The application and future of key learning theories in interprofessional education

1. The application and future of key learning theories in interprofessional education Sarah Hean, (shean@bournemouth.ac.uk) Bournemouth University Deborah Craddock, University of Southampton Cath O’Halloran, University of Huddersfield

2. Current theory • IPE Curriculum design and evaluation accused of being theory less. • Scene changed over past 5 years • Turn to established disciplines: sociology, psychology and education, for theories that have utility in IPE, • Superabundance of theories of potential use in IPE research, each author with a pet approach to articulate his/her own understanding. • Theory must go beyond a list of theories and their individual application. • A heuristic, critical comparison and prioritisation of these theories is needed. • ESRC seminar series: Evolving theory in IPE http://ihcs.bournemouth.ac.uk/etipe/index.html • Before such prioritisation can take place, and to foster a heuristic comparison of these, the range of theories and the relationship between them must first be established.

3. Focus and Definitions • Review of all IPE theories is overambitious and a potentially unwieldy exercise. • Focus on learning theories. • Discussion confined to theories that seek to explore learning as defined as: • a relatively permanent change in behaviour with behaviour incorporating both observable activities along with internal processes such as thinking, attitudes and emotions (Burns 1995). • Curriculum and evaluation poorly underpinned by theory (Craddock, 2007; Payler, 2008)

4. Objectives • Identify key contemporary learning theories from education and used in IPE. • Explore their explicit application in IPE literature in either curriculum design or programme evaluation. • Present overview of learning theories as applied in IPE and their relationships with one another. • Identify areas for future theoretical development in IPE.

5. Methodology • Search strategy on interprofessional (Freeth et al., 2002) • From educational literature, identified contemporary key theories of learning. • Search IPE literature (curriculum and evaluation) for explicit use and application of these theories (e.g. learning theor*; behaviour*) • Medline 1966-2008; CINAHL 1982-2001, BNI 1964-2001 • Hand search JIPC, Learning in Health and Social care

6. Selection • Abstracts reviewed and selected on following criteria: • article related to interprofessional education, using the definition: Members (or students) of two or more professions associated with health or social care, to be engaged in learning with, from and about each other (Freeth et al., 2002). • Explicit use of key learning theory to articulate learning in interprofessional context. • Focus on student and formal education (particularly problematic at macro level of analysis) • Papers in which the learning of two or more groups with, from and about each other • Learning in HEI and practice contexts and at an individual and organisational level were included.

7. Reviewer extracted information on: • learning theory applied; • application to curriculum design or evaluation • unit of analysis: micro or macro level of learning

8. Our overview of contemporary learning theories (used in IPE) MICRO BEHAVIOURISM interprofessional competencies A ADULT LEARNING Self directed, experiential, problem based, discovery interprofessional, collaborative B-1-1 CONSTRUCTIVISM B MACRO Cognitive Developmental/stage theory Self directed, experiential, problem based, discovery B-1 Social Social conflict theory Socio-cultural learning Situated learning Collaborative learning Interprofessional learning B2 Expansive learning B3

9. Overview of Behaviourism • Early version of behaviourism described by Thorndike’s early experiments with hungry cats. • Learning occurs through experiencing the consequences of one’s own behaviour. • Trial and error may be part of such learning. • Less interested in thought processes and how learning has occurred, but focus on learning outcomes.

10. Contribution of behaviourism • Outcome based curricula and evaluation • Students’ own activity is central Criticisms • Focus on the outcomes or products of learning ignores processes. • Emphasises learning by doing. Students become involved in practicalities of experience, and fail to reflect on their actions during this process • Students may also become overly focussed on the assessment and achieving the stated behavioural objectives.

11. Application to IPE • “..need to build a set of competencies that reflect interprofessional education and practice. At the present there is no commonly agreed on set of such competencies” (Gilbert, 2008). • Norris et al. (2005): The ability to: • work in challenging situations • managing change • resolve conflict • Negotiate • Arrendo et al. (2004) • Foundational knowledge e.g. theories of interprofessional collaboration, theories of organizational behaviour). • an awareness of their own beliefs and values. • Be able to distinguish between what they know and do not know in different and contexts in terms of their abilities to collaborate. • appreciate and act on different, conflicting world views

12. Barr (1998): The ability to: • Work with other professions to assess, plan and provide care. • Describe their roles and responsibilities to other professions; • Recognise and respect the roles, responsibilities and competence of other professions; • Cope with uncertainty and ambiguity; • Facilitate interprofessional case conferences and meetings; • Handle conflict with other professions; • Curriculum • Explicit application of IPE competencies rather than competencies in an interprofessional manner: Nil • Comments • Grey literature • Role of traditional uniprofessional staff development in curriculum design

13. Evaluation • Kirkpatrick’s model of evaluation (Freeth et al., 2002). E.g. one of levels is measurement of change in attitudes, acquisition of knowledge. (McNair et al 2005)(Carpenter et al. 2005) • If broader definition of competencies includes student attitudes and knowledge as well as behaviour then there are several instances in which competences have been incorporated into evaluations. E.g., changes in students’ attitudes are seen as IPE learning outcome monitored in several evaluations (Hean et al, 2006; Mandy et al, 2005; Hind et al., 2003). • Model of evaluation focusing on measurement of learning outcomes alone and any process measures are excluded.

14. Gaps • Lack of measurement of actual behaviour (Barr et al., 2006): • Much on changing attitudes but little on changing students’ actual behaviour. • some few exceptions include: • Self reports of their developing interprofessional competencies and interprofessional confidence and involvement (Mcnair et al., 2005). • suggest that facilitator observation of student working be included in future measurement of behavioural change • collects students ‘self reports of their own communication skills (Pollard et al (2006) ) • Dearth because measurement of behavioural change in IPE programmes (team work behaviours) are hard to identify and measure effectively.

15. Overview of Constructivism • Articulate the processes of learning • Emphasise the importance of personal experience and interpretation of learning. • Students construct new concepts based on current knowledge • Curriculum should build on what they have already learned. • cognitive constructivism • concerned with how learners comprehend things/cognitive structures (Dewey (1966) and Piaget (1973). • higher order skills such as problem solving and the development of insights (Burns 1995). (Atherton 2005) • social constructivism. • Social constructivism emphasises how social encounters influence learners’ meanings and understanding (Atherton 2005). • Learner is more actively involved in the of constructing new meaning in a collaborative enterprise with the tutor (Atherton 2005).

16. Contribution of Cognitive Constructivism • Curriculum needs to take account of students’ existing knowledge. • Advocated importance of activity, experience and self direction in development. • Adult learning theories (Experiential learning (Kolb, 1984); Inquiry based learning) • Developmental/stage theories and processes of assimilation, conflict and accommodation, social conflict (Piaget) • Stages translated into moral and ethical development

17. Application to IPE Curricula: • Cognitive constructivist approach manifest in numerous descriptions of experiential, inquiry based learning etc in IPE curricula . • Hughes et al. (2004) describes a third year undergraduate online interprofessional module, UWE. • An inquiry based learning approach was taken to this initiative but the theories of Piaget, Vygotsky and Schon are integrated into the design. • Good example of using bits of theory from tool kit • Students given the opportunity to revisit and rework initial submissions of group work in an iterative process. • Hereby successive layers of knowledge added to existing knowledge through each cycle of the process. • In keeping with Piaget’s processes of assimilation or accommodation of new knowledge.

18. Evaluation • Realistic method of evaluation (Pawson and Tilley, 1997) in which mechanisms and processes are addressed in the evaluations of IPE modules (Clarke et al., 2005).

19. Application to IPE of developmental theories • Theoretical development of theory • Daghlen(2006): Stages of interprofessional development and decentering. • Clark (2006): 4 stages in their development of interprofessional knowledge and values. These stages were termed dualism, multiplicity, relativism and commitment to relativism. • a commitment to relativism, in which they are prepared to take a stand or a particular perspective but are aware that this perspective is governed by a system of value and belief systems and recognise that others may also have committed to a different but equally valid perspectives based on their own value and belief systems. • Explicit reference in curriculum design and evaluation to measure of stages of development: Nil;

20. Contribution of Social constructivism Socio cultural learning theory • Developed mainly through work of Vygotsky • Student Learning is mediated by through socio cultural tools such as language • Description of Zone of Proximal Development • Scaffolding

21. How have theories been applied in IPE • Zorga (2006) • describes a developmental–educational model of professional supervision in practice. • The supervisor mediates the learner’s reflection on a work issue from which they wish to learn/develop. The process of supervision is seen as a cultural product that can accelerate learning across the ZPD, a form of scaffolding for the learner under supervision. • Inter-dependnce is not encouraged and the supervision sessions are finite in order that scaffolding can be removed once the subject has developed sufficiently. Hughes et al (2004) • Describe the interactions between peers and peer review activity within a virtual IPE programme. • Describe this in terms of Vygotsky’s ZPD.

22. D’eon (2005) • Practical means of scaffolding applied to IPE. • They propose a range of increasing complex learning tasks for students must work through. • These tasks become progressively more complex in two ways: • from paper based scenario to real life setting. • From simple interaction between two professionals, to a case in which a range of professionals are involved. • When scaffolding is removed (i.e., the tasks are completed) students should be able to apply or transfer their interprofessional learning “to novel cases and situations”. • Evaluation: Nil

23. Gaps • Move adult learning theory theories from a “how to” to a “ a why to”? • Need to develop ideas of stages of IPE development beyond theoretical applying this to curriculum development and evaluation. • Need to increase prevalence and develop ideas of scaffolding, ZPD into curricula design and evaluation, e.g. e-learning as a scaffolding, an exploration of peer lead or tutor lead discussions.

24. Criticism • Concentrated on individual as unit of analysis

25. Macro level of analysis: • Communities of Practice (CoP): situated learning • Activity theory: expansive learning

26. CoP and Situated learning • Communities of practice are groups of individuals engaged in joint activity, one that is mutually recognised, an activity which binds them together and one in which common cultural resources are shared. Situated learning occurs within these CoP. • Focus of study was learning and student learning, therefore initial searches on situated learning. Broadened search to include “Communities of practice” • Showed increasing popularity to describe working in health and social care in terms of CoPs • Frequently CoPs used structurally to articulate how people work together rather than specifically addressing knowledge creation or learning that occur within them. • If student learning is a focus, and employed to frame student learning experiences in practice, then it focuses on professional learning of a single profession rather than the interprofessional takes place in practice simultaneously.

27. Greater complexity • An evolution of Vygotsky’s triangle of individual activity (mediated by cultural tools) into a description of collective human activity (2nd and third generation).

28. Expansive learning takes place within these collective activity frameworks. • Expansive learning takes place when contradictions in activity system occur. • Knowledge is unstable, unidentifiable and not understood. Is generated by joint activity

29. Application to IPE • Curricula: • Moving away from issues of curricula as no longer about individual learning; • Engestrom (2001) (Child care in Helsinki)

30. Examples of situated learning and expansive learning Research • Robinson and Cottrell (2005): (not strictly speaking student learning) • An investigation of evaluation of decision making and knowledge sharing in multi-agency teams. • Explore the professional knowledge generated, learning and ways of working created as result of being part of this activity system. • Phase1 applies Wenger’s (1998) constructs of participation and reification; Phase 2 and 3 guided by learning cycles, conflicts and resolutions in service delivery. Evaluation: • Payler et al., 2007 • Evaluation of a IPE CPD intervention; • Used activity theory in relation to other theories to create a matrix with which a pedagogic evaluation of the latter was to be constructed.

31. Criticism • Ignores processes within the individual • Over simplistic (CoP). • Cop does not look at dimensions of Power • Practice learning can be idealised

32. Conclusions • Conclusion: there is scope to apply theories of situated learning and CoPs; expansive learning and activity theory more rigorously to articulate student’s interprofessional learning in practice. • Should guide curriculum design as well as evaluation

33. Overall conclusions • Understanding of evolution and connectedness of theories helps position ourselves as practitioners. • Lack of theoretical underpinning limits potential of educational interventions (e.g. assessment opportunities) and their evaluation (see Mikkelson Kyrkebo et al., 2007) • Contemporary learning theories in education are being reflected in interprofessional education also • Theory as a political tool • Theories are not mutually exclusive but have a different emphasis • Much overlap between theories: learning by doing, student centeredness are key

34. Cont…. • IPE evaluation focussed on measurement of stereotype change • Positivist back ground • Outcome orientated: behaviourist • Moved into social psychology • Focussed on the individual • Theories in which the social context of learning and working is recognised are key. E.g., activity theory and socio-cultural learning took precedence over other learning theories. It is this nature of this component that differentiates interprofessional from uniprofessional learning.

35. Specific conclusions • Interprofessional competencies not translated into curriculum design • Need to increase and improve measurement of interprofessional behaviours and competencies • Adult learning can be subsumed under constructivism: • cognitive (e,g, experiential learning) • sociocultural learning (e.g. collaborative learning) • Adult learning theories need to progress from “how” to “why” application. • Theory needs to go beyond absence or the single sentence with no further development • Altogether better health conference encouraging. • Ideas of interprofessional stage development needs to move from theoretical to curriculum and evaluation applications e.g. how to measure students’ stage of interprofessional development and enable them to progress to a stage of commitment to relativism.

36. And finally… • After some neglect, theory is moving towards socio cultural and more meso level stages of analysis but this is changing. • Ideas of scaffolding and ZPD could progress further to explore, understand and improve our educational practice using scaffolds such as e-learning and mediating learning through peer and tutor facilitated e-learning; • Greater application of issues of expansive learning and third generation activity systems to IPE curricula and evaluation (see Payler et al., 2007)