting of changesaround professional boundaries where blurring istaking place. Although they do not ignore thepotential conflict that can exist for themselves andtheir students, the doves largely seek to manage thisconflict and look to a consensus approach.
In contrast, the ‘hawks’ are more concerned withissues of professional erosion and look to developmore combative strategies around the maintenanceof the existing boundaries and their currentprofessional identity. It is argued that this approachhas more of a conflict base.
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Is effectivecommunicationpossiblebetweenprofessionalswho speakdifferentlanguages?Communicationskills training hasfailed?
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Messages from Pietroni
“To encourage such a wide-range reflective processamongst professionals is not at all an easy task, but it isincreasingly clear that the high-ground of collaborativework will not be achieved unless attempts are made to
integrate ‘language sub-sets’ identified in this paper” p16.
• Points to Schöns work on reflective practitioners
• Address communication issues within interprofessional work andthe need for team training
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Wackerhausen, S. (2009). Collaboration, professional identity and reflection across boundaries.Journal of Interprofessional Care, 23, 244-473.
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Messages: First order reflection
First order reflection: Self-affirmative toprofession specific thinking - the topic willresult in what our kind normally think about.
Possessing a professional - vocabulary, certainkey-concepts, a certain disposition to perceive,to understand and to explain “the way we doit”.
These types of reflections therefore do notchallenge the way this kind does things.
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Messages: Second order reflection
‘How do we transgress the boundaries and self-affirmative reflective patterns of first orderreflection: i.e. how do we create reflectiveactivities that are not predetermined tostabilize the already stabilized (tradition), buthave the potential to de-stabilize thestabilized?’
Answer - increase the number of perspectivesfrom which we reflect….
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Effective team working in health and social careis not straight-forward
• Historic power relations ‘Doctors as the leaders ininterprofessional collaborations’
• Different culture, language, behaviour
• Different organisational structures, contractualobligations, physical presence
• Distinct professional boundaries – including identity,status, and discretion
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Assessment
• Separate and different education and training ofthe professional groups leading to:
– Strong perceptions (often negative) of oneanother
– Strong emphasise on uni professionalassessment
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AimsConsider the added value of interprofessionallearning (IPL) in practice
• Context
– Our challenges for Practice-based IPL
• Analyse your clinical area
– Are you ready?
• Models that work
– Steps to follow with examples
• Take home messages
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1. Analysis of your clinical area: AreYour Ready?
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Dominantlymedical ledpatient care
Some leadershipmovement away
from doctors
Patients involvedto some extent
in shareddecision making;
more sharedleadership
Patient centredinterprofessional
team-basedpractice
Systems where there is collaborative practiceHierarchicalSystem
Do you understand your local context?
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Communities of Practice (Wenger 1998)
• Shared agreements
– patterns of work and communication exchange
• A team that comes together to reflect
– seek to constantly improve
• Boundary objects are understood
– e.g. writing in different records
• Help students move from periphery to centre- valued, included, engaged
• Socialise together e.g. coffee
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Theory to Practice: Team working
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Collaborative Leaders
• Leaders
– Role models
• Bridge builders link theory to practice
– Create learning opportunities
– Explore, explain, challenge, assess
• Attitudes about your own and othersidentities
– You have a professional body of capability -identity
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Systemic Thinking
Build andrebuild
relationships
Self actualisation
Alternativeapproachesto solvingcomplexproblems
Vaggers, J, 2015
Four Collaborative Leadership Qualities
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Theory
• Avoid in-groups and out-groups
– Sharing social capital (Bourdieu, 1997)
• How to form a team:
– Forming
– Norming
– Storming
– Performing (Tuckman, 1965)
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Photo shot of simulation
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1. Gettingready
2. Working together to assess,diagnose and plan care
3.Delivering
care
4.Reviewing
care
Step1Getting ReadyforCollaborativeTeamwork
Step 2Teamwork to:• Gather information• Determine the required health/social needs• Obtain further information• Set goals and the treatment plan to address identified
patient/family needs• Develop guidelines to measure progress toward patient care
goals
Step 3ImplementingPatientTreatment Plan
Step 4Assessment ofProgress for:Achievement,revision, expansionof patient treatmentgoals
Reflecting on Teamwork throughout the process
Collaborative Patient-Centred Practice
Underpinning Competence Framework www.cihc.ca• Interprofessional Communication• Patient/family/community centred care
• Role clarification• Team functioning• Collaborative leadership• Interprofessional conflict resolution
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AimsConsider the added value of interprofessionallearning (IPL) in practice
• Context
– Our challenges for Practice-based IPL
• Analyse your clinical area
– Are you ready?
• Models that work
– Steps to follow
– examples
• Take home messages
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Models with examples
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Preparation• Alignment to curriculum• Pre-reading• Introduction• Team formation
1. Experience• Patient contact• Community/ward
2. IP Reflection• Theory• Profession-specific
perspectives
3. Assimilation• New thinking• Integrating perspectives• Planning
4. Outcomes• Joint presentation• Debate• Changing practice
The Leicester Model
Assessment;learning taken
forward into practiceFro
mpro
fessio
nsp
ecific…
..toin
terp
rofe
ssio
nalw
ork
ing
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Ethics
• Preparation/support for patients (Hospital/Community)• Consent process• Confidentiality• Student professionalism
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Theory
Kolb, DA. (1984). Experiential Learning. Prentice-Hall, Englewood Cliffs: New Jersey.
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• Experiential learning(D’Eon 2005; Clarke2006)
• Reflective practice(Schön 1987; Dewey1938)
• Trialogical learning(Hakkarainen &Paavola, 2007)
• Synthesis(Vygotsky, 1978;Wackerhausen, 2009)
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What HappensThe Leicester Model: Short-PracticePlacements
Preparation forpractice
Theory• Contact
hypothesis(Allport 1979;Carpenter andHewstone,1996)
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1. Learning and workingwith patients and
practitioners
(acute hospital ward)
Theory• Experiential
Learning(Kolb, 1984;D’Eon, 2005;Clarke, 2006)
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2. Reflection on learning.Students apply profession-specific understandingsasking questions about whatand why decisions havebeen made.Guided by facilitators
TheoryReflection andTrialogicalunderstanding(Schön 2004;Dewey 1938;Hakkarainen &Paavola, 2007)
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3. Assimilation:Students agreetogether potentialsolutions to problemsand begin to makesense of their learningand prepare topresent their findings.
4. Outcomes: Studentspresent their findingsand propose solutionsin discussion withexperts. Clinical errorsare referred back tothe clinical team.
• Changes to patient care• Students take forward their learning
TheorySynthesising forchange(Vygotsky 1978)
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The acquisitionmetaphor
(Monological, withinmind approach)
Theparticipation
metaphor(dialogicalinteractionapproach)
The knowledge-creation(trialogical developingcollaborative shared
objectives and artifacts)
Expanding knowledge learning in groups and communitiesHakkarainen K. & Paavola S. (2007)
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Anxiety Flow
Apathy Boredom
Competence/Skill
Ch
alle
nge
(ris
k)
Four Channel Flow Model:Engaging learners
Csikszentmihalyi, M 1990
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Slide 8
Studentssupported to makemeaning together
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Systematic Reviews IPE
• (21+ 25) = 46 High Quality IPE studies
• 19 UK studies
• Positive findings:
– Student attitudes
– Collaborative knowledge and skills
• More evidence still required:
– Changes in behaviour
– Changes to patient care
– Organisational impacts
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Kirkpatrick Modified by the Joint Evaluation(JET) Team
1. Reaction Learners views positive ++++++++
2. a Modification ofattitudes/perceptions
Changes in reciprocal attitudes or perceptions ofone another ++++++++
2 .b. Acquisition of knowledgeand skills
Increases in collaborative knowledge +++++
3. Behavioural change Limited but growing evidence of changes tobehaviour
4. a change in organisationalpractice
Limited but growing evidence of changes toorganisational practice and delivery of care
4. b. Benefits topatients/clients
Limited but growing evidence of improvementsto patients/client care
Originally designed for evaluating training in a business organisation
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Summary - Take home messages
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Challenging and changing
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IPE Challenge
• We need to show them that IPE is thesolution
– Most healthcare managers, educators, policywriters… still don’t get it
• Patients see we don’t work together…
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‘It [IPE] is a good idea……..bringing them all together because it is the problem…….theleft hand doesn’t know what the right hand is doing.’‘There needs to be a holistic approach… there are so many agencies involved...’
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The old NHS is a place of archaichierarchies; where patients are incidental;where what is important is your job title;where experience; expertise andknowledge count for nothing; where adoctor assumes superiority of status andknowledge irrespective of their actualexpertise and knowledge. A place wheremanagers rule with an iron rod of fear,threatening any staff, patients or familieswho don't tow the line. A place wherestaff or families who raise concerns arethreatened, bullied and abused. A placewhere social media is feared and thosewho use it are attacked if they step out ofline; a place where healthcare is for the fitand healthy who have a fleeting illnessfrom which they can 100% recover.
The new NHS is a very different world.Patients are at the centre of everything itdoes. Engagement, participation, feedback,values, #HelloMyNameIis and the 6Cs are notjust hollow phrases but realities. All patientsare valued, even cherished, no matter howelderly, frail, young or disabled. The new NHSis a partnership of equals where theorganisations most senior staff engage withthe NHS's most vulnerable patients in thispartnership of equals. A place withouthierarchies, where everyone from the CEO tothe sickest child patient is valued for theexperience and expertise they bring; not justto their situation whether as an employee,volunteer, director or patient, but to theorganisation as a whole. A place where socialmedia is embraced as a wonderful platformfor the exchange of ideas and values
Blog by: Adams Mother: I see both these NHSs frequently. I am sure many others do too.http://thetriangulationofthought.blogspot.co.uk/#!/2014/11/patients-first-casualty-of-nhs-at-war.html
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IPL bridges the gap… to achieve change
Sinfield, P., Donoghue, K., Horobin, A & Anderson ES. (2012). Placing interprofessional learning atthe heart of improving practice: The activities and achievements of CLAHRC in Leicestershire,Northamptonshire and Rutland. Quality in Primary Care, 20(3),191-8.
‘…increase the implementation of research evidence…. Aninterprofessional and interdisciplinary approach is used andincorporates a range of activities including: applied research,service evaluation and pilot projects, education and training events,knowledge dissemination activities and developing networks…
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Improving Safety Through Education and Training: Reportby the Commission on Education and Training for PatientSafety: March 2016
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A patient safety culture…. It is aboutindividual, group and organisational values,
attitudes and perceptions, competencies andpatterns of behaviours. Education and
training must start to address the culturalbarriers that contribute to unsafe care.
Interprofessional training was repeatedmentioned as a way of breaking down
silos between professions andencouraging teams to work together…
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Your Vision
‘To have a health and social care workforce inwhich individual practitioners fully understandthe value of education for learners, patients,carers and other health care practitioners’
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ReferencesAnderson. ES., Hean. S., O’Halloran. C., Pitt. R. & Hammick, M. (2014). FacultyDevelopment and Interprofessional Education and Practice. Chapter 14, 287-310. In:Steinert,Y. (Eds Faculty Development in the Health Professions: A focus on Research andPractice’. New York: Springer.
Bourdieu, P. (1997) The forms of Capitol. In. A. H. Halsey, H. Lauder, P. Brown. & A. StuartWells (Eds). Education: Culture, economy and society pp46-58. Oxford University press:Oxford UK
Csikszentmihalyi, M 1990. Flow the psychology of optimal experience. New York: HarperPerennial Modern Classics
Commission on Training and Education: www.hee.nhs.uk/the-commission-on-education-and-training-for-patient-safety.
Engeström, Y. (2001). Expansive theory at work: Towards an activity theoreticalreconceptualisation. Journal of Education and Work, 14, 133–156.
Hakkarainen K. & Paavola S. (2007) From monological and dialogical to trialogicalapproaches to learning. Paper presented at the international workshop ‘Guided
Construction of Knowledge in Classrooms’. Availableat:http://escalate.org.il/construction_knowledge/papers/hakkarainen.pdf (last accessed 10December 2010).
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Tuckman, BW. (1965). Development sequence in small groups. PsychologicalReview. 63, 384-399.
Wenger, E. 1998. Communities of Practice. Learning, Meaning and Identity.Cambridge University Press: Cambridge
World Health Organisation. Framework for Action on Interprofessional Education& Collaborative Practice. p13, Geneva: WHO. 2010.
Engeström, Y. (2001). Expansive theory at work: Towards an activity theoreticalreconceptualisation. Journal of Education and Work, 14, 133–156.
IOM (Institute of Medicine, 2015. Measuring the impact of interprofessionaleducation and collaborative practice and patient outcomes. Washington, DC: TheNational Academic Press.
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans E, Fineberg, H et al. Healthprofessionals for a new century: transforming education to strengthen healthsystems in an interdependent world. The Lancet 2010; 275 (9721): 1137-8.
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References: The Leicester Model
Lennox, A. & Anderson, ES, (2007). The Leicester Model of Interprofessional Education. Apractical guide for implementation in health and social care. Higher Education Academy, subjectcentre Medicine, Dentistry and Veterinary Medicine. Special Report 9. ISBN 978-1-905788-45-3
https://www.heacademy.ac.uk/sites/default/files/leicester-model-of-interprofessional-education.pdf
Anderson, ES. & Lennox, A. (2009). The Leicester Model of Interprofessional education:Developing, Delivering and Learning from student voices for 10 years. Journal ofInterprofessional Care, 23(6), 557-573. http://dx.doi.org/10.3109/13561820903051451
Kinnair, D., Anderson ES, Thorpe, LN (2012) . Development of interprofessional education inmental health practice: Adapting the Leicester Model. Journal of Interprofessional Care. 26:189-197. http://dx.doi.org/10.3109/13561820.2011.647994
Lennox, A. & Anderson, ES. (2012). Delivering quality improvements in patient care: Theapplication of the Leicester model or interprofessional education. Quality in Primary Care, 20(3),219-226.
Anderson ES., Thorpe, LN. (2014). Students improve patient care and prepare for professionalpractice: an interprofessional community-based study. Medical Teacher. 36: 495–504.http://dx.doi.org/10.3109/0142159X.2014.890703
Anderson, ES., Lakhani, N. (2016) Interprofessional learning on polypharmacy. Clinical Teacher.13: 291–297.
Anderson, ES., Kinnair, D, Ford, J. (2016). Interprofessional Education and Practice Guide No.6:Developing Practice-Based interprofessional learning using a short placement model. Journal ofInterprofessional Care, http://www.tandfonline.com/doi/full/10.3109/13561820.2016.1160040.