commentaries
Interprofessional education in allied health: is this yet another silo? Lesley Bainbridge Collaborative practice models in health care have been discussed for the past 50 years without resulting in a clear pathway to the development of a health care system in which all practitioners, families and patients collaborate effectively to improve the quality of care and concomitant health outcomes. In recent years, the literature has paid attention to theories such as those of social identity1,2 and social contact3 in order to provide potential explanations of the phenomena observed when health care providers and patients and their families work together to achieve common goals. In addition, issues of power and hierarchy come to the fore in attempts to explain behaviours that prevent effective collaboration. Interprofessional education (IPE) is the educational strategy used to develop collaborative practitioners and is becoming increasingly embedded in most health professional curricula to a greater or lesser extent. It has been defined in various ways, but most commonly as ‘occasions when two or more professions learn with, from and about each other to improve collaboration and quality of care’.4
Vancouver, British Columbia, Canada
Correspondence: Dr Lesley Bainbridge, Department of Physical Therapy, University of British Columbia, 400 2194 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada. Tel: 00 1 604 822 1712; E-mail: [email protected] doi: 10.1111/medu.12414
Issues of power and hierarchy come to the fore in attempts to explain behaviours that prevent effective collaboration
In this issue, Olson and Bialocerkowski5 suggest that IPE models used in nursing and medicine may not be applicable in the collective of the allied health professions, or at least that we should not assume that they are transferable. By focusing only on the allied health professions, however, we may be creating yet another silo for IPE. Although the notion is seemingly oxymoronic, there is a tendency today to see competition for IPE ‘credit’ creeping into curricula and practice contexts and so the creation of another silo may be counterproductive. The general principles of collaboration6 are relevant to all health care providers, but in order to fully understand how to apply collaborative practice skills in the health care system, both students and practitioners from any professional background require interaction and active engagement with each other to fully understand what collaboration means. In developing different models of IPE for different groups, we are at risk of increasing stereotyping behaviours and minimising the opportunities for creating a level playing field on which all participants are valued equally. In IPE and interprofessional collaboration (IPC), it is the differences that offer the added value. If we do not embrace the differences through educational models that include all health care providers,
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
we lose tremendous opportunities for teachable moments.
The general principles of collaboration are relevant to all health care providers
With reference to the broad concept of collaboration, it may be time to put the ‘I’ back into team. Across professions, we need to teach students and practitioners how to collaborate, but we do not need to continue to teach them about collaboration. There is a subtle but important difference. If we are to provide individuals with the skills to develop, nurture and sustain their collaborative networks – those that help them to achieve their professional goals and help patients and their families to achieve their health goals – the concept of applying different models of IPE in different professional groups makes no sense. We need to teach students and practitioners how to collaborate, but we do not need to continue to teach them about collaboration
For example, social capital is defined as: ‘…the goodwill available to individuals or groups. Its source lies in the structure and content of the actor’s social relations. Its effects flow from the information, influence, and solidarity it makes available to the actor.’7 When this is applied to health care practitioners, it implies that we need to understand how we build, and how we burn, social capital. In order to collaborate effectively, we need to
229
commentaries build social capital. We need to be trustworthy, reliable, honest, professionally credible, respectful and respected. That takes work as individuals so that we ‘fit’ into effective collaborative practice models in a positive way. Conversely, it takes mere seconds to burn social capital, destroy trust, and erode the collaborative practice model. By teaching individuals how to understand and apply the concepts of social capital, across professions, we are contributing to improved collaboration in practice. Another key example is the art of framing or rhetoric,8 which refers to the words we choose when we communicate with colleagues and patients and their families. Particularly in this era of electronic communication in the workplace, our choice of words is especially important, as is the way that we say them. We can easily alienate colleagues and patients and their families if we imply a lack of caring or understanding, if we don’t explain our words, if we use technical language inappropriately, if we forget to acknowledge pain or loss, and if we seem too hurried to be actively present in the conversation. We can teach effective framing strategies and individuals can become adept at mentally rehearsing their words before they engage in conversation or reply to e-mails. The effective use of rhetoric can improve collaboration by avoiding misunderstandings and acknowledging the importance of each and every conversation.
If we are to provide the skills to nurture collaborative networks, the concept of applying different models of IPE in different professional groups makes no sense
There are other dimensions to this individual approach to learn-
230
ing how to collaborate, such as those of perspective taking9 and negotiation,10 but let’s return to the central premise of using different IPE models for different audiences. If our principal aim is to teach people how to collaborate, we may defeat our objective if we see the differences in professional attributes or pedagogies as barriers to effective IPE rather than as facilitators designed to enable better collaboration across professions. It is true that the context of practice matters and that collaboration models in different contexts may operate differently. For this reason, the mix of students or practitioners engaging in IPE needs to replicate that found in actual clinical situations. Creating IPE models in which the case is too contrived, or which require the participation of members of professions that would rarely play a role in the case, not only risks ineffective learning but may also perpetuate negative stereotypes and indifference to the concept of IPC. The perceived differences in what works for whom and in what contexts do not imply the use of different models of IPE in different professional groups. Professional socialisation and learning how to collaborate require interaction among all professions equally, but explicit attention to who is involved in which activities may also be required in order to assure relevance and application. In addition, although different pedagogic styles may dominate in different professional programmes, one of the important aspects of IPE is faculty development and thus different pedagogies can be used to exemplify how different approaches add value to the learning experience.
The perceived differences in what works for whom and in what contexts do not imply the use of different models of IPE in different professional groups
So, should IPE in allied health look different to IPE in nursing or in medicine? The short answer is no. The principles of IPE apply across all professions and the creation of IPE silos serves no useful purpose. Training individuals how to collaborate will enable them to use their professional backgrounds and their unique lenses to full advantage in any context when working with colleagues and with patients and their families.
REFERENCES 1 Tajfel H, Turner JC. The social identity theory of intergroup behaviour. In: Worschel S, Austin W, eds. Psychology of Intergroup Relations. Chicago, IL: Nelson-Hall 1986;7–24. 2 Kreindler SA, Dowd D, Star N, Gottschalk T. Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in healthcare. Milbank Q 2012;90 (2):347–74. 3 Pettigrew TF. Intergroup contact theory. Annu Rev Psychol 1998;49: 65–85. 4 Centre for the Advancement of Interprofessional Education (CAIPE). Defining IPE. 2001. http://www.caipe.org.uk/ about-us/defining-ipe/? keywords=principles. [Accessed 6 August 2008.] 5 Olson R, Bialocerkowski A. Interprofessional education in allied health: a systematic review. Med Educ 2014;48:236–46. 6 Way D, Jones L, Busing N. Implementation Strategies: Collaboration in Primary Care: Family Doctors and Nurse Practitioners Delivering Shared Care. Toronto, ON: Ontario College of Family Physicians 2000.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
commentaries 7 Adler PS, Kwon S-W. Social capital: prospects for a new concept. Acad Manage Rev 2002;27 (1):17– 40. 8 Fairhurst G. Reframing the art of framing: problems and prospects
for leadership. Leadership 2005;1 (2):165–85. 9 Krauss RM, Fussell SR. Perspectivetaking in communication: representations of others’ knowledge in reference. Soc Cognit 1991;9:2–24.
10 Fairman D, Chigas D, McClintock E, Drager N. Negotiating Public Health in a Globalized World. SpringerBriefs in Public Health. Dordrecht: Springer Netherlands 2012.
The curse of the teenage learner Liz Mossop The Hollywood film Field of Dreams depicts a farmer who dreams of hosting professional baseball games on his land. As he walks through his fields of corn, a ghostly voice, referring to the farmer’s imagined baseball field, the star player and the spectators who will consequently flock to the site, calls: ‘If you build it, he will come.’ As clinical educators, we make similar assumptions all the time. We want to do what is best for our learners. We assume that if we invest time, energy and money into developing an interactive and engaging curriculum, students will attend. Not only will they attend, but they will also have completed the pre-sessional tasks we have set them, and will focus on their learning during the session, abandoning the distractions of social media and their peers. Why wouldn’t they do this? They want to be clinicians, so surely they recognise the need to
Nottingham, UK
Correspondence: Liz Mossop, School of Veterinary Medicine and Science, University of Nottingham, College Road, Sutton Bonington LE12 5RD, UK. Tel: 00 44 115 951 6480; E-mail: liz.mossop@nottingham. ac.uk This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. doi: 10.1111/medu.12405
come to teaching sessions and engage with faculty staff? We assume that if we invest time, energy and money into developing an interactive and engaging curriculum, students will attend.
Unfortunately, the frank and honest paper by White et al.1 published in this issue of the journal, shows that our best efforts to produce a student-centred curriculum to encourage active learning and engagement can sometimes fail to deliver the experience we predicted. In this example of an obviously genuine attempt to deliver a modern new curriculum with a flipped classroom approach, student attendance dropped as low as 25%.1 It is easy to picture a faculty meeting at this institution, at which frustrated voices cite the wasting of resources and the pointless implementation of new methods of delivery. Why should we bother taking new approaches when students fail to fulfil their obligations as learners? Surely it would be sensible to retain the ‘safe option’ of didactic delivery? Why should we bother taking new approaches when students fail to fulfil their obligations as learners?
Rather than allowing the effort put into making these changes to
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
go to waste, White et al.1 have taken time to consider the reasons for this disengagement. Their conclusions are very useful: they suggest that students need better training to learn effectively this way, and that faculty development is also required. However, it is also essential to consider the culture in which this change was attempted. The learning culture has much to answer for when curricular changes are made. Although it is true that students entering undergraduate training may not be ready for a more ‘grown-up’ form of learning, and may not yet possess the self-direction and selfmotivation they require for success, there may also be unseen influences that prevent successful delivery. Impressionable teenage learners, who have not yet learned the skills of adult learning, are not only exposed to the formal curriculum we deliver, but also to the unseen influences of peer role models and rituals within the hidden curriculum.2 These latter influences may pull them away from their core activities of study and learning, distracting them from their central focus of learning to be a clinician. A change in learning culture is therefore necessary in order to implement new teaching strategies such as those involved in the flipped classroom3 and, furthermore, both students and
231
Interprofessional education in allied health: is this yet another silo? Lesley Bainbridge Collaborative practice models in health care have been discussed for the past 50 years without resulting in a clear pathway to the development of a health care system in which all practitioners, families and patients collaborate effectively to improve the quality of care and concomitant health outcomes. In recent years, the literature has paid attention to theories such as those of social identity1,2 and social contact3 in order to provide potential explanations of the phenomena observed when health care providers and patients and their families work together to achieve common goals. In addition, issues of power and hierarchy come to the fore in attempts to explain behaviours that prevent effective collaboration. Interprofessional education (IPE) is the educational strategy used to develop collaborative practitioners and is becoming increasingly embedded in most health professional curricula to a greater or lesser extent. It has been defined in various ways, but most commonly as ‘occasions when two or more professions learn with, from and about each other to improve collaboration and quality of care’.4
Vancouver, British Columbia, Canada
Correspondence: Dr Lesley Bainbridge, Department of Physical Therapy, University of British Columbia, 400 2194 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada. Tel: 00 1 604 822 1712; E-mail: [email protected] doi: 10.1111/medu.12414
Issues of power and hierarchy come to the fore in attempts to explain behaviours that prevent effective collaboration
In this issue, Olson and Bialocerkowski5 suggest that IPE models used in nursing and medicine may not be applicable in the collective of the allied health professions, or at least that we should not assume that they are transferable. By focusing only on the allied health professions, however, we may be creating yet another silo for IPE. Although the notion is seemingly oxymoronic, there is a tendency today to see competition for IPE ‘credit’ creeping into curricula and practice contexts and so the creation of another silo may be counterproductive. The general principles of collaboration6 are relevant to all health care providers, but in order to fully understand how to apply collaborative practice skills in the health care system, both students and practitioners from any professional background require interaction and active engagement with each other to fully understand what collaboration means. In developing different models of IPE for different groups, we are at risk of increasing stereotyping behaviours and minimising the opportunities for creating a level playing field on which all participants are valued equally. In IPE and interprofessional collaboration (IPC), it is the differences that offer the added value. If we do not embrace the differences through educational models that include all health care providers,
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
we lose tremendous opportunities for teachable moments.
The general principles of collaboration are relevant to all health care providers
With reference to the broad concept of collaboration, it may be time to put the ‘I’ back into team. Across professions, we need to teach students and practitioners how to collaborate, but we do not need to continue to teach them about collaboration. There is a subtle but important difference. If we are to provide individuals with the skills to develop, nurture and sustain their collaborative networks – those that help them to achieve their professional goals and help patients and their families to achieve their health goals – the concept of applying different models of IPE in different professional groups makes no sense. We need to teach students and practitioners how to collaborate, but we do not need to continue to teach them about collaboration
For example, social capital is defined as: ‘…the goodwill available to individuals or groups. Its source lies in the structure and content of the actor’s social relations. Its effects flow from the information, influence, and solidarity it makes available to the actor.’7 When this is applied to health care practitioners, it implies that we need to understand how we build, and how we burn, social capital. In order to collaborate effectively, we need to
229
commentaries build social capital. We need to be trustworthy, reliable, honest, professionally credible, respectful and respected. That takes work as individuals so that we ‘fit’ into effective collaborative practice models in a positive way. Conversely, it takes mere seconds to burn social capital, destroy trust, and erode the collaborative practice model. By teaching individuals how to understand and apply the concepts of social capital, across professions, we are contributing to improved collaboration in practice. Another key example is the art of framing or rhetoric,8 which refers to the words we choose when we communicate with colleagues and patients and their families. Particularly in this era of electronic communication in the workplace, our choice of words is especially important, as is the way that we say them. We can easily alienate colleagues and patients and their families if we imply a lack of caring or understanding, if we don’t explain our words, if we use technical language inappropriately, if we forget to acknowledge pain or loss, and if we seem too hurried to be actively present in the conversation. We can teach effective framing strategies and individuals can become adept at mentally rehearsing their words before they engage in conversation or reply to e-mails. The effective use of rhetoric can improve collaboration by avoiding misunderstandings and acknowledging the importance of each and every conversation.
If we are to provide the skills to nurture collaborative networks, the concept of applying different models of IPE in different professional groups makes no sense
There are other dimensions to this individual approach to learn-
230
ing how to collaborate, such as those of perspective taking9 and negotiation,10 but let’s return to the central premise of using different IPE models for different audiences. If our principal aim is to teach people how to collaborate, we may defeat our objective if we see the differences in professional attributes or pedagogies as barriers to effective IPE rather than as facilitators designed to enable better collaboration across professions. It is true that the context of practice matters and that collaboration models in different contexts may operate differently. For this reason, the mix of students or practitioners engaging in IPE needs to replicate that found in actual clinical situations. Creating IPE models in which the case is too contrived, or which require the participation of members of professions that would rarely play a role in the case, not only risks ineffective learning but may also perpetuate negative stereotypes and indifference to the concept of IPC. The perceived differences in what works for whom and in what contexts do not imply the use of different models of IPE in different professional groups. Professional socialisation and learning how to collaborate require interaction among all professions equally, but explicit attention to who is involved in which activities may also be required in order to assure relevance and application. In addition, although different pedagogic styles may dominate in different professional programmes, one of the important aspects of IPE is faculty development and thus different pedagogies can be used to exemplify how different approaches add value to the learning experience.
The perceived differences in what works for whom and in what contexts do not imply the use of different models of IPE in different professional groups
So, should IPE in allied health look different to IPE in nursing or in medicine? The short answer is no. The principles of IPE apply across all professions and the creation of IPE silos serves no useful purpose. Training individuals how to collaborate will enable them to use their professional backgrounds and their unique lenses to full advantage in any context when working with colleagues and with patients and their families.
REFERENCES 1 Tajfel H, Turner JC. The social identity theory of intergroup behaviour. In: Worschel S, Austin W, eds. Psychology of Intergroup Relations. Chicago, IL: Nelson-Hall 1986;7–24. 2 Kreindler SA, Dowd D, Star N, Gottschalk T. Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in healthcare. Milbank Q 2012;90 (2):347–74. 3 Pettigrew TF. Intergroup contact theory. Annu Rev Psychol 1998;49: 65–85. 4 Centre for the Advancement of Interprofessional Education (CAIPE). Defining IPE. 2001. http://www.caipe.org.uk/ about-us/defining-ipe/? keywords=principles. [Accessed 6 August 2008.] 5 Olson R, Bialocerkowski A. Interprofessional education in allied health: a systematic review. Med Educ 2014;48:236–46. 6 Way D, Jones L, Busing N. Implementation Strategies: Collaboration in Primary Care: Family Doctors and Nurse Practitioners Delivering Shared Care. Toronto, ON: Ontario College of Family Physicians 2000.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
commentaries 7 Adler PS, Kwon S-W. Social capital: prospects for a new concept. Acad Manage Rev 2002;27 (1):17– 40. 8 Fairhurst G. Reframing the art of framing: problems and prospects
for leadership. Leadership 2005;1 (2):165–85. 9 Krauss RM, Fussell SR. Perspectivetaking in communication: representations of others’ knowledge in reference. Soc Cognit 1991;9:2–24.
10 Fairman D, Chigas D, McClintock E, Drager N. Negotiating Public Health in a Globalized World. SpringerBriefs in Public Health. Dordrecht: Springer Netherlands 2012.
The curse of the teenage learner Liz Mossop The Hollywood film Field of Dreams depicts a farmer who dreams of hosting professional baseball games on his land. As he walks through his fields of corn, a ghostly voice, referring to the farmer’s imagined baseball field, the star player and the spectators who will consequently flock to the site, calls: ‘If you build it, he will come.’ As clinical educators, we make similar assumptions all the time. We want to do what is best for our learners. We assume that if we invest time, energy and money into developing an interactive and engaging curriculum, students will attend. Not only will they attend, but they will also have completed the pre-sessional tasks we have set them, and will focus on their learning during the session, abandoning the distractions of social media and their peers. Why wouldn’t they do this? They want to be clinicians, so surely they recognise the need to
Nottingham, UK
Correspondence: Liz Mossop, School of Veterinary Medicine and Science, University of Nottingham, College Road, Sutton Bonington LE12 5RD, UK. Tel: 00 44 115 951 6480; E-mail: liz.mossop@nottingham. ac.uk This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. doi: 10.1111/medu.12405
come to teaching sessions and engage with faculty staff? We assume that if we invest time, energy and money into developing an interactive and engaging curriculum, students will attend.
Unfortunately, the frank and honest paper by White et al.1 published in this issue of the journal, shows that our best efforts to produce a student-centred curriculum to encourage active learning and engagement can sometimes fail to deliver the experience we predicted. In this example of an obviously genuine attempt to deliver a modern new curriculum with a flipped classroom approach, student attendance dropped as low as 25%.1 It is easy to picture a faculty meeting at this institution, at which frustrated voices cite the wasting of resources and the pointless implementation of new methods of delivery. Why should we bother taking new approaches when students fail to fulfil their obligations as learners? Surely it would be sensible to retain the ‘safe option’ of didactic delivery? Why should we bother taking new approaches when students fail to fulfil their obligations as learners?
Rather than allowing the effort put into making these changes to
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 225–233
go to waste, White et al.1 have taken time to consider the reasons for this disengagement. Their conclusions are very useful: they suggest that students need better training to learn effectively this way, and that faculty development is also required. However, it is also essential to consider the culture in which this change was attempted. The learning culture has much to answer for when curricular changes are made. Although it is true that students entering undergraduate training may not be ready for a more ‘grown-up’ form of learning, and may not yet possess the self-direction and selfmotivation they require for success, there may also be unseen influences that prevent successful delivery. Impressionable teenage learners, who have not yet learned the skills of adult learning, are not only exposed to the formal curriculum we deliver, but also to the unseen influences of peer role models and rituals within the hidden curriculum.2 These latter influences may pull them away from their core activities of study and learning, distracting them from their central focus of learning to be a clinician. A change in learning culture is therefore necessary in order to implement new teaching strategies such as those involved in the flipped classroom3 and, furthermore, both students and
231
