Discussion Paper - (2012) Volume 20, Issue 3
Senior Lecturer, Medical Education and General Practitioner
ES Anderson
Senior Lecturer in Shared Learning
Department of Medical and Social Care Education, University of Leicester, UK
Received date: 9 January 2012; Accepted date: 22 March 2012
BackgroundThis paper places the importance of evidence-based models of inter-professional education (IPE) within the context of a changing National Health Service (NHS). The coalition government has placed integrated care at the heart of its vision for England’s health system. Its principles are to put patients at the centre of the NHS, empower clinicians to lead commissioning and change the emphasis of measurement to quality clinical outcomes. As a result, NHS services are being increasingly tendered along evidence-based care pathways and commissioners are introducing payment by results tariffs, requiring providers to achieve quality outcomes as a requirement of full payment. Aim We argue that in preparing the health and social care workforce for outcome-based practice, the development of technical skills should be complemented with skills for effective team working and collaborative practice. MethodsThis paper shares the achievements of the Leicester Model of IPE which is underpinned by theoretical models of learning and implemented entirely in clinical practice; mixed research methods demonstrate that its learning potential is as relevant today as when it was first implemented in 1996. ResultsOur extensive research evidence demonstrates that students and healthcare professionals undertaking these programmes are enabled to perceive care pathways from service and providers perspectives; they gain valuable insights into how teams balance task- and patient-related issues, offer clarity about the team’s effectiveness and gain new insights into collaborative opportunities to address patients’ needs. ConclusionWe demonstrate that models such as ours offer evidence-based solutions which will support the achievement of quality outcomes for service providers, many of whom are reviewing their business plans to address the financial implications of payment by results. The current NHS reforms provide a hugely important lever in which IPE can come of age – in return we need to ensure that our NHS colleagues are informed of its potential.
evidenced-based model of education, general practice, interprofessional learning, prac-tice-based, primary care
Following decades of innovation, interprofessional education (IPE) as defined by the Centre for the Advancement of Interprofessional Education in the UK (CAIPE),[1] has become a national and inter-national priority.[2,3] In practice, however, IPE remains a ‘Cinderella’ subject, a ‘bolt-on’ instead of an integral part of every healthcare professional’s training and continuing development.
The General Medical Council (GMC) states that medical students ‘must ... work with and learn from other health and social care professionals and students’; their directives are less clear on how the knowledge, skills and attitudes relating to teamworking and collaborative practice should be achieved and assessed. A large variability therefore exists between medical schools concerning how students are prepared for teamworking and collaborative practice and indeed whether it is assessed at all, with few developing an integrated IPE curriculum.[4,5] The journey to main-stream IPE within medical education therefore re-mains in its infancy.[6]
Once qualified, doctors are expected to develop relevant knowledge, skills and attitudes to work with colleagues from other professions and deliver efective interprofessional practice.[7] This is reinforced within the Foundation Programme where, for example, team-working is assessed through a 360-degree appraisal, while training for general practice demands appreci-ation of teamworking.[8]
There is increasing evidence of the benefits of inter-professional practice for team effciency and IPE for preparing students with the right knowledge, skills and attitudes to work collaboratively.[9–11] Yet despite this evidence, scepticism remains concerning IPE’s potential to improve patient outcomes. This may be related to conceptual misunderstandings of inter-professional terms and activities, as well as the prac-ticalities of its organisation and delivery.[12,13] Robust IPE theory, research and evaluation is beginning to emerge and long-term studies are only just being published.[11,14,15] Much of this disparity results from the lack of agreed theoretical understanding of what constitutes an efective IPE curriculum and how and why this learning should take place.[16] Consequently, there are few agreed assessment measures which endorse and ensure progression for professional practice, espe-cially in medicine.[4,17]
Within the NHS, the emergence of evidenced-based care pathways and payment by results increases the challenges on healthcare providers to deliver effcient, ‘evidenced’ quality outcomes.[18,19] With full payment dependent on measured outcomes it is no wonder that many providers are reviewing their current business models, concerned about phasing of cash flow and the realistic likelihood of financial claw-backs if quality outcomes are not achieved.
The challenges and financial risks placed on the healthcare providers bring new opportunities for advo-cates of IPE since we can ofer some relief. Providers will need to develop their current workforce for this new environment, however, technical skills alone will not address the wider requirements of delivering safe and efective patient care; a truly integrated inter-professional team can consider solutions to service delivery and enable teams to practice in effcient new ways.[20]
The Leicester Model of IPE (LMIPE) is one of the early entrepreneurial developments which has been hard to mainstream.[16,21] Nevertheless, we have man- aged to achieve a great deal over the last 12 years, which places this model in a pivotal place to become endorsed as relevant for any integrated IPE curricu-lum, whether for undergraduate studies or profes-sional practice. We will outline how the model can help teams identify their strengths and weaknesses in order to enhance effciency and efectiveness and improve patient outcomes.
The Leicester Model of IPE
The model delivers quality interprofessional learning (IPL) which adheres to the principles of IPE set out by CAIPE.[1] How does the model work? In essence, the LMIPE enables a robust examination of the quality of patient care by combining patient and professional perspectives of what is actually happening at any moment in time as the patient progresses along a care pathway. Practically, it uses a step-by-step ap-proach to re-examine the patient journey using ex-periential learning, enquiry through case analysis, application of evidence to practice and reflection. The outcome is to arrive at a new understanding of patients’ problems. The learning takes place in a dynamic clinical environment in which the student team and the patient’s current professional team, work and learn alongside one another. Together, through the educational process, they arrive at new knowledge and understanding to improve patient outcomes. Insights are achieved relating to teamworking and practical solutions to problems are identified along the patient care pathway.
Courses are structured into cohorts of 24–36 students who work together in interprofessional groups of four. The programme commences with an induction and group work preparation. Each small group interviews a patient in their home to understand medical and social care issues impacting on their physical, psycho-logical and social functioning. The patient’s priorities and attitudes are explored alongside their relationship with the services involved in their current care. The group then interview the workers of three or four agencies providing care to their patient to explore the strengths and deficiencies of the service, and to com-pare service priorities with those of their patient. Facil-itated by experienced clinical and academic tutors, the student group reflects on each interview to prioritise the issues identified. The education cycle is completed with groups presenting their care management sol-utions to members of the patient’s current profes-sional team, including their managers. The learning cycle is outlined in Figure 1.
Figure 1: Synopsis of the model adopted from the Kolb learning cycle23
Underpinned with robust ethical principles, the model permits active team membership, facilitated through the supervision of a clinical and academic team. It highlights how, when and where team members should work together to efect care through service delivery and design which can focus on the individual, team or health and social care system (Box 1).
Box 1: Achievements of the Leicester Model
The model uses a constructivist approach to learn-ing and adopts a cyclical advance following the stages of the Kolb learning cycle.[22,23] Using reflection, it prepares teams to re-examine their care through patients’ experiences of services and addresses the realities of team-based care delivery.[24] Placing the learning at the point of delivery of care ensures social learning and an appreciation of processes of reflection within a community of practice.[21,25]
The LMIPE is an analytical process which ofers a tool for practitioners to assess the quality of their individual and collective practice. The tool can be used by any team member as well as for undergraduate and postgraduate learners. The model has been shown to identify:
• operational issues within team processes
• practical problems of delivering care
• cost saving, patient-centred outcomes
• wasted resources, for example, repeated assess-ments
• hidden or unexpected issues.[26,27]
Over a 10-year period we have evaluated the impact of the learning model using quantitative, qualitative and mixed methods, which are outlined and shared in this paper, and we direct the reader to the published papers for further clarification of these methods.
Achievements of the model over 12 years
The LMIPE has been adapted for learning for under-graduate and postgraduate students. Following its origins in primary care, the model has been success-fully applied to acute hospital care, community rehab-ilitation hospitals and within mental health teams.[26–28] The model has also been successfully reproduced and implemented across the UK and internationally. Ro-bust educational research has continued to shape its design and adaptability for learning within a range of clinical teams.[16,26–28] Outcomes impact upon patients,professionals, healthcare teams and learners. Patients feel they are contributing to developing better services and they enjoy sharing their experi-ences. Many reflect that having students consider their needs has boosted their morale. Although never acknowledged during consent, patient participation has brought about improvements in their treatment and care. A longitudinal examination of the original learning based in inner-city primary care has ident-ified significant impacts of the learning model on patient outcomes and will be submitted for publi-cation in 2012.
Professional and front-line agencies are driven to keep up-to-date as students challenge their knowledge. Many report actively widening their skills and knowl-edge base because of these challenges. For others there have been opportunities for career progression as several have taken up opportunities to become clinical teachers. Many report a sense of fulfilment despite often finding the analysis of their practice challenging. All value the student insights into patient situations especially because they rarely have enough time to achieve such detailed analysis or time to listen to family’s and carers’ insights.
Healthcare teams widen their local referral networks with statutory and voluntary agencies in the commu-nity and hospital as a result of the student analysis, which frequently generates recommendations for wider multidisciplinary support for patients. Healthcare teams value student input as a fresh pair of eyes, often providing new information about the patient and family. In one hospital setting, students frequently ensured safer discharges from hospital because they had had time to listen to family issues.[26] Others stated that the students brought fun and encouraged team cohesion. For some clinical teams, this was the first time they had engaged with students and as a result staf felt valued and motivated. All stated the useful-ness of the student’s feedback presentations.
Learners endorse the LMIPE as relevant for inter-professional learning. Students developed skills in communication, particularly when challenging each other’s perspectives or in preparing feedback assess-ments. They demonstrated an appreciation of the value of collaborative practice by seeing health teams work-ing alongside social care, education, policing and volun-tary agencies. Students positively commented on the opportunity to participate in clinical decision making by contributing their insights and influencing patient management plans.
Applicability of LMIPE: an example of use for post-qualified learners from primary healthcare teams
From 2002 to 2005 we applied the LMIPE to a range of recently qualified professionals including trainee gen-eral practitioners (GPs), student health visitors, prac-tice nurses and newly qualified social workers. The model proved to be valuable for preparing these learners for the collaborative team-based practice which would be expected of them in their future practice.
These findings have been presented at national con-ferences and we present them here, together with the key lessons concerning sustainability for post-quali-fied IPE. This course also created a lasting education partnership between the University of Leicester, De Montfort University and Leicester City Social Services.
The learning consisted of a two-day programme in which small mixed professional student teams worked together with a patient living in a socially dis-advantaged area. They progressed through the learn-ing cycle, however, in contrast to our undergraduate programmes, these postgraduate learners additionally explored theoretical principles of teamworking, and were given an opportunity to complete a team analysis using the Myers Briggs test.
Course evaluation consisted of a semi-structured questionnaire distributed pre and post course. Scored questions using a five-point Likert scale related to the nine learning outcomes, where one indicated little learning and five a great deal. Open questions asked for analysis of the value of the programme for prep-aration for practice.
Of the 214 learners (Table 1) the pre and post scores showed a significant self-perceived knowledge gain for all nine learning outcomes, for all professional groups (p <0.005 to p<0.001, Wilcoxon paired signed rank non-parametric test, two-tailed). This is in-line with our other reported evaluations.[16,28]
Table 1: Course participants
Analysis of the free-text comments for themes did not identify any negative outcomes. Learners gained insights in the importance of interprofessional collab-oration and teamwork as shown by these representa-tive comments:
‘I have been able to examine my role and function within a team.’ (student district nurse)
‘I have been reminded of the importance of communi-cation within teams aiming for the same goal.’ (student health visitor)
‘I will consider more appropriate referrals and use of allied services.’ (GP trainee)
‘Helped me to work more efectively in a team.’ (GP trainee)
‘I have become more aware of the interprofessional approach and its benefits to service users.’ (first year social worker)
Learners felt inspired to promote teamwork, improve interagency communication and make greater use of allied services. They listened to and positively regarded each other’s professions and were able to compromise to address the challenges of delivering integrated clinical services. Ultimately, they were helped to reflect to consider the value an interprofessional approach to benefit patients.
The course required curriculum alignment across many programmes and for this reason it was diffcult to sustain when new curricula emerged. The oppor-tunity for these post-qualified students to learn together interprofessionally prior to working in multidiscip-linary healthcare teams should be mandatory in our view.
As the NHS Health & Social Care Bill progresses through its readings in the House of Commons the architecture of the NHS continues to change and clinician-led commissioning is well on its way to implementation. Payment by results may well turn out to be the lever that IPE has been waiting for in order to transform from its Cinderella-like status to mainstream for the continuing development of NHS teams.
The LMIPE ofers a valid approach for learners and all professional practitioners to analyse and propose improvements for patient-centred teamworking. It acts as a catalyst for healthcare teams to review their current activities in order to improve patient outcomes. In some recent adaptations, patients have formed part of the feedback process.[29]
We can demonstrate that the LMIPE robustly demonstrates improvements in outcome-based team-working, and we therefore postulate that investment in training teams across care pathways will not only improve outcomes, but will also facilitate delivery of financial effciencies and provider sustainability.
We now need to increase our engagement with healthcare commissioners and providers. They should be informed about the benefits to service delivery that IPE can bring and advised on the logistics of applying IPE models of learning in operational practice.
We believe that evidence of IPE should be a re-quirement of all new care pathway tenders; however, to mainstream this aspiration the research rigor which underpins the development of evidence-based com-missioning should be evident in our educational re-search. The research agenda should increasingly reflect the outcomes expected of the NHS workforce in terms of patient engagement, integrated care, quality out-comes and cost-efficiency.
The LMIPE is but one of several working within practice settings. We are ready to graduate and be-come an essential resource to enable efective clinical teamwork.
Unfunded.
Commissioned, not externally peer reviewed.
Conflicts of Interest
None.
