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Interprofessional education in a midwifery curriculum: the learning through the exploration of the professional task project (LEAPT)
ARTICLE IN PRESS Midwifery (2004) 20, 358–366
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Interprofessional education in a midwifery curriculum: the learning through the exploration of the professional task project (LEAPT) Christine Furber, BSc, MSc, RM, MTD (Lecturer)a,*, Janet Hickie, BA, RM, ADM, MT (Lecturer)a, Karen Lee, MA, RM, ADM, PGCE (Lecturer)a, Aileen McLoughlin, BSc (Hons), MSc, RM, MTD (Lecturer)a, Caroline Boggis, MBBS, FRCR (Hospital Dean for Clinical Studies)b, Adrian Sutton, BSc, MBBS, FRCPsych, UKCP (Consultant in Child and Family Psychiatry and Psychotherapy)c, Sam Cooke, BSc (Hons) (Research Assistant)b, Ann Wakefield, MSc, PhD, RGN, Cert Ed (Lecturer in Nursing)d a
School of Nursing, Midwifery and Social Work, The University of Manchester, Gateway House, Piccadilly South, Manchester M60 7LP, UK b South Manchester University Hospitals NHS Trust, Wythenshawe, South Manchester M23 9LT, UK c The Winnicott Centre, Manchester M13 0JE, UK d School of Nursing, Midwifery and Social Work, The University of Manchester, Coupland III Building, Oxford Road, Manchester M13 9PL, UK Received 23 June 2003; received in revised form 24 March 2004, 31 March 2004; accepted 1 April 2004
Summary Objective: to develop interprofessional education for students of midwifery, nursing and medicine. To foster collaborative working and learning between students of midwifery, nursing and medicine. Design: a quasi-experimental method to evaluate the outcomes of an intervention (a problem-based learning (PBL) scenario) with interprofessional students and facilitators. Data were collected using pre- and post-test questionnaires. Setting: a University and National Health Service healthcare facilities in the North of England. Participants: 40 students of midwifery, nursing and medicine. Findings: student midwives participating in the PBL scenario in this interprofessional format improved their attitudes to working in this environment. All students enjoyed the opportunity to learn in an interprofessional team, and they felt that the experience provided a safe environment to help prepare for their future roles. The learning opportunity enabled all students to reflect on each other’s role and to
*Corresponding author. E-mail address: [email protected] (C. Furber). 0266-6138/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2004.04.001
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discuss differing perspectives of care, although the student midwives had mixed feelings about the PBL experience. Implications for practice: interprofessional learning using PBL is a useful environment for students to learn about each others’ role, and to prepare for working together as qualified professionals in a collaborative manner. However, time and commitment is required to plan joint working in order to maximise the benefits. & 2004 Elsevier Ltd. All rights reserved.
Introduction Recent government documents have stated that the future of the UK healthcare system lies in the provision of a collaborative and seamless service (Department of Health (DoH), 2000). This differs from previous service provision where health and social services professionals have operated within defined and specific role boundaries, and engaged in limited communication with each other. However, ‘partnerships in practice’, where organisational barriers are broken down, have been recommended for the future to improve clientfocused care and increase efficiency (DoH, 1997). Interprofessional education and learning is one step towards meeting these changing needs and assisting in the development of an integrated health and social care service (United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKKC), 1999). According to Cable (2002) ‘this challenge has created a need to bring together separate but interdependent health and care professionals’ (p. 1).
Interprofessional education Interprofessional education is defined as educational initiatives that incorporate interactive learning methods between different professionals in order to foster collaborative practice (Hale, 2003). This differs from multiprofessional education, which involves the use of teaching methods, such as lectures, to large groups of different professionals who learn rather more passively (Hale, 2003). Interprofessional education has the potential to be an initiative that may encourage students from a wide variety of educational programmes of study to communicate, function and study together in a team. Yet, according to some studies describing interprofessional education (Mires et al., 1999; Fraser et al., 2000), the teaching and learning sessions themselves comprise only a part of the process. Generally, such learning opportunities allow students from various backgrounds (e.g. midwifery, medicine, nursing) to work actively together to ‘solve problems’. This mode of learning
has the potential to prepare students for future clinical practice; helping to promote solid and professional relationships by generating respect for each other’s roles. Interprofessional education has been introduced into some midwifery curricula in the UK already. For example, Mires et al. (1999) and Fraser et al. (2000) both describe pilot studies involving shared learning between student midwives and student doctors. Interprofessional education is also evident in the undergraduate programmes of other disciplines, such as occupational therapists and physiotherapists (Reynolds, 2003). In addition, interprofessional learning has also started to emerge in post-registration/postgraduate primarycare specialist nurse programmes involving podiatrists, dieticians and breast-feeding counsellors (Partis, 2001). An evaluation of these studies suggests that there is the potential to develop interprofessional learning further, as the students found it a positive and useful experience (Fraser et al., 2000; Partis, 2001; Reynolds, 2003). Fraser et al. (2000) suggest that students find problemsolving exercises particularly valuable as they permit them to explore each other’s roles. However, interprofessional learning can also be problematic as it involves an element of risk, requires considerable resource investments (Fraser et al., 2000; Sengupta et al., 2003) and may ignite interprofessional rivalry between groups (Partis, 2001). In the UK, the advent of clinical governance and the focus on clinical improvement means that it is essential that health professionals collaborate in order for decisions and actions to be evidence based and of a high standard (Miller, 2001). Interprofessional working is now established in the production of national and local midwifery guidelines and recommendations for practice (National Institute of Clinical Excellence, 2001). Many hospital and community policies have an interprofessional focus and evidence base, which ensures that resources are used effectively, leading to higher satisfaction levels among users. However, Engel (2002) has suggested that we should also be preparing our students to work together, and across disciplines, in order to face the ever-growing
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dilemmas of health care in the 21st Century; one way to achieve this is through the introduction of problem-based learning (PBL).
Problem-based learning PBL offers an opportunity to practice and develop interpersonal, group and team-working skills. Students are then encouraged to use the expertise gained across clinical and academic boundaries to integrate different forms of disciplinary knowledge into their work. Thus, it is envisaged that such resources will equip students to work in the constantly changing world of midwifery, nursing and medicine as competent practitioners and effective team members. PBL is not a new phenomenon in education; it has been the teaching and learning method of choice across many healthcare-related programmes since its inception at McMaster University in Canada, in 1974 (Thomas et al., 1998; Antepohl and Herzig, 1999; Biley, 1999; Williams, 1999). Learning through PBL requires students to identify issues that emerge from the process of critical analysis of a given problem or scenario or ‘trigger’ (Thomas and Cooke, 1999). Thomas and McCourt (2001a) emphasise the relevance of using practice-based scenarios or ‘triggers’, as this relates closely to the aims of a competency-based programme designed to develop critical thinkers in practice. The students work through the problem in a given series of steps with a tutor(s) facilitating the process. This is different to traditional teaching methods, where students are presented with factual data and expected to apply their knowledge to a particular clinical situation. For example, students may receive an initial taught session related to the physiology of labour and then are presented with a scenario, requiring them to analyse options for care. The advantages claimed for PBL have gained wide recognition. These include the benefits of deep learning over superficial learning, the development of critical and creative thinking, the encouragement of personal growth, confidence and self-esteem. It is also said to promote ownership of the learning process and develops group cohesiveness, which enhances the notion of supportive challenge and gives the students a greater sense of learning within the ‘real world’, thus helping to close the theory to practice gap (Woods, 1997; Amos and White, 1998; Thomas and McCourt, 2001b). However, several criticisms have been made of the process highlighted in the published literature. Woods (1997) argues that, for PBL to be successful, it must be acknowlwedged that this form of
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learning might not suit all people. For example, Biley and Smith (1999) found that students sometimes experience anxieties while undertaking PBL. These anxieties tended to focus on the uncertainty of knowledge acquisition, the group processes (which were not always positive) and the role of the facilitator (which can be perceived as ‘inconsistent’). The main difficulty seemed to be a tension resulting from the transition to a PBL style from a traditional learning style, and forgetting the aims of PBL, which might be to achieve the process rather than the product (Biley, 1999). Woods (1997) likened the symptoms of this tension to the grieving process, in particular shock, denial, anger and resistance, with eventual acceptance, followed by a struggle to adjust to the new situation. Facilitators have also been faced with challenges to their traditional role of teacher. In addition, there seems to be no clear definition of ‘facilitator’, which has been shown to mean different things to different people (Haith-Cooper, 2000). This poses a dilemma concerning when and how much to intervene in the group process. Tutors who pose challenging questions to help students develop a more analytical approach to their discussions often find themselves central to any group conflict (Thomas, 2001). This raises the question of how viable learning is within these conditions. Other criticisms concern the efficacy of the step-by-step process, as some have suggested that it renders learning a taskorientated process, generating a disinclination to explore beyond the defined remit (Biley and Smith, 1999). Thomas and McCourt (2001b) found little research to support the notion that PBL reduces the theory–practice gap. It has also been suggested that PBL may not be the best method for developing the acquisition of skills requiring manual dexterity (Williams, 1999). However, Woods (1997) remains adamant that, if these issues are recognised, then strategies can be devised to avoid them, enabling students and tutors to benefit from PBL. Woods (1997) also found that the use of inventory tools to identify the needs of both students and staff was helpful in planning appropriately designed workshops to develop the required skills. In addition, continuous support through team meetings can have a similarly positive effect (Thomas, 2001).
The learning through the exploration of the professional task study Public health has a new focus in UK health care; a comprehensive national strategy has been designed that recognises the role of the midwife in improving the health of the people, and reducing inequalities in
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health (DoH, 1999). However, in order to be effective, joint working between professionals and users of the services is essential (DoH, 1999). It is appropriate then to consider the development of interprofessional, undergraduate education between student midwives, doctors and nurses, as these professionals work collaboratively in the care of women and their families during childbearing and beyond. In this paper, we describe a pilot study to implement and evaluate joint learning between student midwives, nurses and doctors. The student nurses were studying for the Bachelor of Nursing (Hons) (BNurs) degree; the student doctors were studying for the Bachelor of Medicine: Bachelor of Chirology degree; and the student midwives were studying for the Diploma in Professional Studies in Midwifery (DPSM) award. Student nurses participated in the study while they were undertaking their ‘Maternal and Child HealthFWell Person’ module, whereas the student doctors were engaged in their ‘Families and Children’ module during the study. The point at which it was felt most appropriate for the DPSM programme students to participate was during their ‘Midwife and Public Health’ module. At this point in the programme, student midwives are encouraged to develop partnerships in practice between different health professionals in line with current public health practice (DoH, 1999). PBL was selected as the teaching and learning method, as the student doctors were familiar with this already; PBL is the main educational approach used to teach medical undergraduates (O’Neill et al., 1999). To give added weight to the method of teaching, the midwifery educationalists were already exploring ways of integrating PBL into their own curriculum. PBL is used as a teaching method on the BNurs programme; however, this is at a later stage than the ‘Maternal and Child HealthFWell Person’ module, and so the student nurses had not yet experienced this teaching method. Hence, as Mires et al. (1999) and Fraser et al. (2000) found that interactive teaching methods contributed to their positive evaluations, incorporating PBL into the study presented the research team with an ideal opportunity to develop meaningful PBL initiatives and to learn from the experiences of others. The aims of the study were to develop interprofessional education and to foster collaborative working and learning.
Methods A quasi-experimental method was used to evaluate the outcomes and progress of the intervention. The
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intervention in this case was the presentation of a PBL scenario to an interprofessional group of students comprising three student midwives, three doctors and two student nurses (Burns, 2000). The representation of students was disproportionate, owing to the number of student nurses who volunteered. Two interprofessional facilitators supported each group. The facilitators were any two individuals drawn from a medical, nursing or midwifery background. The study design was a ‘one group experiment’, as there was no control group for comparison (Polit and Hungler, 1991). Preand post-test questionnaires were used to assess changes in attitudes towards interprofessional learning. Preparation took place 6 months before the start of the intervention. This consisted of bi-monthly meetings of the steering group. Although PBL was well established within the medical curriculum, this type of learning was new to the staff and students on the DPSM and BNurs programmes. Therefore, a review was conducted in order to identify relevant issues for PBL, and teaching and learning, within an interprofessional team. During these meetings, ‘fine tuning’ of the trigger was undertaken. In addition, a PBL training programme was devised for students and facilitators not familiar with this style of teaching and learning. The practical preparation of linking timetables for the three disparate courses, and negotiating for venues and resources was also undertaken. The training programme for facilitators involved experiential learning using a different trigger coupled with information about the intervention. This covered one full day in all. Student midwives and nurses all had a half-day training, which included experiential learning using the same trigger as the facilitators. Student doctors had no training, as they were already familiar with this style of learning through their degree studies. The integration of timetables proved to be particularly difficult because of the diverse commitments of the students. The numbers of student nurses and student doctors proved too many to include them all, so the intervention was designed as an ‘extra curricula’ activity. Eventually, a compromise was reached, and three sessions were planned with fortnightly intervals between them. This took place concurrently with other course work. The student midwives were at the beginning of their third year, the student nurses at the beginning of their second year and student doctors at the beginning of their fourth year. All had reached ‘level two’ in their studies, with the nurses and doctors having arrived at a point in their curriculum where they would usually encounter
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clinical placements and theory related to the maternity services.
Recruitment Volunteers were asked to participate from all three disciplines. The total cohort of 17 student midwives all agreed to participate, and their involvement was easily incorporated into the ‘Midwife and Public Health’ module. Ten student nurses volunteered from a cohort of 40. However, only 10 students were able to undertake the module, as the cohort was divided into four groups to facilitate access to clinical placements. Despite being a much larger group, recruitment of the student doctors was initially slow, as the students already had a full timetable, hence they were reluctant to give up their free time. For this reason, a stipend of d25 was offered to all participating students (nurses, midwives and doctors) payable at the end of the study. From a cohort of 128 student doctors, 13 volunteered to take part.
Ethical considerations Ethical approval to carry out the study was gained from the School of Nursing, Midwifery and Social Work’s Ethics Committee (a sub-committee of the University Ethics Committee) before commencing the study. All participating students and facilitators were asked to sign a consent form stating that they were happy to be involved, and that they could withdraw from the study at any time. Anonymity was assured in completing the questionnaire, as all students were given a code. No midwives withdrew, but some nurses and doctors did not attend all three sessions owing to sickness, confusion about the venue and pressure of other study.
The intervention Five interprofessional groups consisting of seven to eight students and two facilitators were established as outlined above. All were given the same trigger related to maternal and child health. The trigger took the form of a scripted conversation between two fictitious health-service planners. The outcome of their discussion was the commissioning of a working party to develop a ‘User’s Guide’ to uncomplicated pregnancy, labour and the puerperium. This then became the task of each interprofessional group. Facilitators were given a Tutor’s Manual, which highlighted key points that needed to be discussed in the groups. Comprehensive resource lists were
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also available for facilitators. The venues reflected the interprofessional approach, and included teaching accommodation at the university, a teaching hospital and a specialist health clinic. Refreshments were provided for all sessions.
Data collection and analysis All students completed pre- and post-intervention questionnaires, which used open questions to ascertain their thoughts and expectations of the project before and after participation. Questions before the intervention focused on anxieties, concerns and thoughts on interprofessional working. Questions after the intervention focused on feelings about participation and any problems encountered. Students were also given a further two questionnaires before and after the intervention. This comprised 26 statements (Box 1) related to attitudes towards interprofessional teamwork, and were adapted from Wolf (1999). Two categories were devised: ‘team working,’ comprising 12 questions and ‘interprofessional’ attitudes comprising 14 questions. A Likert scale of 1 (strongly agree) to 6 (strongly disagree) was used to assess the student’s endorsement of the statement (Fink, 1995). A neutral response was not included in order to maximise responses and to avoid giving students the opportunity to avoid answering the question (Fink, 1995). Consequently, the scores for the ‘team working’ category of the questionnaire had a minimum of 12 (strongly disagree) and maximum of 72 (strongly agree). The adaptation to the questionnaire consisted of some of the stem statements being reversed. This resulted in some positively orientated reactions and other negative responses. This was to ensure that students gave a considered opinion rather than simply selecting an ‘incorrect’ or ‘correct’ response. Each questionnaire was coded to ensure that only the researchers knew the discipline of the respondent. SPSS was used to analyse quantitative data. The qualitative data from the open questions were independently coded and then categorised into emerging themes by AW and SC.
Findings Quantitative data Forty students initially volunteered to take part; 32 (80%) of these completed both pre- and postintervention questionnaires. These 32 sets of
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Box 1 Statements related to team-working and interprofessional working Team-working statements: I enjoy working within a team to solve problems I would rather make decisions in a group than work on a team I get excited about working in a group decision-making process I feel my ideas are stifled when I work in a group I only work in a group because I have to I like to work by myself I like working in groups Work teams provide the opportunity for better problem-solving than individual alone I feel free to express my thoughts in work groups I would rather solve problems alone than as part of a team Problem-solving in teams is part of my undergraduate training To be effective in my job, I need more training in group problem-solving Interprofessional working statements: I feel comfortable working in multidisciplinary teams I enjoy being requested to learn new tasks outside of my profession Performing jobs associated with other professions is frustrating Working in multidisciplinary teams is a mandatory part of today’s healthcare I enjoy sharing tasks from my profession with persons in other professions Patient-focused care decreases the quality of care I dislike working in a multidisciplinary team I prefer to work in a department composed of only my discipline rather than a multidisciplinary team I enjoy taking on new task outside my profession Being part of a multidisciplinary team motivates me Multidisciplinary health teams increase the quality of patient care In multidisciplinary teams, my talents are not used to capacity In a multidisciplinary team, I work to my potential I would like to be more involved in team problem-solving than I am Students were asked to rank these statements according to their agreement with the following: 1. Strongly agree; 2. Moderately agree; 3. Slightly agree; 4. Slightly disagree; 5. Moderately disagree; 6. Strongly disagree.
questionnaires were analysed. Of the remaining eight participants, four questionnaires were spoiled and four did not complete both questionnaires.
numbers in the sample were too small to be significant.
Qualitative data Attitudes towards interprofessional teamwork Overall, there was little change in responses before and after the intervention. The student midwives increased their post-test scores for ‘teamworking’ by two points (54–56), the student doctors by one point (54–55); nursing students increased by one point (56–57). With ‘interprofessional working’, the total scores were a minimum of 14 (strongly disagree) and maximum of 84 (strongly agree). By the end of the intervention, the student midwives had increased their scores by two points (67–69), student doctors by four points (66–70) and student nurses by two points. However, the student nurses demonstrated the most positive attitudes to interprofessional learning (72–74). Although inferential statistics were conducted on these data, the
The data from this study suggest that, overall, the process of communicating with each other during the intervention increased students’ perceived levels of confidence about communicating with women, their families and with each other in clinical practice. The themes identified from the qualitative data were (1) working in teams; (2) sharing of knowledge, skills and different perspectives and (3) trying out PBL. Working in Teams: As the following statements indicate, the students enjoyed the opportunity to work in interprofessional teams. For example, they commented that the pilot study had given them the following benefits: the chance to see that we can work together as a team and (y) we can learn from each other (Nurse 1).
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an (opportunity to) build a team working ethic for future practice (Doctor 9).
Moreover, it could help them yinteract within the hospital setting (Nurse 2).
In particular, the interprofessional learning format provided opportunities to prepare for their future professional roles in a secure and safe environment. This was illustrated by the following comment: It breaks down professional barriers to provide the best care for patients (Midwife 5).
Another student midwife stated that the project was good as it allowed the students as a whole to ‘to understand each other’s role’. These data concur with Glen and Leiba’s (2002) point that interprofessional teaching and learning increases the likelihood of students engaging in collaborative working once qualified. The students involved in this exercise seemed to be willing to listen to each other and to respect each other’s professional role as illustrated below: It has proved that we can pull together as a multidisciplinary team (Nurse 1). Better understanding leads to more mutual co-operation and respect, which in turn improves patient care (Doctor 8). (It was good to) get some idea of how much others know about my profession (Midwife 5).
These findings suggest that the aim of fostering collaborative working was achieved by facilitating appropriate attitudes (Barr, 1996), and the motivation to work with allied professionals by collaborating with them confidently and competently (Barr, 1998). Sharing of knowledge skills and different perspectives on care: These data also illustrate that sharing is a fundamental reason for implementing interprofessional learning. The following comments illustrate how the study provided the opportunity for students to reflect on each other’s perspective on care: Everybody was co-operative. People were willing to listen and learn from others. Ideas were shared from different perspectives (Nurse 2). We all had different ideas of what was important (Doctor 6).
The study also provided the opportunity for the interprofessional students to try out ideas with each other, and to discuss and debate each others’ philosophies of care. These discussions facilitated the sharing of knowledge and provided the oppor-
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tunity to explore each others’ perceptions of their role. I was not aware of the roles of midwives and I learnt a lot (Doctor 6).
Trying out PBL: The student midwives were the only participants to comment about the PBL experience. This is surprising, as the student nurses had not previously experienced PBL in their education either. However, their comments had positive and negative connotations. Some enjoyed the learning experience as this comment explains: My main reason for volunteering was to enjoy a different learning styleFI have done this (Midwife 5).
Others felt that the lack of preparation for PBL inhibited their participation in the project. This statement below explains this: Lack of familiarity with PBL caused difficulty for me and knowing that we were doing the right thing during the session (Midwife 4).
Discussion This study is only a pilot with small numbers of participating students. It is important that these limitations are recognised. The amended questionnaire of Wolf (1999) was not tested before its use, and therefore ambiguity of the questions cannot be excluded. For the student doctors and nurses, there was competition in attending all of the three PBL sessions because of their extant curricula activities (Albanese, 2000). This subsequently contributed to their non-attendance, which may have affected the group dynamics during the ‘working through of the problem’ stage of the PBL process. However, the evidence provided by the quantitative and qualitative data reinforced the learning opportunities provided by the project. The students wanted to learn together and, in doing so, benefited in several ways. The desire to learn in interprofessional teams was enhanced after completing the study. The student midwives benefited by having been given an opportunity to communicate with students from two other disciplines. Their professional knowledge was strengthened and challenged by having to explain themselves to students from the other participating disciplines. In addition, involvement in the study enhanced their negotiation and team-working skills. The findings of this small study support Brandon and Majumdar’s (1997) suggestions that PBL encourages co-operation over competition.
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The study, however, did require a considerable amount of commitment from all involved, as it was logistically complex and time consuming to plan. This is not unusual, as other authors have highlighted the need for commitment from all staff involved in developing interprofessional education in order for it to be successful (Fraser et al., 2000). The findings outlined in this paper suggest that PBL is a useful teaching and learning method to facilitate interprofessional education because of its interactive nature. Students worked together with the trigger material, which generated detailed discussion about the maternity services as a whole. However, not all of the student midwives were comfortable with the PBL learning experiences, reflecting comments reported by Biley and Smith (1999). This highlights the need for thorough preparation, and suggests that the half-day session provided for these students was inadequate for their needs. More experience in the use of this teaching and learning method was necessary. Despite the limitations, the study has provided some useful evidence from which to build future opportunities for collaborative and interprofessional education. Further consideration needs to be given to the format of such collaboration, its timing and place within the curriculum, and the degree to which it becomes a regular and integral part of the programme for all health professionals. Leiba (2002) suggests that the increasing tendency for specialised roles within individual professions increases the likelihood that a team approach to care will be required. The need for such a team approach is also deemed to be vital when coordinating the response to obstetric and neonatal crises or emergency situations in post-registration interprofessional education, and is recommended by key national audits (Confidential Enquiries into Stillbirths and Deaths in Infancy, 2000; Confidential Enquiries into Maternal Deaths, 2001). Leiba (2002) suggests that, in order to embrace this, professional roles need to converge from an early stage in their education, thus also enhancing understanding and respect for the multiplicity of professional perspectives. It would seem then, that by engaging in experience-related learning such as PBL, and examining the real world of professional work, this study provided students with a multiprofessional interactive learning experience. This was not only enjoyable, but vital to the future of nursing, midwifery and medical education. This will contribute to the future of the health services, and particularly to public health practice. However, it is recommended that further research is developed that incorporates larger numbers of students of
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differing disciplines with midwives. In particular, an increasing number of rigorous studies are required to be more confident of the value of interprofessional education (Zwarenstein et al., 2000).
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Interprofessional education in a midwifery curriculum: the learning through the exploration of the professional task project (LEAPT) Christine Furber, BSc, MSc, RM, MTD (Lecturer)a,*, Janet Hickie, BA, RM, ADM, MT (Lecturer)a, Karen Lee, MA, RM, ADM, PGCE (Lecturer)a, Aileen McLoughlin, BSc (Hons), MSc, RM, MTD (Lecturer)a, Caroline Boggis, MBBS, FRCR (Hospital Dean for Clinical Studies)b, Adrian Sutton, BSc, MBBS, FRCPsych, UKCP (Consultant in Child and Family Psychiatry and Psychotherapy)c, Sam Cooke, BSc (Hons) (Research Assistant)b, Ann Wakefield, MSc, PhD, RGN, Cert Ed (Lecturer in Nursing)d a
School of Nursing, Midwifery and Social Work, The University of Manchester, Gateway House, Piccadilly South, Manchester M60 7LP, UK b South Manchester University Hospitals NHS Trust, Wythenshawe, South Manchester M23 9LT, UK c The Winnicott Centre, Manchester M13 0JE, UK d School of Nursing, Midwifery and Social Work, The University of Manchester, Coupland III Building, Oxford Road, Manchester M13 9PL, UK Received 23 June 2003; received in revised form 24 March 2004, 31 March 2004; accepted 1 April 2004
Summary Objective: to develop interprofessional education for students of midwifery, nursing and medicine. To foster collaborative working and learning between students of midwifery, nursing and medicine. Design: a quasi-experimental method to evaluate the outcomes of an intervention (a problem-based learning (PBL) scenario) with interprofessional students and facilitators. Data were collected using pre- and post-test questionnaires. Setting: a University and National Health Service healthcare facilities in the North of England. Participants: 40 students of midwifery, nursing and medicine. Findings: student midwives participating in the PBL scenario in this interprofessional format improved their attitudes to working in this environment. All students enjoyed the opportunity to learn in an interprofessional team, and they felt that the experience provided a safe environment to help prepare for their future roles. The learning opportunity enabled all students to reflect on each other’s role and to
*Corresponding author. E-mail address: [email protected] (C. Furber). 0266-6138/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2004.04.001
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discuss differing perspectives of care, although the student midwives had mixed feelings about the PBL experience. Implications for practice: interprofessional learning using PBL is a useful environment for students to learn about each others’ role, and to prepare for working together as qualified professionals in a collaborative manner. However, time and commitment is required to plan joint working in order to maximise the benefits. & 2004 Elsevier Ltd. All rights reserved.
Introduction Recent government documents have stated that the future of the UK healthcare system lies in the provision of a collaborative and seamless service (Department of Health (DoH), 2000). This differs from previous service provision where health and social services professionals have operated within defined and specific role boundaries, and engaged in limited communication with each other. However, ‘partnerships in practice’, where organisational barriers are broken down, have been recommended for the future to improve clientfocused care and increase efficiency (DoH, 1997). Interprofessional education and learning is one step towards meeting these changing needs and assisting in the development of an integrated health and social care service (United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKKC), 1999). According to Cable (2002) ‘this challenge has created a need to bring together separate but interdependent health and care professionals’ (p. 1).
Interprofessional education Interprofessional education is defined as educational initiatives that incorporate interactive learning methods between different professionals in order to foster collaborative practice (Hale, 2003). This differs from multiprofessional education, which involves the use of teaching methods, such as lectures, to large groups of different professionals who learn rather more passively (Hale, 2003). Interprofessional education has the potential to be an initiative that may encourage students from a wide variety of educational programmes of study to communicate, function and study together in a team. Yet, according to some studies describing interprofessional education (Mires et al., 1999; Fraser et al., 2000), the teaching and learning sessions themselves comprise only a part of the process. Generally, such learning opportunities allow students from various backgrounds (e.g. midwifery, medicine, nursing) to work actively together to ‘solve problems’. This mode of learning
has the potential to prepare students for future clinical practice; helping to promote solid and professional relationships by generating respect for each other’s roles. Interprofessional education has been introduced into some midwifery curricula in the UK already. For example, Mires et al. (1999) and Fraser et al. (2000) both describe pilot studies involving shared learning between student midwives and student doctors. Interprofessional education is also evident in the undergraduate programmes of other disciplines, such as occupational therapists and physiotherapists (Reynolds, 2003). In addition, interprofessional learning has also started to emerge in post-registration/postgraduate primarycare specialist nurse programmes involving podiatrists, dieticians and breast-feeding counsellors (Partis, 2001). An evaluation of these studies suggests that there is the potential to develop interprofessional learning further, as the students found it a positive and useful experience (Fraser et al., 2000; Partis, 2001; Reynolds, 2003). Fraser et al. (2000) suggest that students find problemsolving exercises particularly valuable as they permit them to explore each other’s roles. However, interprofessional learning can also be problematic as it involves an element of risk, requires considerable resource investments (Fraser et al., 2000; Sengupta et al., 2003) and may ignite interprofessional rivalry between groups (Partis, 2001). In the UK, the advent of clinical governance and the focus on clinical improvement means that it is essential that health professionals collaborate in order for decisions and actions to be evidence based and of a high standard (Miller, 2001). Interprofessional working is now established in the production of national and local midwifery guidelines and recommendations for practice (National Institute of Clinical Excellence, 2001). Many hospital and community policies have an interprofessional focus and evidence base, which ensures that resources are used effectively, leading to higher satisfaction levels among users. However, Engel (2002) has suggested that we should also be preparing our students to work together, and across disciplines, in order to face the ever-growing
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dilemmas of health care in the 21st Century; one way to achieve this is through the introduction of problem-based learning (PBL).
Problem-based learning PBL offers an opportunity to practice and develop interpersonal, group and team-working skills. Students are then encouraged to use the expertise gained across clinical and academic boundaries to integrate different forms of disciplinary knowledge into their work. Thus, it is envisaged that such resources will equip students to work in the constantly changing world of midwifery, nursing and medicine as competent practitioners and effective team members. PBL is not a new phenomenon in education; it has been the teaching and learning method of choice across many healthcare-related programmes since its inception at McMaster University in Canada, in 1974 (Thomas et al., 1998; Antepohl and Herzig, 1999; Biley, 1999; Williams, 1999). Learning through PBL requires students to identify issues that emerge from the process of critical analysis of a given problem or scenario or ‘trigger’ (Thomas and Cooke, 1999). Thomas and McCourt (2001a) emphasise the relevance of using practice-based scenarios or ‘triggers’, as this relates closely to the aims of a competency-based programme designed to develop critical thinkers in practice. The students work through the problem in a given series of steps with a tutor(s) facilitating the process. This is different to traditional teaching methods, where students are presented with factual data and expected to apply their knowledge to a particular clinical situation. For example, students may receive an initial taught session related to the physiology of labour and then are presented with a scenario, requiring them to analyse options for care. The advantages claimed for PBL have gained wide recognition. These include the benefits of deep learning over superficial learning, the development of critical and creative thinking, the encouragement of personal growth, confidence and self-esteem. It is also said to promote ownership of the learning process and develops group cohesiveness, which enhances the notion of supportive challenge and gives the students a greater sense of learning within the ‘real world’, thus helping to close the theory to practice gap (Woods, 1997; Amos and White, 1998; Thomas and McCourt, 2001b). However, several criticisms have been made of the process highlighted in the published literature. Woods (1997) argues that, for PBL to be successful, it must be acknowlwedged that this form of
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learning might not suit all people. For example, Biley and Smith (1999) found that students sometimes experience anxieties while undertaking PBL. These anxieties tended to focus on the uncertainty of knowledge acquisition, the group processes (which were not always positive) and the role of the facilitator (which can be perceived as ‘inconsistent’). The main difficulty seemed to be a tension resulting from the transition to a PBL style from a traditional learning style, and forgetting the aims of PBL, which might be to achieve the process rather than the product (Biley, 1999). Woods (1997) likened the symptoms of this tension to the grieving process, in particular shock, denial, anger and resistance, with eventual acceptance, followed by a struggle to adjust to the new situation. Facilitators have also been faced with challenges to their traditional role of teacher. In addition, there seems to be no clear definition of ‘facilitator’, which has been shown to mean different things to different people (Haith-Cooper, 2000). This poses a dilemma concerning when and how much to intervene in the group process. Tutors who pose challenging questions to help students develop a more analytical approach to their discussions often find themselves central to any group conflict (Thomas, 2001). This raises the question of how viable learning is within these conditions. Other criticisms concern the efficacy of the step-by-step process, as some have suggested that it renders learning a taskorientated process, generating a disinclination to explore beyond the defined remit (Biley and Smith, 1999). Thomas and McCourt (2001b) found little research to support the notion that PBL reduces the theory–practice gap. It has also been suggested that PBL may not be the best method for developing the acquisition of skills requiring manual dexterity (Williams, 1999). However, Woods (1997) remains adamant that, if these issues are recognised, then strategies can be devised to avoid them, enabling students and tutors to benefit from PBL. Woods (1997) also found that the use of inventory tools to identify the needs of both students and staff was helpful in planning appropriately designed workshops to develop the required skills. In addition, continuous support through team meetings can have a similarly positive effect (Thomas, 2001).
The learning through the exploration of the professional task study Public health has a new focus in UK health care; a comprehensive national strategy has been designed that recognises the role of the midwife in improving the health of the people, and reducing inequalities in
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health (DoH, 1999). However, in order to be effective, joint working between professionals and users of the services is essential (DoH, 1999). It is appropriate then to consider the development of interprofessional, undergraduate education between student midwives, doctors and nurses, as these professionals work collaboratively in the care of women and their families during childbearing and beyond. In this paper, we describe a pilot study to implement and evaluate joint learning between student midwives, nurses and doctors. The student nurses were studying for the Bachelor of Nursing (Hons) (BNurs) degree; the student doctors were studying for the Bachelor of Medicine: Bachelor of Chirology degree; and the student midwives were studying for the Diploma in Professional Studies in Midwifery (DPSM) award. Student nurses participated in the study while they were undertaking their ‘Maternal and Child HealthFWell Person’ module, whereas the student doctors were engaged in their ‘Families and Children’ module during the study. The point at which it was felt most appropriate for the DPSM programme students to participate was during their ‘Midwife and Public Health’ module. At this point in the programme, student midwives are encouraged to develop partnerships in practice between different health professionals in line with current public health practice (DoH, 1999). PBL was selected as the teaching and learning method, as the student doctors were familiar with this already; PBL is the main educational approach used to teach medical undergraduates (O’Neill et al., 1999). To give added weight to the method of teaching, the midwifery educationalists were already exploring ways of integrating PBL into their own curriculum. PBL is used as a teaching method on the BNurs programme; however, this is at a later stage than the ‘Maternal and Child HealthFWell Person’ module, and so the student nurses had not yet experienced this teaching method. Hence, as Mires et al. (1999) and Fraser et al. (2000) found that interactive teaching methods contributed to their positive evaluations, incorporating PBL into the study presented the research team with an ideal opportunity to develop meaningful PBL initiatives and to learn from the experiences of others. The aims of the study were to develop interprofessional education and to foster collaborative working and learning.
Methods A quasi-experimental method was used to evaluate the outcomes and progress of the intervention. The
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intervention in this case was the presentation of a PBL scenario to an interprofessional group of students comprising three student midwives, three doctors and two student nurses (Burns, 2000). The representation of students was disproportionate, owing to the number of student nurses who volunteered. Two interprofessional facilitators supported each group. The facilitators were any two individuals drawn from a medical, nursing or midwifery background. The study design was a ‘one group experiment’, as there was no control group for comparison (Polit and Hungler, 1991). Preand post-test questionnaires were used to assess changes in attitudes towards interprofessional learning. Preparation took place 6 months before the start of the intervention. This consisted of bi-monthly meetings of the steering group. Although PBL was well established within the medical curriculum, this type of learning was new to the staff and students on the DPSM and BNurs programmes. Therefore, a review was conducted in order to identify relevant issues for PBL, and teaching and learning, within an interprofessional team. During these meetings, ‘fine tuning’ of the trigger was undertaken. In addition, a PBL training programme was devised for students and facilitators not familiar with this style of teaching and learning. The practical preparation of linking timetables for the three disparate courses, and negotiating for venues and resources was also undertaken. The training programme for facilitators involved experiential learning using a different trigger coupled with information about the intervention. This covered one full day in all. Student midwives and nurses all had a half-day training, which included experiential learning using the same trigger as the facilitators. Student doctors had no training, as they were already familiar with this style of learning through their degree studies. The integration of timetables proved to be particularly difficult because of the diverse commitments of the students. The numbers of student nurses and student doctors proved too many to include them all, so the intervention was designed as an ‘extra curricula’ activity. Eventually, a compromise was reached, and three sessions were planned with fortnightly intervals between them. This took place concurrently with other course work. The student midwives were at the beginning of their third year, the student nurses at the beginning of their second year and student doctors at the beginning of their fourth year. All had reached ‘level two’ in their studies, with the nurses and doctors having arrived at a point in their curriculum where they would usually encounter
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clinical placements and theory related to the maternity services.
Recruitment Volunteers were asked to participate from all three disciplines. The total cohort of 17 student midwives all agreed to participate, and their involvement was easily incorporated into the ‘Midwife and Public Health’ module. Ten student nurses volunteered from a cohort of 40. However, only 10 students were able to undertake the module, as the cohort was divided into four groups to facilitate access to clinical placements. Despite being a much larger group, recruitment of the student doctors was initially slow, as the students already had a full timetable, hence they were reluctant to give up their free time. For this reason, a stipend of d25 was offered to all participating students (nurses, midwives and doctors) payable at the end of the study. From a cohort of 128 student doctors, 13 volunteered to take part.
Ethical considerations Ethical approval to carry out the study was gained from the School of Nursing, Midwifery and Social Work’s Ethics Committee (a sub-committee of the University Ethics Committee) before commencing the study. All participating students and facilitators were asked to sign a consent form stating that they were happy to be involved, and that they could withdraw from the study at any time. Anonymity was assured in completing the questionnaire, as all students were given a code. No midwives withdrew, but some nurses and doctors did not attend all three sessions owing to sickness, confusion about the venue and pressure of other study.
The intervention Five interprofessional groups consisting of seven to eight students and two facilitators were established as outlined above. All were given the same trigger related to maternal and child health. The trigger took the form of a scripted conversation between two fictitious health-service planners. The outcome of their discussion was the commissioning of a working party to develop a ‘User’s Guide’ to uncomplicated pregnancy, labour and the puerperium. This then became the task of each interprofessional group. Facilitators were given a Tutor’s Manual, which highlighted key points that needed to be discussed in the groups. Comprehensive resource lists were
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also available for facilitators. The venues reflected the interprofessional approach, and included teaching accommodation at the university, a teaching hospital and a specialist health clinic. Refreshments were provided for all sessions.
Data collection and analysis All students completed pre- and post-intervention questionnaires, which used open questions to ascertain their thoughts and expectations of the project before and after participation. Questions before the intervention focused on anxieties, concerns and thoughts on interprofessional working. Questions after the intervention focused on feelings about participation and any problems encountered. Students were also given a further two questionnaires before and after the intervention. This comprised 26 statements (Box 1) related to attitudes towards interprofessional teamwork, and were adapted from Wolf (1999). Two categories were devised: ‘team working,’ comprising 12 questions and ‘interprofessional’ attitudes comprising 14 questions. A Likert scale of 1 (strongly agree) to 6 (strongly disagree) was used to assess the student’s endorsement of the statement (Fink, 1995). A neutral response was not included in order to maximise responses and to avoid giving students the opportunity to avoid answering the question (Fink, 1995). Consequently, the scores for the ‘team working’ category of the questionnaire had a minimum of 12 (strongly disagree) and maximum of 72 (strongly agree). The adaptation to the questionnaire consisted of some of the stem statements being reversed. This resulted in some positively orientated reactions and other negative responses. This was to ensure that students gave a considered opinion rather than simply selecting an ‘incorrect’ or ‘correct’ response. Each questionnaire was coded to ensure that only the researchers knew the discipline of the respondent. SPSS was used to analyse quantitative data. The qualitative data from the open questions were independently coded and then categorised into emerging themes by AW and SC.
Findings Quantitative data Forty students initially volunteered to take part; 32 (80%) of these completed both pre- and postintervention questionnaires. These 32 sets of
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Box 1 Statements related to team-working and interprofessional working Team-working statements: I enjoy working within a team to solve problems I would rather make decisions in a group than work on a team I get excited about working in a group decision-making process I feel my ideas are stifled when I work in a group I only work in a group because I have to I like to work by myself I like working in groups Work teams provide the opportunity for better problem-solving than individual alone I feel free to express my thoughts in work groups I would rather solve problems alone than as part of a team Problem-solving in teams is part of my undergraduate training To be effective in my job, I need more training in group problem-solving Interprofessional working statements: I feel comfortable working in multidisciplinary teams I enjoy being requested to learn new tasks outside of my profession Performing jobs associated with other professions is frustrating Working in multidisciplinary teams is a mandatory part of today’s healthcare I enjoy sharing tasks from my profession with persons in other professions Patient-focused care decreases the quality of care I dislike working in a multidisciplinary team I prefer to work in a department composed of only my discipline rather than a multidisciplinary team I enjoy taking on new task outside my profession Being part of a multidisciplinary team motivates me Multidisciplinary health teams increase the quality of patient care In multidisciplinary teams, my talents are not used to capacity In a multidisciplinary team, I work to my potential I would like to be more involved in team problem-solving than I am Students were asked to rank these statements according to their agreement with the following: 1. Strongly agree; 2. Moderately agree; 3. Slightly agree; 4. Slightly disagree; 5. Moderately disagree; 6. Strongly disagree.
questionnaires were analysed. Of the remaining eight participants, four questionnaires were spoiled and four did not complete both questionnaires.
numbers in the sample were too small to be significant.
Qualitative data Attitudes towards interprofessional teamwork Overall, there was little change in responses before and after the intervention. The student midwives increased their post-test scores for ‘teamworking’ by two points (54–56), the student doctors by one point (54–55); nursing students increased by one point (56–57). With ‘interprofessional working’, the total scores were a minimum of 14 (strongly disagree) and maximum of 84 (strongly agree). By the end of the intervention, the student midwives had increased their scores by two points (67–69), student doctors by four points (66–70) and student nurses by two points. However, the student nurses demonstrated the most positive attitudes to interprofessional learning (72–74). Although inferential statistics were conducted on these data, the
The data from this study suggest that, overall, the process of communicating with each other during the intervention increased students’ perceived levels of confidence about communicating with women, their families and with each other in clinical practice. The themes identified from the qualitative data were (1) working in teams; (2) sharing of knowledge, skills and different perspectives and (3) trying out PBL. Working in Teams: As the following statements indicate, the students enjoyed the opportunity to work in interprofessional teams. For example, they commented that the pilot study had given them the following benefits: the chance to see that we can work together as a team and (y) we can learn from each other (Nurse 1).
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an (opportunity to) build a team working ethic for future practice (Doctor 9).
Moreover, it could help them yinteract within the hospital setting (Nurse 2).
In particular, the interprofessional learning format provided opportunities to prepare for their future professional roles in a secure and safe environment. This was illustrated by the following comment: It breaks down professional barriers to provide the best care for patients (Midwife 5).
Another student midwife stated that the project was good as it allowed the students as a whole to ‘to understand each other’s role’. These data concur with Glen and Leiba’s (2002) point that interprofessional teaching and learning increases the likelihood of students engaging in collaborative working once qualified. The students involved in this exercise seemed to be willing to listen to each other and to respect each other’s professional role as illustrated below: It has proved that we can pull together as a multidisciplinary team (Nurse 1). Better understanding leads to more mutual co-operation and respect, which in turn improves patient care (Doctor 8). (It was good to) get some idea of how much others know about my profession (Midwife 5).
These findings suggest that the aim of fostering collaborative working was achieved by facilitating appropriate attitudes (Barr, 1996), and the motivation to work with allied professionals by collaborating with them confidently and competently (Barr, 1998). Sharing of knowledge skills and different perspectives on care: These data also illustrate that sharing is a fundamental reason for implementing interprofessional learning. The following comments illustrate how the study provided the opportunity for students to reflect on each other’s perspective on care: Everybody was co-operative. People were willing to listen and learn from others. Ideas were shared from different perspectives (Nurse 2). We all had different ideas of what was important (Doctor 6).
The study also provided the opportunity for the interprofessional students to try out ideas with each other, and to discuss and debate each others’ philosophies of care. These discussions facilitated the sharing of knowledge and provided the oppor-
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tunity to explore each others’ perceptions of their role. I was not aware of the roles of midwives and I learnt a lot (Doctor 6).
Trying out PBL: The student midwives were the only participants to comment about the PBL experience. This is surprising, as the student nurses had not previously experienced PBL in their education either. However, their comments had positive and negative connotations. Some enjoyed the learning experience as this comment explains: My main reason for volunteering was to enjoy a different learning styleFI have done this (Midwife 5).
Others felt that the lack of preparation for PBL inhibited their participation in the project. This statement below explains this: Lack of familiarity with PBL caused difficulty for me and knowing that we were doing the right thing during the session (Midwife 4).
Discussion This study is only a pilot with small numbers of participating students. It is important that these limitations are recognised. The amended questionnaire of Wolf (1999) was not tested before its use, and therefore ambiguity of the questions cannot be excluded. For the student doctors and nurses, there was competition in attending all of the three PBL sessions because of their extant curricula activities (Albanese, 2000). This subsequently contributed to their non-attendance, which may have affected the group dynamics during the ‘working through of the problem’ stage of the PBL process. However, the evidence provided by the quantitative and qualitative data reinforced the learning opportunities provided by the project. The students wanted to learn together and, in doing so, benefited in several ways. The desire to learn in interprofessional teams was enhanced after completing the study. The student midwives benefited by having been given an opportunity to communicate with students from two other disciplines. Their professional knowledge was strengthened and challenged by having to explain themselves to students from the other participating disciplines. In addition, involvement in the study enhanced their negotiation and team-working skills. The findings of this small study support Brandon and Majumdar’s (1997) suggestions that PBL encourages co-operation over competition.
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The study, however, did require a considerable amount of commitment from all involved, as it was logistically complex and time consuming to plan. This is not unusual, as other authors have highlighted the need for commitment from all staff involved in developing interprofessional education in order for it to be successful (Fraser et al., 2000). The findings outlined in this paper suggest that PBL is a useful teaching and learning method to facilitate interprofessional education because of its interactive nature. Students worked together with the trigger material, which generated detailed discussion about the maternity services as a whole. However, not all of the student midwives were comfortable with the PBL learning experiences, reflecting comments reported by Biley and Smith (1999). This highlights the need for thorough preparation, and suggests that the half-day session provided for these students was inadequate for their needs. More experience in the use of this teaching and learning method was necessary. Despite the limitations, the study has provided some useful evidence from which to build future opportunities for collaborative and interprofessional education. Further consideration needs to be given to the format of such collaboration, its timing and place within the curriculum, and the degree to which it becomes a regular and integral part of the programme for all health professionals. Leiba (2002) suggests that the increasing tendency for specialised roles within individual professions increases the likelihood that a team approach to care will be required. The need for such a team approach is also deemed to be vital when coordinating the response to obstetric and neonatal crises or emergency situations in post-registration interprofessional education, and is recommended by key national audits (Confidential Enquiries into Stillbirths and Deaths in Infancy, 2000; Confidential Enquiries into Maternal Deaths, 2001). Leiba (2002) suggests that, in order to embrace this, professional roles need to converge from an early stage in their education, thus also enhancing understanding and respect for the multiplicity of professional perspectives. It would seem then, that by engaging in experience-related learning such as PBL, and examining the real world of professional work, this study provided students with a multiprofessional interactive learning experience. This was not only enjoyable, but vital to the future of nursing, midwifery and medical education. This will contribute to the future of the health services, and particularly to public health practice. However, it is recommended that further research is developed that incorporates larger numbers of students of
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differing disciplines with midwives. In particular, an increasing number of rigorous studies are required to be more confident of the value of interprofessional education (Zwarenstein et al., 2000).
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