How interprofessional learning improves care

Nursing Practice Review Students

Keywords: Interprofessional/ Education/Health professionals

This article has been double-blind peer reviewed

Students from different disciplines who learnt together developed interpersonal and teamwork skills and gained knowledge of how other professionals work

How interprofessional

learning improves care

In this article...

W here the idea of interprofessional learning came from O utcomes of using IPL in healthcare training R ecommendations for practice

Author Jennifer Barwell, Frances Arnold and Helen Berry are all fourth-year medical students at Norwich medical school, University of East Anglia. Abstract Barwell J et al (2013) How interprofessional learning improves care. Nursing Times; 109: 21, 14-16. Students from different health disciplines often have little idea of what each other's roles entail. Interprofessional learning increase this knowledge, as well as giving students an understanding of the interpersonal skills needed for liaison and communication. IPL has been shown to create teams that work together better and improve patient experience. It has been introduced successfully at the University of East Anglia and at other higher education institutions.

Many questions could be asked about the way nurses, doctors and allied health professionals trained in the past and how they were prepared for multidisciplinary working. Every professional has its own roles, skills and responsibilities making for efficient practices in curing, managing or treating particular ailments, but has this always created cohesive teamworking in day-to-day working life? In the past, did we respect our colleagues working in different health professions? Perhaps most importantly, is there a better way of working together?

In the late 1980s, the World Health Organization recognised that, if health professionals were taught together in a multiprofessional educational setting and learned to collaborate as a team during their student years, they were far more likely to work effectively together in their

professional lives in a clinical setting (WHO, 1988). Interprofessional learning (IPL) was born.

Initially, IPL was defined as "learning together to promote collaborative practice" (Hammick, 1998). Nowadays, the more widely used definition is from the Centre for the Advancement of Interprofessional Education (CAIPE): "Interprofessional education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care... and includes all such learning in academic and work-based settings before and after qualification, adopting an inclusive view of professional (caipe.ipl)."

Government policy emphasises the need for effective collaborative working in the NHS to provide optimal and safe patient care. The need for effective interprofessional learning and teamworking was highlighted in the Victoria Climbi? case (DH, 2003) and the Bristol and Alder Hey (DH, 2001) case before that. These both illustrated how poor teamworking and communication between health professionals can have a hugely negative impact. Research by Grumbach and Bodenheimer (2004) reinforces the argument that better teamwork between health professionals positively affects patient outcomes. If this is the case, shouldn't IPL be fundamental to health professionals' education and training?

The present The faculty of medicine and health at the UEA has worked to produce health professionals who not have experience of but also value IPL and teamwork.

In autumn 2004, a pre-registration IPL

5 key points

1The World Health Organization recognised that multiprofessional learning leads to better interprofessional working

2Better teamwork between health professionals improves patient outcomes

3IPL helps students to appreciate the importance of personalities and interpersonal skills

4 Institutional hierarchies can hinder communication, which can negatively affect patient care

5Research is needed on the effects of IPL learning beyond undergraduate studies

Learning with students in other disciplines supports later collaboration at work

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TABLE 1. UEA PRE-REGISTRATION INTERPROFESSIONAL LEARNING PROGRAMME

Programme component What's involved:

Level 1

Piloted in 2003 and developed with students and staff from the different health schools at UEA (Lindqvist et al, 2005), level one is compulsory for all first-year students in medicine, nursing, occupational therapy, operating department practice, pharmacy, midwifery, physiotherapy and speech and language therapy. Problem and case-based learning is applied and, in mixed-course groups, students meet on four occasions with a facilitator, and twice without. The final goals are to: Produce a joint report regarding management of patients in a provided case scenario Discuss interprofessional issues arising from the scenario Give a group presentation to illustrate what has been learnt from the experience

Level 2

This is compulsory for students in the second year of their studies. Once again, working in crossprofessional groups, students attend three workshops where they work through a handbook in small groups. Afterwards, they each produce reflective statements

Level 3

This is an optional one-day conference. Third and/or final-year students from medicine, midwifery, nursing, occupational therapy, pharmacy and physiotherapy participate and are joined by qualified health and social care professionals and service users. Delegates are able to share their experiences of healthcare from a number of perspectives: as members of health and social care teams; as carers; and as patients

Level 4

A fourth level was piloted in 2008 and is now run as two half-day, optional, problem-based workshops. Students, qualified professionals and patients come together to discuss stories and experiences relating to a central issue such as drug misuse or alcoholism. Participants are asked to gather their thoughts and reflect on the topics before attending and the workshop focuses on discussion as a means of learning

Centre for Interpersonal Practice at UEA (2012)

programme was developed for all health schools in the faculty (Table 1). The programme was created as part of the national aim to improve care and professional relationships (Box 1). This strategy was also intended to increase the flexibility and responsiveness of the workforce as part of NHS modernisation (DH, 2000).

A comparative review carried out by CAIPE in September 2010 (Barr and Norrie, 2010) drew together the professional responsibilities regarding "interprofessional education and collaborative practice" presented by the General Medical Council (2009), the Department of Health (2002), the Nursing and Midwifery Council (2010), the General Social Care Council (2008) and the Health and Care Professions Council (2008).

In its 2009 Tomorrow's Doctors document, the GMC makes reference to communicating clearly, sensitively and effectively not only with patients and relatives but also with other health professionals. It highlights the importance of respecting colleagues and "learning effectively within a multiprofessional team" (Barr and Norrie, 2010). This is echoed in the NMC standards, where reference is made to working "in partnership" collaboratively across professional barriers to achieve "integrated person-centred care" (NMC, 2010). GSCC codes of conduct refer to "working openly and cooperatively with colleagues while respecting the roles and expertise of workers across the healthcare organisation".

This significant overlap between the policies of each governing body demonstrates a cross-professional consensus on the implementation and value of interprofessional teamwork and collaboration.

IPL ? does it work? IPL has been trialled in various formats in the undergraduate curriculum.

One of these approaches has been opening a training ward to facilitate students from different disciplines learning together. This was piloted in 2004 by St George's Hospital, University of London, Kingston University and Brunel University, following the success of trials in Link?ping University, Sweden

BOX 1. AIMS OF UEA'S IPL PROGRAMME

Identify key principles that facilitate interprofessional teamworking Understand why improvements in interprofessional practice are important to patient care Describe their own role as a health professional as part of a multiprofessional team Learn about the role of other health professions and how they would collaborate to provide the best care Begin to understand the benefits of and constraints of interprofessional teamworking

(Wilhelmsson, 2009). The training ward acts as a practice placement and enables medical, nursing, occupational therapy and physiotherapy students to work in teams on an elderly person's rehabilitation ward. The placement allows students to put their teamwork skills into practice, learn about each other's roles and responsibilities and develop communication skills to make a cohesive team. During the placement, students were supervised by a generic facilitator as well as their profession-specific mentors, and together the team were jointly responsible for sharing the care of consenting patients where it was felt multidisciplinary input would be beneficial. The aim of the project is for the students to acquire teamworking skills and experiences for proficient interprofessional practice (Table 2).

The student feedback on this experience was positive and the most significant positives recorded were: ? Appreciation of importance of

personalities and interpersonal skills for liaison and communication; ? Gaining experience of how other members of the team work; ? Improved knowledge of illnesses; ? Greater appreciation of how wards function (Mackenzie, 2007). In their evaluation, students reported that as the student team had lacked the normal hierarchy, they were able to question, share knowledge and learn together without professional and defensive boundaries. Often, an institutional hierarchy may

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TABLE 2. BENEFITS AND DRAWBACKS OF IPL

Benefits of IPL

Creates a nurturing environment for students to share their views and learn in a balanced, comfortable environment Improves general interactions between future health professionals, to establish good practice at an early stage Increases student knowledge of different professions and within the multidisciplinary team the value of these roles in relation to patient management Develops skills for a successful multidisciplinary team Enables students to learn when and how to refer patients and the benefits of appropriate patient care Improves general communication among the team to improve interprofessional relations as well as ultimately improving patient care Students can learn how to critique and reflect upon practice they observe, learning from mistakes as well as developing reflective skills on their own practice

Drawbacks of IPL

Increased demands on academic and clinical staff Logistically challenging to implement within an already full academic timetable Timetables may not be synchronised across all health professions. Requires full group participation, which may not always be possible Discussion-based learning may not be the best medium for all students

obstruct the flow of communication and prevent all team members from contributing and feeling valued, which ultimately can negatively affect patient care (Reynolds, 2005).

Policies and current literature are recognising the benefits of interprofessional learning and recommend it is scheduled early on in professional education. The purpose of IPL is to improve professional practice (it is not a substitute for subjectspecific learning) and it would be beneficial to incorporate it into the continuum of both professional and interprofessional learning.

The future With an ageing population, greater migration, health inequality and technological advances, demands on the NHS, staff and resources are continuing to increase.

Through the principles of IPL, there is hope that the team will be more robust to adjust to these challenges.

Historically, these practical challenges are often encountered after qualification but, by beginning this process early on in training, the outcomes may be more favourable. The healthcare professional may have been exposed to situations in training that can be reflected on, they know how to behave towards other staff and should have good communication

skills that will help them work well in a team. The legacy of IPL is to prepare students with the interprofessional skills that will later form the core of their professional identity and pave a smoother route to optimal patient care.

More longitudinal studies are needed that follow students through and beyond their undergraduate studies, along with critical observation of the learning process. Teaching of IPL at different universities and in different health professionals' undergraduate programmes is varied but the effects of incorporating IPL are well documented in healthcare training programmes worldwide. The different methods of IPL have all been found to be beneficial for preparing students and improving clinical outcomes in different UK undergraduate programmes.

Standardising IPL in the curricula of all health professionals can improve key skills and prepare students for their careers by driving up standards of professionalism and best practice. NT

References Barr H, Norrie C (2010) Requirements Regarding Interprofessional Education and Practice ? a Comparative Review for Health and Social Care. Centre for the Advancement of Interprofessional Education. CAIPE-IPLeducation Centre for Interpersonal Practice at UEA (2012) Pre-Registration IPL Programme. Norwich: Univeristy of East Anglia. uea.ac.uk/cipp/Pre-Reg

Department of Health (2003) Laming Report. The Victoria Climbi? Inquiry-Report of an Inquiry by Lord Laming. VClimbie-Inquiry Department of Health (2002) Requirements for Social Work Training. London. Department of Health. Department of Health (2001) Learning From Bristol: the Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary. London: Stationery Office. Department of Health (2000). The NHS Plan: a Plan for Investment, a Plan for Reform. London: DH. DH-NHSplan2000 General Medical Council (2009) Tomorrow's Doctors. Manchester: GMC. education/undergraduate/tomorrows_ doctors_2009.asp General Medical Council and Medical Schools Council (2009) Medical Students: Professional Values and Fitness to Practise. Guidance from the GMC and MSC. static/ documents/content/GMC_Medical_Students.pdf General Social Care Council (2010) Codes of Practice for Social Workers. socialw-code Grumbach K, Bodenheimer T (2004) Can health care teams improve primary health care practice? Journal of the American Medical Association; 291: 10, 1246?51. Hammick M (1998) Interprofessional education: concept, theory and application. Journal of Interprofessional Care; 12, 323-332 Health and Care Professions Council (2008) Standards of Education and Training. London: Health and Care Professions Council. hpc-uk. org/aboutregistration/standards/sets/ Lindqvist S et al (2005) Case-based learning in cross-professional groups ? the development of a pre-registration interprofessional learning programme. Journal of Interprofessional Care; 19: 5, 509-520. Mackenzie A et al (2007) Interprofessional learning in practice: the student experience. British Journal of Occupational Therapy; 70: 8, 358-361. Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education. London: NMC. NMC-training-standards Reynolds F (2005) Communication and Clinical Effectiveness in Rehabilitation. Edinburgh: Elsevier Butterworth-Heinemann Wilhelmsson N et al (2009) Twenty years of interprofessional education in Linkoping--ground breaking and sustainable. Journal of Interprofessional Care; 23: 2, 121-33. World Health Organization (1988) Learning Together to Work Together for Health. Geneva: WHO. WHO-together

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