Nurse Educator Vol. 40, No. 1, pp. E1-E4 Copyright * 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Developing Communities of Interprofessional Practice Using a Communities of Practice Framework for Interprofessional Education Susan E. Sterrett, EdD, RN & Susan R. Hawkins, MSEd, PA-C & Mark L. Hertweck, MA, PA-C Jodi Schreiber, OTD, OTR/L Development of interprofessional education programs that meet new Interprofessional Education Collaborative competencies is a challenge for faculty and administrators. This article describes a curricular design that places students in learning communities over a 2-year period with a plan for 5 learning sessions. Communities of practice is the theoretical framework of the curricular design, creating interprofessional clinicians capable of effective collaborative practice. Keywords: communities of practice; health professions education; interprofessional education; nursing education

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eans and faculty of nursing programs across the United States face a common challenge, that of redesigning their educational programs to create interprofessional student experiences. A growing body of research has identified collaboration among clinicians as a key component leading to quality patient care and efficiency of care delivery.1 The Institute of Medicine’s report, Redesigning Health Professions Education,2 listed interprofessional education (IPE) as a tenet of educational redesign. In 2009, 6 national education associations of schools of the health professions, including the American Association of Colleges of Nursing, formed the Interprofessional Education Collaborative (IPEC). One outcome of that joint effort was identification of 4 competencies for interprofessional practice: (1) roles and responsibilities of the health care team, (2) teams and teamwork, (3) interprofessional communication, and (4) values and ethics of interprofessional practice.3 Many barriers exist to bring students from various health professions together. Curricula invariably have no electives with different academic calendars depending on the timing of clinical education. Beyond this, there are restrictions in obtaining space large enough for the number of students involved. The traditional academic structure does not reward and often does not even accommodate for teaching or planning for courses outside the disciplinary curriculum. Territoriality exists as well as a lack of perceived value. One approach to IPE, taken at a small urban university in the northeastern United States, uses learning communities Author Affiliation: Chatham University, Pittsburgh, Pennsylvania. The authors declare no conflicts of interest. Correspondence: Dr Sterrett, Chatham University, Eastside Campus, Rm 220, 6585 Penn Ave, Pittsburgh, PA 15201 ([email protected]). Accepted for publication: September 30, 2014 DOI: 10.1097/NNE.0000000000000109

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to develop students’ competence in the defined skills of collaboration, as well as advancing their interprofessional identity. More than 300 students, representing 5 disciplines, met in learning communities with events focused on the 4 IPEC competencies. All the students are prelicensure, obtaining their initial education leading to licensure in their profession, and all are graduate students except the nursing students who are in a diploma program. This article describes the curricular structure and theoretical framework of the program.

Background Interprofessional programs were first developed in 2007. Initially, there was an annual event that used a case study review in which faculty from different programs discussed their professional roles within the case. Subsequently, 6 faculty from the health professions began to meet, and in 2011, a 2-year curriculum with a learning community framework was initiated. This article describes the curriculum design. Each year, new students are placed into learning communities of approximately 10 students. An initial opening event includes a description of the concept and importance of IPE and the requirements of the 2-year curriculum, and a patient and spouse discuss their care experience. Students are seated at round tables, and time is also allotted at that event for the students to become acquainted with each other. Over the next 2 years, 4 learning events occur, each focused on 1 of the 4 IPEC competencies.

Communities of Practice as a Theoretical Framework IPE differs from professional education in that knowledge is often socially created through interactions with students and faculty from other health professions. Literature on IPE educational theories suggests social psychology and complexity Volume 40 & Number 1 & January/February 2015

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theory as well as social learning theory and Communities of Practice (CoPs)4-7 as appropriate theory for IPE development. CoP is a conceptual model developed by Jean Lave and Etienne Wenger and is categorized as a social learning theory. The basic tenet is that learning occurs when people participate in the practices of social communities and construct identities in relation to them. The 3 dimensions of a CoP are mutual engagement, joint enterprise, and shared repertoire.4 This framework provides an interesting lens from which to view interprofessional learning because of its focus on the social and cultural context of learning. Wenger4 states that learning starts with the assumption that engagement in social practice is the fundamental process by which we learn and become who we are. The primary unit of analysis is not the individual as learner, or the institutions in which they are learning, but the CoP that people form as they pursue shared enterprises. Students in an interprofessional practice fellowship identified characteristics of mutual engagement, joint enterprise, and shared repertoire as they described their experiences in a grounded theory study.8 Health profession students form a CoP as they learn about and become enculturated in their discipline. Through their coursework and clinical education, they experience mutual engagement, joint enterprise, and a shared repertoire that marks a community of practice. They come to the interprofessional experience with a disciplinary community established, and as a result of the same activities, students develop an interprofessional identity as they also become a member of this interprofessional community. Becoming a member of a community allows learning to take place and an identity to form.9 A uniprofessional identity can lead students to viewing their profession as different and better than others.10 While developing their professional identity, students in interprofessional programs are also coming to terms with an interprofessional identity. These 2 identities not only can assist the practitioner to be an effective collaborator in the clinical setting, but also can lead to role confusion.9 The students may be struggling with the dual memberships in their disciplinary and interprofessional community. Identifying this process to the students allows them a deeper understanding of the outcome of being an effective collaborative practitioner.5 Faculty took this concept of learning through establishing community and developed a process in which students would be placed in interprofessional communities and remain in these groups over the course of 2 years and 5 learning events. The learning events focused on developing competence in teamwork, collaborative communication, understanding roles and responsibilities of other professions, and the values and ethics of interprofessional care. By using a learning community design, the knowledge of competencies for teamwork and collaboration develops within a social setting as the students meet in the same group over time, forming relationships with students from other professions.

Curricular Structure and Implementation Process The curriculum was developed within the framework of creating community and a learning environment that support the development of relationships as the means to develop both understanding of the IPEC competencies and an identity as E2

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an interprofessional clinician.5 The communities are created intentionally with students from each profession prior to the initial meeting. The first event is in the fall, during the first week of the term; the 2 remaining events in the first year occur in the later fall and early spring terms. Events are 2 to 3 hours in length. The events in year 2 are planned to occur online.

Event 1: Introductory Event The opening event occurs on a weekday evening with a speaker to allow students in predetermined groups to meet and learn about the concept and potential value of IPE. This involves more than 300 students and takes place in a gymnasium set with round tables of 10. Students receive an e-mail prior to the event telling them their group number, which is also the table number. Students introduce themselves to their learning community and share their health profession and why they chose that profession. There is a presentation with a patient and his wife discussing their care experience. At the end of the event, students choose a Saturday 3-hour time slot for their next event in the fall semester. Event 2: Communication Event 2 focuses on communication. Learning objectives include choosing effective communication tools and techniques when working collaboratively and obtaining the ability to give timely, effective feedback while maintaining respect of all members. The PEEER communication model11 is presented including videos representing positive and negative representations of team communication. After discussion of these scenarios, the groups develop skits that are then demonstrated to their peers. Groups chose a positive or negative example, not restricted to health care examples. The session ends with skits presented in the large assembly, and concluding discussion focuses on the learning objectives. Event 3: Roles and Responsibilities The next event is a 2-hour program focused on understanding the roles and responsibilities of differing professions. This IPEC competency domain is essential to understanding collaborative care and the part each profession plays in patient care. Learning objectives of this event include being able to explain their professional role and gain an understanding of the roles of other members of the health care team. Students meet as a large group initially and then break into their CoP, each group with a faculty facilitator. A discussion of a complex case of a homeless man admitted for leg fractures and with psychiatric and drug history occurs in the small groups, with the groups reporting on their findings. Students propose how they would develop a plan of care from their disciplinary viewpoint, and a discussion evolves about the differences in approach to the patient and any overlapping responsibilities in care. Event 4: Values and Ethics for Interprofessional Practice The final 2 events are planned to occur online in the second year as students are often in clinical placements and assembling would be difficult. Students remain in their communities as the online discussion forums contain the members of their group. The focus of event 4 is the IPEC initial competency domain of values and ethics. Students should develop a shared purpose to support the common good in health care Nurse Educator

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and reflect a shared commitment with other team members to creating safer, more efficient systems of care.3 Students generate a list of terms that indicate professionalism. Each learning community then through the discussion board generates a shared definition of professionalism. The second activity is to post and report on their profession’s code of ethics leading to the development of a shared code. This content was developed from publication on a comparison of disciplinespecific codes of ethics.12

Event 5: Teams and Teamwork Learning to be interprofessional means learning to be a collaborative member of a team. Learning objectives include gaining the ability to engage other health professionals, appropriate to a specific care situation in shared, patient-centered problem solving, and reflecting on individual and team performance improvement. The online module has readings with associated discussion questions initially asking students to describe a group experience that went well and one that did not. They then discuss the essential elements of each scenario. Background content for the development of the module came from Lencioni’s13 work on the 5 dysfunctions of a team and the book, Crucial Conversations.14 Finally, each individual reflects on their learning and the development of their learning community.

Implementation Process and Strategies Organizing programming for 300 health profession students is challenging. Over the 2 years, the faculty task force developed these approaches to implementation.

Assignments to Learning Communities Initial learning community assignments are made by a faculty member. They receive the list of incoming first-year students and create the learning communities using proportions equivalent to the size of the programs. Distribution of students in each of the health professions is dependent on enrollment in each of the programs. Each faculty acts as a facilitator for 5 communities. Credit Assignment This program occurs outside the professional curriculum, overcoming the hurdle of where to ‘‘fit it in.’’ Faculty from each program determine how credit will be applied within a disciplinary course that is taken concurrently with the IPE learning session. Credit for PA, PT, and OT students is in most cases a course assignment. In counseling psychology, it is an elective option, and for nursing, it is a program requirement. Creating the Community of Faculty Six faculty have collaborated for 7 years on the IPE program. In an environment with few rewards for this teaching, it has been the faculty’s belief in the importance of the education that has provided the incentive to complete the work. There was no administrative mandate to develop the program. The fact that it has been a bottom-up program development instead of an administrative request may have created a camaraderie leading to a sense of cohesion in the group. Meetings occur regularly to plan programs and as well as conduct research on them and write manuscripts. This occurred initially with all working together. Eventually, there were multiple Nurse Educator

manuscripts partially written and the need to design the curriculum, and the group divided, with 1 group focused on writing and the other on the curriculum.

Faculty Credit for Workload The faculty work of developing IPE programs and facilitating the learning experiences generally fall outside the faculty workload. This lack of faculty credit is a barrier to the initiation and sustainability of IPE programs.15 For deliberate and planned change, a shift in institutional values is needed. IPE may always be outside the academic mainstream and needs a process of regular infusion of energy and support to succeed.16 Achieving visibility by administration required frequent requests by the faculty group for meetings to keep them aware of our program. Eventually, the group was granted university committee status to be able to gain some credit for the workload, that is, serving on a university committee. Still, faculty spend 18 hours a year in actual face-to-face programs plus online support fall and spring in year 2. There is no credit allocation for faculty for this work.

Evaluating Outcomes Evaluation and publication were built into our IPE experience. We are currently examining the results of a questionnaire on students’ self-report of knowledge of the IPEC competencies. Initial efforts, prior to the development of the described program, were evaluated with the Readiness for Interprofessional Learning Scale (RIPLS).17 This scale has 19 items using a Likert scale with 4 subscales: teamwork and collaboration, negative professional identity, positive professional identity, and roles and responsibilities. The results identified gender differences, with women having greater readiness for interprofessional learning than males, as well as differences between professions, with PA students scoring significantly lower than the other professions on 3 of the subscales.18,19 Use of the RIPLS, however, does not allow for identification of achievement of the IPEC competencies. As these students graduate and begin to work, there has been discussion on assessing their attitudes and knowledge in the clinical setting.

Discussion This article has summarized an innovative curricula design that allows the health profession student to gain an understanding of core IP concepts as well as gain relationships with students from other professional programs, leading to the development of both a professional and an interprofessional identity. The design has a theoretical grounding in CoP. There are advantages and disadvantages to completing the curriculum over 2 years. This length of the program has the advantage of having students at different stages of their professional development. They have more clinical experience to draw on in their discussions and more time with their community to develop relationships. A more compact 1-year program would require less student and faculty time. Because the nursing program does not have students obtaining their initial nursing education, we were able to work with a diploma nursing program that has ties to the university. These diploma students become part of the communities and provide the important voice of the nursing profession to students from the other programs. Volume 40 & Number 1 & January/February 2015

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Research on the effectiveness of different models of IPE is developing. Literature on the use of CoP in health care focuses on practice care initiatives20,21 and descriptions of online models.22,23 More evaluation of the effectiveness of this approach to IPE is needed. It is hoped that with the application of theory and research, health profession collaboratives will have evidence-based pedagogical models to be implemented.

Summary Interprofessional education is an essential aspect of health profession education. Determining a design that is workable, considering the many barriers to implementation can seem an insurmountable task. This format incorporates CoP theory into a curricular design that is outside the formal curriculum, but builds credit for the activity within disciplinary courses. An advantage of the model is its applicability outside the traditional curriculum. This learning community IPE curriculum brings health profession students together in a way that allows relationships to develop, along with the development of an interprofessional identity. Content focuses on the 4 core IPEC competencies. The desired end product is a clinician who understands interprofessional relationships and collaborative team-based care. Acknowledgment The authors thank Anthony Goreczny, PhD, of Chatham University.

References 1. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009; (3):CD000072. DOI: 10.1002/14651858.CD00072.pub2. 2. Committee on the Health Professions Education SummitGreiner AC, eds. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 2003. Available at http://www.nap.edu/openbook.php?record_id=10681. Accessed June 20, 2014. 3. Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; 2011. 4. Wenger E. Communities of Practice: Learning, Meaning, and Identity. Cambridge: Cambridge University Press; 1998. 5. Khalili H, Orchard C, Laschinger H, Farah R. An Interprofessional socialization framework for developing an Interprofessional identity among health profession students. J Interprof Care. 2013;27(6):448-453. 6. Thistlethwaite J. Interprofessional education: a review of context, learning and the research agenda. Med Ed. 2012;46:58-70.

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7. Hean S, Craddock D, O’Halloran C. Learning theories and Interprofessional education: a user’s guide. Learn Health Soc Care. 2009; 8(4):250-262. 8. Sterrett S. Becoming an interprofessional community of practice: a qualitative study of an interprofessional fellowship. J Res Interprof Pract Educ. 2010;1(3). 9. DeMatteo D, Reeves S. Introducing first year students to interprofessionalism: exploring professional identity in the ‘‘enterprise culture’’: a Foucauldian analysis. J Interprof Care. 2013;27:27-33. 10. Baker L, Egan-Lee E, Martimianakis MA, Reeves S. Relationships of power: implications for interprofessional education. J Interprof Care. 2011;25(2):98-104. 11. Conigliaro R, Kuperstein J, Welsh D, Taylor S, Weber D, Jones M. The PEEER model: effective healthcare team-patient communications MedEd Portal; 2013. Available at www.mededportal.org/ publication/9360. Accessed October 14, 2014. 12. Akerson E, Stewart A, Baldwin J, Bryson B, Gloeckner J, Cockley D. Got ethics? Exploring the value of interprofessional collaboration through a comparison of discipline specific codes of ethics. MedEdPORTAL. 2013. Available at www.mededportal .org/publication/9331. Accessed October 14, 2014. 13. Lencioni P. The Five Dysfunctions of a Team: A Leadership Fable. San Francisco, CA: Jossey-Bass; 2002. 14. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When the Stakes Are High. New York: McGraw Hill. 15. Lawlis T, Anson J, Greenfield D. Barriers and enablers that influence sustainable interprofessional education: a literature review. J Interprof Care. 2014;28(4):305-310. 16. Clark P. The devil is in the details: the seven deadly sins of organizing and continuing interprofessional education in the US. J Interprof Care. 2011;25:321-327. 17. McFadyen A, Webster V, Strachan K, Figgins E, Brown H, McKechnie J. The readiness for interprofessional learning scale: a possible more stable sub-scale for the original version of RIPLS. J Interprof Care. 2005;19(6):595-603. 18. Hertweck M, Hawkins S, Bednarek M, Goreczny AJ, Schreiber J, Sterrett S. Attitudes towards interprofessional education: comparing physician assistant and other health care professions students. J Physician Assist Educ. 2012;23(2):8-15. 19. Schreiber J, Bednarek M, Hawkins S, Hertweck M, Goreczny AJ, Sterrett S. The effects of a single event interprofessional education experience on occupational therapy students’ attitudes toward IPE. Internet J Allied Health Sci Pract. 2014;12(1). 20. Soubhi H, Bayliss E, Fortin M, et al. Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity. Ann Fam Med. 2010;8(2):170-177. 21. Bentley C, Browman G, Poole B. Conceptual and practical challenges for implementing the communities of practice model on a national scale—a Canadian cancer control initiative. BMC Health Serv Res. 2010;10(3). 22. Walsh M, van Soeren M. Interprofessional learning and virtual communities: an opportunity for the future. J Interprof Care. 2012; 26:43-48. 23. Moule P. E-Learning for healthcare students: developing the communities of practice framework. J Adv Nurs. 2006;54(3):370-380.

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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Developing communities of interprofessional practice: using a communities of practice framework for interprofessional education.

Development of interprofessional education programs that meet new Interprofessional Education Collaborative competencies is a challenge for faculty an...
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