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Nursing and Health Sciences (2014), 16, 321–326
Research Article
Promoting interprofessional understandings through online learning: A qualitative examination Lisa McKenna, RN, RM, MEdSt, PhD,1 Malcolm Boyle, ADipHSc(Amb Off), MICA Cert, BInfoTech, MClinEpi, PhD,2 Claire Palermo, BSc, MND, MPH, GradCertHealthProfEd, PhD,3 Elizabeth Molloy, BPhysio(Hons), PhD,4 Brett Williams, BAVEd, Grad Cert IntensiveCareParamedicine, Grad Dip EmergHlth, MHlthSc, PhD2 and Ted Brown, BScOT(Hons), GradCertHealthProfEd, MPA, MSc, PhD5 1 School of Nursing and Midwifery, 4HealthPEER, Departments of 2Community Emergency Health and Paramedic Practice, 5Occupational Therapy and 3Nutrition and Dietetics, Southern Clinical School, Monash University, Melbourne, Victoria, Australia
Abstract
Interprofessional education is increasingly a core component of health professional curricula. It has been suggested that interprofessional education can directly enhance patient care outcomes. However, literature has reported many difficulties in its successful implementation. This study investigated students’ perceptions of participating in an online, Web-based module to facilitate interprofessional education. Three focus groups, each with 13–15 students, from emergency health (paramedic), nursing, occupational therapy, physiotherapy, and nutrition and dietetics were conducted with students who participated in an online interprofessional education module at one Australian university. Thematic analysis was employed to analyze interview transcripts. Four themes emerged: professional understanding, patient-centeredness, comparison with other interprofessional education activities, and overcoming geographical boundaries. Students were overwhelmingly positive about their learning experiences and the value of the module in assisting their understandings of the roles of other health professionals. Online approaches to interprofessional education have the potential to enhance learning and overcome geographical and logistical issues inherent in delivering face-to-face interprofessional education. Furthermore, our design approach allowed students to watch how other health professionals worked in a way that they were unable to achieve in clinical practice.
Key words
e-learning, focus group, health profession, interprofessional education, online, Web-based.
INTRODUCTION Interprofessional education (IPE) has received extensive attention in health professional literature over the past decade, but dates back to the 1960s (Thistlethwaite, 2012). IPE has been defined by the World Health Organization as that which “occurs when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010, p. 13) Subsequently, the implementation of interprofessional collaborative practice into curricula for students and health professionals has become an important goal for education providers and professional organizations, yet IPE implementation can be challenging. In this paper, we report a pilot activity that sought to develop interprofessional learning using on online approach.
Correspondence address: Lisa McKenna, School of Nursing and Midwifery, Wellington Road, Monash University, Clayton, Vic. 3800, Australia. Email: lisa.mckenna@ monash.edu Received 16 June 2013; revision received 19 September 2013; accepted 4 October 2013
© 2014 Wiley Publishing Asia Pty Ltd.
It has been proposed that the overarching goal of IPE is to improve patient care outcomes through the promotion of teamwork and collaboration between various health professionals (Hammick et al., 2007). IPE has been identified as playing an important role in assisting students develop professional skills not otherwise covered in the curriculum, such as teamwork (Wamsley et al., 2012), the professional roles and responsibilities of themselves and other professionals (Jakobsen et al., 2011), effective interprofessional communication skills, centrality of patient to care delivery, and understanding professional stereotyping (Thistlethwaite, 2012). It has been asserted that these benefits have the potential to enhance patient safety (Aase et al., 2013). Despite its overall perceived benefits, the implementation of IPE has been viewed as “complex, challenging and frequently frustrating” (Matthews et al., 2011). Multiple challenges have been described. These include associated costs and the time required to establish and run programs (Gilbert, 2005; Hammick et al., 2007; Salfi et al., 2012), finding space and alignment within individual curricula (Hammick et al., 2007), logistic issues associated with scheduling and geographical locations (Matthews et al., 2011; Thistlethwaite, doi: 10.1111/nhs.12105
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2012; Aase et al., 2013), and having available interprofessional champions to provide leadership and to sustain ongoing programs (Salfi et al., 2012; Aase et al., 2013).
Online learning approaches Online, e-learning, or Web-based, approaches to teaching and learning have become increasingly used in health professional curricula. These approaches to curriculum delivery have been found to offer benefits of enhanced flexibility and convenience to learning (Gerkin et al., 2009), or complement curriculum content (Gresty et al., 2007). An associated benefit of online learning is that it can assist in overcoming logistical issues in bringing groups of learners together, thus overcoming commonly-encountered scheduling difficulties (Luke et al., 2009; Solomon et al., 2010). Furthermore, online approaches to learning have been found to increase collaboration between learners, as well as facilitators (Santy et al., 2009; Solomon et al., 2010; Hoffman & Dudjak, 2012). Online approaches to facilitate the delivery of IPE have recently begun to appear in related literature, challenging assumptions that learners need to be geographically colocated to learn about – and with – each other. Some of these studies report findings of projects aimed towards increasing interprofessional understandings generally (Santy et al., 2009; Eccott et al., 2012), while others explore specific aspects of care requiring interprofessional work, such as palliative care (Ellman et al., 2012). There is evidence to suggest that online IPE can significantly increase students’ attitudes towards working in interprofessional teams (Eccott et al., 2012). Research also suggests that learners positively receive online IPE activities. Riesen et al. (2012) employed a blended learning approach to IPE for graduate nurses, paramedics, police, and youth workers in Canada using a virtual environment, where each interacted using an avatar, as well as participating in traditional and virtual workshops. These researchers reported that learners were satisfied with the blended approach, and demonstrated significant improvement in interprofessional competence. In their study of online case conferencing with health and social care workers to facilitate interprofessional learning in the UK, Santy et al. (2009) found that learners were “pessimistic” about participating, but enjoyed their learning experiences. In Canada, Solomon et al. (2010) found that students reported online IPE to provide opportunities for them to engage in collaborative problem solving in a team and the importance of including their own professional perspectives. As a result of our own personal experiences encountering difficulties implementing face-to-face IPE, and informed by the literature, we sought to develop a web-based online module in which students could engage and develop interprofessional understandings. In the final product, students worked through a sequence of documents and various media presentations, with each section having to be completed before moving onto the next. Students started the educational package by reading through selected documents defining IPE. They then watched short videos of each participating discipline and their function within the healthcare system. The main video depicted a scenario of a patient with © 2014 Wiley Publishing Asia Pty Ltd.
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cardiovascular disease, in which multiple disciplines, including paramedic, occupational therapy, physiotherapy, nursing, and nutrition and dietetics, oversaw the management of the patient’s condition. The situation utilized interactive input from students to encourage them to communicate with each other as they dealt with the clinical scenarios that arose as the patient moved from their home through the emergency department into the hospital ward and back home after discharge. The case was followed by a video of a team approach to managing a patient in the healthcare system. The final video included two students being interviewed, who had previously been involved in IPE, and their views about the benefits to them and patients. Students could go back and review videos at any time. Within the module, there was an opportunity for students to engage with each other through a facilitated discussion group. Clarification of individual discipline roles was further explored further in focus groups. The module was undertaken within a seven-day period prior to evaluating the experience. Quantitative reporting of student attitudes to the IPE activity has been reported elsewhere (Boyle et al., 2013). In this paper, we report the rich, qualitative data emerging from focus groups following the IPE activity. Through this study, we sought to examine healthprofessional students’ perspectives on the value of using online delivery to facilitate interprofessional understandings and learning.
METHODS Study design and setting A qualitative approach was used to investigate the views of students involved in the IPE learning activity. Qualitative research seeks to “describe routine and problematic moments and meanings in individuals’ lives” (Denzin & Lincoln, 2005, pp. 3–4), so was apt for the phenomenon under exploration. Undergraduate students, in all years, who were enrolled at the time of the study in one of five health-related courses at Monash University (emergency health [paramedic], nursing, occupational therapy, physiotherapy, and nutrition and dietetics) were eligible to participate. An announcement seeking expressions of interest from students to participate was added to the Moodle site for each course. Responses from students were coordinated by researchers from each discipline, with the first two students from each year level of each course offered the chance to participate in the study. A self-selected sample of students (n = 46) enrolled in these courses across all years volunteered to be involved in the IPE learning activity, and thus the study. Prior to commencing, students first read the explanatory statement, which outlined the project, clarified that their participation was voluntary, and that they could withdraw at any time without reason being given. Students were then given access to a passwordprotected website where the IPL package was located. Focus groups (n = 3) were used to investigate views of the students and their experiences of participating in the learning
Interprofessional and online learning
activity. All (46) students who participated in the IPE learning activity were invited to attend a focus group. Focus group questions were drafted based on review of the literature and a process evaluation framework (Hawe et al., 1990). Questions covered the understanding of IPE; experiences of IPE; and students’ experiences, attitudes, and learning from the IPE online learning activity. All researchers reviewed the interview schedule, with minor edits made to ensure that the most appropriate data could be obtained. Questions were used to focus discussions and conversation, rather than as structured questions, as recommended for qualitative inquiry. Focus groups were conducted in October 2011 by three of the authors. There was overwhelming interest in participating, with 13–15 students attending each of the three focus groups. While the focus groups were oversubscribed, and not numbers that would be considered best practice in focus group discussions, techniques were used by facilitators to ensure that all participants had opportunities to contribute to the discussion. Focus groups were digitally audio-recorded and transcribed verbatim.
Ethical clearance Ethical approval to conduct the study was obtained from Monash University Human Research Ethics Committee prior to the commencement of data collection.
Data analysis Interview transcripts were analyzed using a thematic approach informed by Grbich (2009). During the transcription process, participants were allocated pseudonyms, so that individuals could not be recognized in reporting. Each focus group transcript was analyzed by three of the authors independently. This involved initial open coding to establish a coding framework. Codes were then grouped into categories, and key themes extracted from these broader categories. The researchers then came together to agree on codes and themes in order to validate the findings.
RESULTS The analysis of focus group transcripts revealed four main themes relating to students’ learning about IPE through the online module: professional understanding, patientcenteredness, comparison with other IPE activities, and overcoming geographical boundaries.
Professional understanding Students reported that the module enhanced their professional understandings, both of their own and the other health professions. The visual element, through videorecorded clinical scenarios and video-recorded practitioner interview/debriefing, was praised as contributing to the gains in understanding: I thought it was fantastic. Because it sort of gave me an idea of what I would get to do eventually, and I found
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that really interesting. Because I came into it knowing to an extent but not know much . . . of what we do. (Nursing student) Watching the videos online gave students the opportunity to observe other health professionals in practice, and this was widely reported as invaluable and contributed to new appreciations and role understandings: It makes you go, wow. They (nurses) know so much. You’d be silly not to appreciate or take in what they’ve said. Because you know it is just a totally different world, I have no idea. (Occupational therapy student) I really liked the paramedic one that . . . went through the whole treatment of the patient and what they did. I thought that was more beneficial than just having the professional sitting in the chair, saying this is what I do. (Physiotherapy student) It’s certainly outlined all the different roles of what the other . . . occupations in the health profession do, like OT (occupational therapy), physio. Like with OT, I had . . . no idea what their job really entailed until I actually watched. (Nursing student) I didn’t know what an occupational therapist does, and now I do. (Nutrition/dietetics student) A few students also discussed learning from watching the teamwork video, where health professionals worked together in a patient encounter: I liked the fact that it went through all of the different professionals and then . . . went to the end where all of them were working together and you could see it . . . piece together. It made a lot more sense than just reading about all of them doing things separately. (Nursing student)
Patient-centeredness One theme that emerged strongly from all of the focus groups was that the module allowed students to see how the patient was central to how healthcare team members worked together to achieve patient care outcomes: You really clarify the whole thing; you’re putting the patient at the center, not your own image . . . as in that you have got to put all the allied health-professional interests toward that patient, rather than just work on your own what you want you should probably think of everyone . . . and what’s best for the patient. Like it really brought that home. (Occupational therapy student) I think because you’re looking at a specific case study, as well of a patient and his sort of follow through to the hospital, it made it sort of a story, so it . . . was interesting as well at the same time. (Nutrition/dietetics student) Within this context, students recognized the importance of different team members’ contributions in the provision of patient care, and that within the team each was an equal: © 2014 Wiley Publishing Asia Pty Ltd.
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You realize how many . . . it takes a lot of people to . . . work with the client. (Nursing student) You realize too that one (health professional) isn’t any more important that the other. That they’re all just as important, you know, for different reasons. (Nursing student) The experience further expanded students’ understandings of the scope of practice from other disciplines: It was in the cardiac rehab. I never thought like they had a physio. I think it was at one point with the stethoscope kind of looking at the breathing of the patient, and I kind of never associated the breathing with the physio before. I more sort of looked at (the) exercise type thing. (Nursing student) It was actually interesting to see how every health professional has an impact on the one client. So at every stage, like you start with your paramedics to the nurses and then, and just see the progress the client goes through. (Nutrition/dietetics student)
Online module versus other IPE activities Participants were asked to provide their perspectives on the online nature of the module in comparison to their previous face-to-face IPE activities. Students reported that the videos provided allowed them to actually see health professionals working together in context, rather than learning abstract content alongside students from other health professions: IPE in first semester, we did it (for the) first year, this year. At the beginning, I think everyone went off into their groups. I noticed . . . the physios would all sit together and the nurses would all sit together . . . I still didn’t have a great idea of what everyone would do until I saw the modules and the videos and stuff. (Paramedic student) I think this module is better than what we did in like first semester (classroom-based activities), because it was more learning about how to work together, rather than just meeting people who are from those professions and doing assignments. (Nutrition/dietetics student) I think the videos I liked more than (classroom-based) IPE itself . . . IPE . . . helped us get used to each other and the fact that we all have different, like we all do different things at uni, but the videos actually told us what the other people did. We never knew that. (Occupational therapy student) A number of students discussed how clinical placements had not provided opportunities to actually watch what other health professionals did, and the online learning provided such insights: Even though we worked 8 h per shift as a nurse, it is really quite hard for you to have some spare time to look at what others are actually doing . . . I am just . . . running with the nurses and they are showering the patients and © 2014 Wiley Publishing Asia Pty Ltd.
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they’re giving out the medicine. So it would be really great if we can have some spare time to really sit down and look at how others are doing their jobs. (Nursing student) I sat in IPE for the first few weeks of last semester and I didn’t really understand it, because I didn’t know what the other professions did, and I thought that it would have been really good to have something like that. It would have helped a lot. (Nutrition/dietetics student) Others valued seeing medical staff in their patient care roles, as during clinical placements they had few opportunities to interact with medical students: Especially the doctor, the med (medical) students. We were on placement with other students, OT (occupational therapists), nursing and they were great. You know often . . . the med students . . . they wouldn’t interact with us. (Physiotherapy student) Some discipline groups had received formal, structured IPE learning in their first semesters, and sometimes later, of their courses. Within the focus groups, some participants discussed their prior experiences and their perceived value: No one actually told us what an OT (occupational therapist) did or what a nurse did . . . we just went in there and were kind of like blinded. Like, okay, there are all these other professions, like what do they actually do? Like no one actually told us what they did, and being in first year as well, first semester, I don’t think many people knew what they were actually going to do. (Paramedic student) People weren’t really interested in being there. It was often on a day where we weren’t meant to be at the uni. They put on an extra day, so people were really disinterested. They put it on a time where there were four assignments due next week. People weren’t engaged . . . I don’t feel like it was that beneficial. I found a lot of people actually came out of it going, “what was the point of that?” sort of thing. That’s just from like the experiences that I had in first and second year. (Physiotherapy student)
Overcoming geographical boundaries One of the benefits reported by students related to the online program was overcoming challenges associated with geography. At our university, health courses are delivered on four campuses, as well as many clinical sites. Thus, geography can be a limitation to any face-to-face IPE activity. The online module was seen as one means for overcoming such challenge. Some students identified that working interprofessionally in an online context facilitated their working together better than previous face-to-face experiences, as highlighted by one physiotherapy student: In first and second year, (we) did some interprofessional learning with OT (occupational therapists), and in first year, I think we do it with the radiography students from
Interprofessional and online learning
(another campus), as well. . . . It was definitely hard at times, especially with the radiography students who were off campus to try and put together an assignment with them . . . and so I don’t feel like it worked that well. (Physiotherapy student) One student further highlighted the specific benefit for cross-campus interprofessional learning: Dietetics is at (another campus), so if there was a classroom situation, like we would have to come down here, and the likelihood of us probably coming down here would be maybe slim. I don’t know it depends on how dedicated everyone is, so I guess that online environment did create that we could be involved. (Nutrition/ dietetics student)
DISCUSSION IPE is increasingly becoming a core requirement for healthprofessional curricula to promote the development of teamwork and interprofessional understandings. Numerous potential benefits of effective health teamwork have been asserted, including the provision of better patient care (Solomon et al., 2010), the effective use of health services (Mickan, 2005), and improved health outcomes (Mickan, 2005; WHO, 2010). However, curriculum developers often grapple with the most appropriate approach to such content delivery and struggle to overcome associated challenges, including costs, large student numbers, and logistical issues (Hammick et al., 2007; Bennett et al., 2011). Participants in the current study reported positively on an online approach, with an imbedded video scenario where they were able to watch each member of the team engage in patient care, in addition to short videos from different health professionals reflecting on their own roles in practice. Students reported on the uniqueness of being able to sit and watch others in their professional roles. This was something they reported that they were not able to achieve in the context of high-stake pressures in the clinical environment. They reported having more respect for other health professionals, and seeing the patient as central to care, an important outcome of IPE (Thistlethwaite, 2012). The aspect of actually being able to see patient-centered care delivery across different professional contexts, which students reported they were not seeing in clinical placements, is noteworthy. This is a particularly concerning issue that was not expected to emerge in the study. It leads to questions about whether current clinical education models reinforce professional silos if students do not have the opportunity to develop understandings and observe the roles of other health professionals in practice, and how they contribute to overall patient care. This aspect also leads to questions about current IPE objectives and effectiveness, and warrants further exploration. Turale (2011) asserted that the importance of equal partnerships in care delivery and activities, such as ours, might be one way to facilitate the development of such partnerships. Classroom activities that employ video footage, such as those used in our module, might also facilitate learning about other health professionals and their roles.
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Our findings reinforced those of other studies (Santy et al., 2009; Eccott et al., 2012), suggesting that students do not need to be in face-to-face learning situations for effective IPE to occur. Online approaches were well received by our students, and this approach has particular benefits in overcoming some of the reported challenges in IPE delivery; in particular, logistical and scheduling issues (Hammick et al., 2007; Luke et al., 2009; Solomon et al., 2010). Students identified that being able to work with other students from different sites was a benefit of the module. However, such an approach needs further consideration and development, including optimal timing of module delivery and longitudinal evaluation to determine the impact of the online innovation on knowledge and skill translation in practice. Students in this study reported a lack of understanding of IPE as a negative outcome from prior face-to-face IPE experiences. Many of these had been undertaken in the first semester of their course, before they sufficiently understood their own discipline. Students in our study, who had experienced at least one clinical placement, reported that it provided a foundation on which to build further learning. In their study, Luke et al. (2009) found that students were keen to learn about the roles of other health professionals, but they needed to understand their own specific professional role. Tunstall-Pedoe et al. (2003) found that health professional students arrived with stereotypical views on entry to university. Curriculum developers often debate where to place IPE within health professional courses, that is, whether this is best placed early, before students have developed stereotypical perceptions, or placed later, when students have developed their own professional identities (Bradley et al., 2009). Our findings suggest that there is a need for more research on the optimal timing of such IPE activities within the wider curriculum.
Limitations of the study The study design does have limitations. This pilot was only conducted with students at one university in Australia. In the module, students were only presented with one clinical scenario, and there was limited opportunity for students to interact with one another online. Further studies would be needed to explore the broader applicability of such learning. In addition, the students who chose to participate are likely to have been more engaged because they elected to be involved.
Conclusions IPE is increasingly important in health professional programs. However, incorporating targeted activities into curricula has been reported as challenging, especially in terms of logistics and student engagement. The online delivery of IPE has the potential to overcome some of the barriers to face-to-face delivery, while still resulting in effective interprofessional understandings that might not even be achievable in existing structured clinical practice placements. © 2014 Wiley Publishing Asia Pty Ltd.
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CONTRIBUTIONS Study Design: LM, MB, CP, EM, BW, TB. Data Collection and Analysis: LM, CP, EM. Manuscript Writing: LM, MB, CP, EM.
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Hoffman RL, Dudjak LA. From onsite to online: lessons learned from faculty pioneers. J. Prof. Nurs. 2012; 28: 255–258. Jakobsen F, Hansen TB, Eika B. Knowing more about the other professions clarified my own profession. J. Interprof. Care 2011; 25: 441–446. Luke R, Solomon P, Baptiste S et al. Online interprofessional health sciences education: from theory to practice. J. Contin. Educ. Health Prof. 2009; 29: 161–167. Matthews LR, Pockett RB, Nisbet G et al. Building capacity in Australian interprofessional health education: perspectives from key health and higher education stakeholders. Aust. Health Rev. 2011; 35: 136–140. Mickan SM. Evaluating the effectiveness of health care teams. Aust. Health Rev. 2005; 29: 211–217. Riesen E, Morley M, Clendinneng D et al. Improving interprofessional competence in undergraduate students using a novel blended learning approach. J. Interprof. Care 2012; 26: 312– 318. Salfi J, Solomon P, Allen D et al. Overcoming all obstacles: a framework for embedding interprofessional education into a large, multisite Bachelor of Science Nursing program. J. Nurs. Educ. 2012; 51: 106–110. Santy J, Beadle M, Needham Y. Using an online case conference to facilitate interprofessional learning. Nurse Educ. Pract. 2009; 9: 383–387. Solomon P, Baptiste S, Hall P et al. Students’ perceptions of interprofessional learning through facilitated online learning modules. Med. Teach. 2010; 32: e391–e398. Thistlethwaite J. Interprofessional education: a review of context, learning and the research agenda. Med. Educ. 2012; 46: 58–70. Tunstall-Pedoe S, Rink E, Hilton S. Student attitudes to undergraduate interprofessional education. J. Interprof. Care 2003; 17: 161– 172. Turale S. Preparing nurses for the 21st century: reflecting on nursing shortages and other challenges in practice and education. Nurs. Health Sci. 2011; 13: 229–231. Wamsley M, Staves J, Kroon L et al. The impact of an interprofessional standardized patient exercise on attitudes toward working in interprofessional teams. J. Interprof. Care 2012; 26: 28–35. World Health Organization (WHO). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: WHO, 2010.
Nursing and Health Sciences (2014), 16, 321–326
Research Article
Promoting interprofessional understandings through online learning: A qualitative examination Lisa McKenna, RN, RM, MEdSt, PhD,1 Malcolm Boyle, ADipHSc(Amb Off), MICA Cert, BInfoTech, MClinEpi, PhD,2 Claire Palermo, BSc, MND, MPH, GradCertHealthProfEd, PhD,3 Elizabeth Molloy, BPhysio(Hons), PhD,4 Brett Williams, BAVEd, Grad Cert IntensiveCareParamedicine, Grad Dip EmergHlth, MHlthSc, PhD2 and Ted Brown, BScOT(Hons), GradCertHealthProfEd, MPA, MSc, PhD5 1 School of Nursing and Midwifery, 4HealthPEER, Departments of 2Community Emergency Health and Paramedic Practice, 5Occupational Therapy and 3Nutrition and Dietetics, Southern Clinical School, Monash University, Melbourne, Victoria, Australia
Abstract
Interprofessional education is increasingly a core component of health professional curricula. It has been suggested that interprofessional education can directly enhance patient care outcomes. However, literature has reported many difficulties in its successful implementation. This study investigated students’ perceptions of participating in an online, Web-based module to facilitate interprofessional education. Three focus groups, each with 13–15 students, from emergency health (paramedic), nursing, occupational therapy, physiotherapy, and nutrition and dietetics were conducted with students who participated in an online interprofessional education module at one Australian university. Thematic analysis was employed to analyze interview transcripts. Four themes emerged: professional understanding, patient-centeredness, comparison with other interprofessional education activities, and overcoming geographical boundaries. Students were overwhelmingly positive about their learning experiences and the value of the module in assisting their understandings of the roles of other health professionals. Online approaches to interprofessional education have the potential to enhance learning and overcome geographical and logistical issues inherent in delivering face-to-face interprofessional education. Furthermore, our design approach allowed students to watch how other health professionals worked in a way that they were unable to achieve in clinical practice.
Key words
e-learning, focus group, health profession, interprofessional education, online, Web-based.
INTRODUCTION Interprofessional education (IPE) has received extensive attention in health professional literature over the past decade, but dates back to the 1960s (Thistlethwaite, 2012). IPE has been defined by the World Health Organization as that which “occurs when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010, p. 13) Subsequently, the implementation of interprofessional collaborative practice into curricula for students and health professionals has become an important goal for education providers and professional organizations, yet IPE implementation can be challenging. In this paper, we report a pilot activity that sought to develop interprofessional learning using on online approach.
Correspondence address: Lisa McKenna, School of Nursing and Midwifery, Wellington Road, Monash University, Clayton, Vic. 3800, Australia. Email: lisa.mckenna@ monash.edu Received 16 June 2013; revision received 19 September 2013; accepted 4 October 2013
© 2014 Wiley Publishing Asia Pty Ltd.
It has been proposed that the overarching goal of IPE is to improve patient care outcomes through the promotion of teamwork and collaboration between various health professionals (Hammick et al., 2007). IPE has been identified as playing an important role in assisting students develop professional skills not otherwise covered in the curriculum, such as teamwork (Wamsley et al., 2012), the professional roles and responsibilities of themselves and other professionals (Jakobsen et al., 2011), effective interprofessional communication skills, centrality of patient to care delivery, and understanding professional stereotyping (Thistlethwaite, 2012). It has been asserted that these benefits have the potential to enhance patient safety (Aase et al., 2013). Despite its overall perceived benefits, the implementation of IPE has been viewed as “complex, challenging and frequently frustrating” (Matthews et al., 2011). Multiple challenges have been described. These include associated costs and the time required to establish and run programs (Gilbert, 2005; Hammick et al., 2007; Salfi et al., 2012), finding space and alignment within individual curricula (Hammick et al., 2007), logistic issues associated with scheduling and geographical locations (Matthews et al., 2011; Thistlethwaite, doi: 10.1111/nhs.12105
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2012; Aase et al., 2013), and having available interprofessional champions to provide leadership and to sustain ongoing programs (Salfi et al., 2012; Aase et al., 2013).
Online learning approaches Online, e-learning, or Web-based, approaches to teaching and learning have become increasingly used in health professional curricula. These approaches to curriculum delivery have been found to offer benefits of enhanced flexibility and convenience to learning (Gerkin et al., 2009), or complement curriculum content (Gresty et al., 2007). An associated benefit of online learning is that it can assist in overcoming logistical issues in bringing groups of learners together, thus overcoming commonly-encountered scheduling difficulties (Luke et al., 2009; Solomon et al., 2010). Furthermore, online approaches to learning have been found to increase collaboration between learners, as well as facilitators (Santy et al., 2009; Solomon et al., 2010; Hoffman & Dudjak, 2012). Online approaches to facilitate the delivery of IPE have recently begun to appear in related literature, challenging assumptions that learners need to be geographically colocated to learn about – and with – each other. Some of these studies report findings of projects aimed towards increasing interprofessional understandings generally (Santy et al., 2009; Eccott et al., 2012), while others explore specific aspects of care requiring interprofessional work, such as palliative care (Ellman et al., 2012). There is evidence to suggest that online IPE can significantly increase students’ attitudes towards working in interprofessional teams (Eccott et al., 2012). Research also suggests that learners positively receive online IPE activities. Riesen et al. (2012) employed a blended learning approach to IPE for graduate nurses, paramedics, police, and youth workers in Canada using a virtual environment, where each interacted using an avatar, as well as participating in traditional and virtual workshops. These researchers reported that learners were satisfied with the blended approach, and demonstrated significant improvement in interprofessional competence. In their study of online case conferencing with health and social care workers to facilitate interprofessional learning in the UK, Santy et al. (2009) found that learners were “pessimistic” about participating, but enjoyed their learning experiences. In Canada, Solomon et al. (2010) found that students reported online IPE to provide opportunities for them to engage in collaborative problem solving in a team and the importance of including their own professional perspectives. As a result of our own personal experiences encountering difficulties implementing face-to-face IPE, and informed by the literature, we sought to develop a web-based online module in which students could engage and develop interprofessional understandings. In the final product, students worked through a sequence of documents and various media presentations, with each section having to be completed before moving onto the next. Students started the educational package by reading through selected documents defining IPE. They then watched short videos of each participating discipline and their function within the healthcare system. The main video depicted a scenario of a patient with © 2014 Wiley Publishing Asia Pty Ltd.
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cardiovascular disease, in which multiple disciplines, including paramedic, occupational therapy, physiotherapy, nursing, and nutrition and dietetics, oversaw the management of the patient’s condition. The situation utilized interactive input from students to encourage them to communicate with each other as they dealt with the clinical scenarios that arose as the patient moved from their home through the emergency department into the hospital ward and back home after discharge. The case was followed by a video of a team approach to managing a patient in the healthcare system. The final video included two students being interviewed, who had previously been involved in IPE, and their views about the benefits to them and patients. Students could go back and review videos at any time. Within the module, there was an opportunity for students to engage with each other through a facilitated discussion group. Clarification of individual discipline roles was further explored further in focus groups. The module was undertaken within a seven-day period prior to evaluating the experience. Quantitative reporting of student attitudes to the IPE activity has been reported elsewhere (Boyle et al., 2013). In this paper, we report the rich, qualitative data emerging from focus groups following the IPE activity. Through this study, we sought to examine healthprofessional students’ perspectives on the value of using online delivery to facilitate interprofessional understandings and learning.
METHODS Study design and setting A qualitative approach was used to investigate the views of students involved in the IPE learning activity. Qualitative research seeks to “describe routine and problematic moments and meanings in individuals’ lives” (Denzin & Lincoln, 2005, pp. 3–4), so was apt for the phenomenon under exploration. Undergraduate students, in all years, who were enrolled at the time of the study in one of five health-related courses at Monash University (emergency health [paramedic], nursing, occupational therapy, physiotherapy, and nutrition and dietetics) were eligible to participate. An announcement seeking expressions of interest from students to participate was added to the Moodle site for each course. Responses from students were coordinated by researchers from each discipline, with the first two students from each year level of each course offered the chance to participate in the study. A self-selected sample of students (n = 46) enrolled in these courses across all years volunteered to be involved in the IPE learning activity, and thus the study. Prior to commencing, students first read the explanatory statement, which outlined the project, clarified that their participation was voluntary, and that they could withdraw at any time without reason being given. Students were then given access to a passwordprotected website where the IPL package was located. Focus groups (n = 3) were used to investigate views of the students and their experiences of participating in the learning
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activity. All (46) students who participated in the IPE learning activity were invited to attend a focus group. Focus group questions were drafted based on review of the literature and a process evaluation framework (Hawe et al., 1990). Questions covered the understanding of IPE; experiences of IPE; and students’ experiences, attitudes, and learning from the IPE online learning activity. All researchers reviewed the interview schedule, with minor edits made to ensure that the most appropriate data could be obtained. Questions were used to focus discussions and conversation, rather than as structured questions, as recommended for qualitative inquiry. Focus groups were conducted in October 2011 by three of the authors. There was overwhelming interest in participating, with 13–15 students attending each of the three focus groups. While the focus groups were oversubscribed, and not numbers that would be considered best practice in focus group discussions, techniques were used by facilitators to ensure that all participants had opportunities to contribute to the discussion. Focus groups were digitally audio-recorded and transcribed verbatim.
Ethical clearance Ethical approval to conduct the study was obtained from Monash University Human Research Ethics Committee prior to the commencement of data collection.
Data analysis Interview transcripts were analyzed using a thematic approach informed by Grbich (2009). During the transcription process, participants were allocated pseudonyms, so that individuals could not be recognized in reporting. Each focus group transcript was analyzed by three of the authors independently. This involved initial open coding to establish a coding framework. Codes were then grouped into categories, and key themes extracted from these broader categories. The researchers then came together to agree on codes and themes in order to validate the findings.
RESULTS The analysis of focus group transcripts revealed four main themes relating to students’ learning about IPE through the online module: professional understanding, patientcenteredness, comparison with other IPE activities, and overcoming geographical boundaries.
Professional understanding Students reported that the module enhanced their professional understandings, both of their own and the other health professions. The visual element, through videorecorded clinical scenarios and video-recorded practitioner interview/debriefing, was praised as contributing to the gains in understanding: I thought it was fantastic. Because it sort of gave me an idea of what I would get to do eventually, and I found
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that really interesting. Because I came into it knowing to an extent but not know much . . . of what we do. (Nursing student) Watching the videos online gave students the opportunity to observe other health professionals in practice, and this was widely reported as invaluable and contributed to new appreciations and role understandings: It makes you go, wow. They (nurses) know so much. You’d be silly not to appreciate or take in what they’ve said. Because you know it is just a totally different world, I have no idea. (Occupational therapy student) I really liked the paramedic one that . . . went through the whole treatment of the patient and what they did. I thought that was more beneficial than just having the professional sitting in the chair, saying this is what I do. (Physiotherapy student) It’s certainly outlined all the different roles of what the other . . . occupations in the health profession do, like OT (occupational therapy), physio. Like with OT, I had . . . no idea what their job really entailed until I actually watched. (Nursing student) I didn’t know what an occupational therapist does, and now I do. (Nutrition/dietetics student) A few students also discussed learning from watching the teamwork video, where health professionals worked together in a patient encounter: I liked the fact that it went through all of the different professionals and then . . . went to the end where all of them were working together and you could see it . . . piece together. It made a lot more sense than just reading about all of them doing things separately. (Nursing student)
Patient-centeredness One theme that emerged strongly from all of the focus groups was that the module allowed students to see how the patient was central to how healthcare team members worked together to achieve patient care outcomes: You really clarify the whole thing; you’re putting the patient at the center, not your own image . . . as in that you have got to put all the allied health-professional interests toward that patient, rather than just work on your own what you want you should probably think of everyone . . . and what’s best for the patient. Like it really brought that home. (Occupational therapy student) I think because you’re looking at a specific case study, as well of a patient and his sort of follow through to the hospital, it made it sort of a story, so it . . . was interesting as well at the same time. (Nutrition/dietetics student) Within this context, students recognized the importance of different team members’ contributions in the provision of patient care, and that within the team each was an equal: © 2014 Wiley Publishing Asia Pty Ltd.
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You realize how many . . . it takes a lot of people to . . . work with the client. (Nursing student) You realize too that one (health professional) isn’t any more important that the other. That they’re all just as important, you know, for different reasons. (Nursing student) The experience further expanded students’ understandings of the scope of practice from other disciplines: It was in the cardiac rehab. I never thought like they had a physio. I think it was at one point with the stethoscope kind of looking at the breathing of the patient, and I kind of never associated the breathing with the physio before. I more sort of looked at (the) exercise type thing. (Nursing student) It was actually interesting to see how every health professional has an impact on the one client. So at every stage, like you start with your paramedics to the nurses and then, and just see the progress the client goes through. (Nutrition/dietetics student)
Online module versus other IPE activities Participants were asked to provide their perspectives on the online nature of the module in comparison to their previous face-to-face IPE activities. Students reported that the videos provided allowed them to actually see health professionals working together in context, rather than learning abstract content alongside students from other health professions: IPE in first semester, we did it (for the) first year, this year. At the beginning, I think everyone went off into their groups. I noticed . . . the physios would all sit together and the nurses would all sit together . . . I still didn’t have a great idea of what everyone would do until I saw the modules and the videos and stuff. (Paramedic student) I think this module is better than what we did in like first semester (classroom-based activities), because it was more learning about how to work together, rather than just meeting people who are from those professions and doing assignments. (Nutrition/dietetics student) I think the videos I liked more than (classroom-based) IPE itself . . . IPE . . . helped us get used to each other and the fact that we all have different, like we all do different things at uni, but the videos actually told us what the other people did. We never knew that. (Occupational therapy student) A number of students discussed how clinical placements had not provided opportunities to actually watch what other health professionals did, and the online learning provided such insights: Even though we worked 8 h per shift as a nurse, it is really quite hard for you to have some spare time to look at what others are actually doing . . . I am just . . . running with the nurses and they are showering the patients and © 2014 Wiley Publishing Asia Pty Ltd.
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they’re giving out the medicine. So it would be really great if we can have some spare time to really sit down and look at how others are doing their jobs. (Nursing student) I sat in IPE for the first few weeks of last semester and I didn’t really understand it, because I didn’t know what the other professions did, and I thought that it would have been really good to have something like that. It would have helped a lot. (Nutrition/dietetics student) Others valued seeing medical staff in their patient care roles, as during clinical placements they had few opportunities to interact with medical students: Especially the doctor, the med (medical) students. We were on placement with other students, OT (occupational therapists), nursing and they were great. You know often . . . the med students . . . they wouldn’t interact with us. (Physiotherapy student) Some discipline groups had received formal, structured IPE learning in their first semesters, and sometimes later, of their courses. Within the focus groups, some participants discussed their prior experiences and their perceived value: No one actually told us what an OT (occupational therapist) did or what a nurse did . . . we just went in there and were kind of like blinded. Like, okay, there are all these other professions, like what do they actually do? Like no one actually told us what they did, and being in first year as well, first semester, I don’t think many people knew what they were actually going to do. (Paramedic student) People weren’t really interested in being there. It was often on a day where we weren’t meant to be at the uni. They put on an extra day, so people were really disinterested. They put it on a time where there were four assignments due next week. People weren’t engaged . . . I don’t feel like it was that beneficial. I found a lot of people actually came out of it going, “what was the point of that?” sort of thing. That’s just from like the experiences that I had in first and second year. (Physiotherapy student)
Overcoming geographical boundaries One of the benefits reported by students related to the online program was overcoming challenges associated with geography. At our university, health courses are delivered on four campuses, as well as many clinical sites. Thus, geography can be a limitation to any face-to-face IPE activity. The online module was seen as one means for overcoming such challenge. Some students identified that working interprofessionally in an online context facilitated their working together better than previous face-to-face experiences, as highlighted by one physiotherapy student: In first and second year, (we) did some interprofessional learning with OT (occupational therapists), and in first year, I think we do it with the radiography students from
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(another campus), as well. . . . It was definitely hard at times, especially with the radiography students who were off campus to try and put together an assignment with them . . . and so I don’t feel like it worked that well. (Physiotherapy student) One student further highlighted the specific benefit for cross-campus interprofessional learning: Dietetics is at (another campus), so if there was a classroom situation, like we would have to come down here, and the likelihood of us probably coming down here would be maybe slim. I don’t know it depends on how dedicated everyone is, so I guess that online environment did create that we could be involved. (Nutrition/ dietetics student)
DISCUSSION IPE is increasingly becoming a core requirement for healthprofessional curricula to promote the development of teamwork and interprofessional understandings. Numerous potential benefits of effective health teamwork have been asserted, including the provision of better patient care (Solomon et al., 2010), the effective use of health services (Mickan, 2005), and improved health outcomes (Mickan, 2005; WHO, 2010). However, curriculum developers often grapple with the most appropriate approach to such content delivery and struggle to overcome associated challenges, including costs, large student numbers, and logistical issues (Hammick et al., 2007; Bennett et al., 2011). Participants in the current study reported positively on an online approach, with an imbedded video scenario where they were able to watch each member of the team engage in patient care, in addition to short videos from different health professionals reflecting on their own roles in practice. Students reported on the uniqueness of being able to sit and watch others in their professional roles. This was something they reported that they were not able to achieve in the context of high-stake pressures in the clinical environment. They reported having more respect for other health professionals, and seeing the patient as central to care, an important outcome of IPE (Thistlethwaite, 2012). The aspect of actually being able to see patient-centered care delivery across different professional contexts, which students reported they were not seeing in clinical placements, is noteworthy. This is a particularly concerning issue that was not expected to emerge in the study. It leads to questions about whether current clinical education models reinforce professional silos if students do not have the opportunity to develop understandings and observe the roles of other health professionals in practice, and how they contribute to overall patient care. This aspect also leads to questions about current IPE objectives and effectiveness, and warrants further exploration. Turale (2011) asserted that the importance of equal partnerships in care delivery and activities, such as ours, might be one way to facilitate the development of such partnerships. Classroom activities that employ video footage, such as those used in our module, might also facilitate learning about other health professionals and their roles.
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Our findings reinforced those of other studies (Santy et al., 2009; Eccott et al., 2012), suggesting that students do not need to be in face-to-face learning situations for effective IPE to occur. Online approaches were well received by our students, and this approach has particular benefits in overcoming some of the reported challenges in IPE delivery; in particular, logistical and scheduling issues (Hammick et al., 2007; Luke et al., 2009; Solomon et al., 2010). Students identified that being able to work with other students from different sites was a benefit of the module. However, such an approach needs further consideration and development, including optimal timing of module delivery and longitudinal evaluation to determine the impact of the online innovation on knowledge and skill translation in practice. Students in this study reported a lack of understanding of IPE as a negative outcome from prior face-to-face IPE experiences. Many of these had been undertaken in the first semester of their course, before they sufficiently understood their own discipline. Students in our study, who had experienced at least one clinical placement, reported that it provided a foundation on which to build further learning. In their study, Luke et al. (2009) found that students were keen to learn about the roles of other health professionals, but they needed to understand their own specific professional role. Tunstall-Pedoe et al. (2003) found that health professional students arrived with stereotypical views on entry to university. Curriculum developers often debate where to place IPE within health professional courses, that is, whether this is best placed early, before students have developed stereotypical perceptions, or placed later, when students have developed their own professional identities (Bradley et al., 2009). Our findings suggest that there is a need for more research on the optimal timing of such IPE activities within the wider curriculum.
Limitations of the study The study design does have limitations. This pilot was only conducted with students at one university in Australia. In the module, students were only presented with one clinical scenario, and there was limited opportunity for students to interact with one another online. Further studies would be needed to explore the broader applicability of such learning. In addition, the students who chose to participate are likely to have been more engaged because they elected to be involved.
Conclusions IPE is increasingly important in health professional programs. However, incorporating targeted activities into curricula has been reported as challenging, especially in terms of logistics and student engagement. The online delivery of IPE has the potential to overcome some of the barriers to face-to-face delivery, while still resulting in effective interprofessional understandings that might not even be achievable in existing structured clinical practice placements. © 2014 Wiley Publishing Asia Pty Ltd.
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CONTRIBUTIONS Study Design: LM, MB, CP, EM, BW, TB. Data Collection and Analysis: LM, CP, EM. Manuscript Writing: LM, MB, CP, EM.
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