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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context
  5. Assessment in IPL
  6. Conclusions
  7. Acknowledgments
  8. References

Medical Education 2010: 44: 396–403

Context  There is increasing agreement that graduates who finish tertiary education with the full complement of skills and knowledge required for their designated profession are not ‘work-ready’ unless they also acquire interpersonal, collaborative practice and team-working capabilities. Health workers are unable to contribute to organisational culture in a positive way unless they too attain these capabilities. These capabilities have been shown to improve health care in terms of patient safety, worker satisfaction and health service efficiency. Given the importance of interprofessional learning (IPL) which seeks to address these capabilities, why is IPL not consistently embedded into the education of undergraduates, postgraduates and vocationally qualified personnel through formal assessment?

Methods  This paper offers an argument for the formal assessment of IPL. It illustrates how the interests of the many stakeholders in IPL can benefit from, and contribute to, the integration of IPL into mainstream professional development and tertiary education. It offers practical examples of assessment in IPL which could drive learning and offer authentic, contextual teaching and learning experiences to undergraduates and health workers alike.

Conclusions  Assessment drives learning and without formal assessment IPL will continue to be viewed as an optional topic of little relative importance for learners. In order to make the next step forward, IPL needs to be recognised and endorsed through formal assessment, both at the tertiary education level and within the workplace environment. This is supported by workforce initiatives and tertiary education policy which can be used to specify the capabilities or generic skills necessary for effective teamwork and collaborative practice.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context
  5. Assessment in IPL
  6. Conclusions
  7. Acknowledgments
  8. References

This paper seeks to draw together the many threads influencing interprofessional learning (IPL) to produce an argument promoting the formal assessment of IPL both in a tertiary education context and within health services as part of established continuing professional development (CPD) programmes. For clarity of meaning, the term ‘interprofessional learning’ is taken throughout this paper to include interprofessional education (IPE) and any teaching and learning activity promoting collaborative practice. Interprofessional learning represents an overarching philosophical stance, embracing lifelong learning, adult learning principles, critical reflection and an ongoing, active learning process, across cultures and disciplines within health care.

‘Assessment’ throughout this paper refers to the practice of awarding an individual credit points, marks or a grade. This award serves as an approximate measure of an individual’s demonstrated capability in the given domain of learning intended by the education intervention. In this context assessment refers to the measurement of an individual’s capacity to behave in an interprofessional way.

‘Health worker’ is a generic term used throughout this paper to include all health professionals and support workers. The interprofessional team is made up of all those who contribute, either directly or indirectly, to the quality of patient care.

Technical expertise and cognitive intelligence in health care teams are insufficient; team members also need emotional intelligence in order to be able to work effectively with colleagues, patients and carers.1 Longstanding hierarchical and disciplinary dynamics affect the emotional climate of practice and individual ability to work safely in teams and achieve patient-centred care. A study driven by the Clinical Excellence Commission in Australia details several consistent themes from eight inquiries into adverse events in health care.2 One significant recurring theme centres upon deficient teamwork and suggests that health workers who are assessed as clinically competent are not necessarily safe to work with one another. The Bristol Inquiry in the UK pre-empted this finding, stating that health professionals needed to be educated in communication skills, teamwork and shared learning across professional boundaries in order to improve patient safety.3 Evidence that IPL improves health outcomes and patient safety is slowly building and has already been shown to be effective in reducing clinical error, improving collaborative team behaviour and supporting team culture.4

Across Australia IPL is an inconsistent entity, both within the health worker’s undergraduate curriculum and across CPD. Although communication, teamwork and professionalism abilities are accepted as important generic skills that relate to an individual’s employability, these skills are seldom specifically taught and rarely formally assessed. Often ‘communication’ is taken to mean communication between a patient and a health worker and does not include skills for effective communication between health workers.5 Tutors can often feel unprepared for facilitating IPL, but it is the effectiveness of this facilitation that is key to determining learning outcomes.6 Delivery of IPL is complex and demanding and should not be left up to a few individuals who already suffer from workload issues.

Assessment, if not thoughtfully aligned to enhance learning, can have a negative effect.7 For IPL assessment to be successfully aligned it must put aside traditional assessment methods, which tend to discourage collaboration, in favour of assessment tools which make collaboration essential. In a mixed-methods study of IPL based around resuscitation skills, the authors used an adapted ‘Leadership Behaviour Description Questionnaire’ and an ‘Emergency Team Dynamics’ scale to assess teamwork.8 They recorded the interactions and interplay between participants to help score their performance within a relevant and authentic teaching activity for all health workers. These tools could potentially form part of a formal assessment for any IPL intervention.

If the intention to move IPL into the realms of core practice for all health workers is serious, making IPL a mandatory requirement of health standards of practice, accreditation and registration, and then developing a coherent approach to the assessment, and thereby to the policy, teaching and learning, of IPL is necessary.

Context

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context
  5. Assessment in IPL
  6. Conclusions
  7. Acknowledgments
  8. References

To date IPL interventions have largely targeted undergraduate health professionals and have been presented as ‘optional’ or ‘extra’ items in already overfull curricula. Interprofessional learning is not consistently an integral part of formal teaching and assessment in any discipline. It is often evaluated in terms of student enjoyment, and the attitudes and perspectives of participating disciplinary groups and individuals. This evaluation may be useful in giving subjective feedback about the immediate effects of the intervention, but well-aligned, formal assessment is required to track the development of knowledge, skills, behaviour and performance following IPL.

Figure 1 seeks to convey a vision of the potentially positive influences which could be used to move IPL forward. Encompassing this diagram are the service users in health, who should be the primary influence for the implementation of IPL. Their stories, journeys and experiences are the initial drivers for all change in health care.

image

Figure 1.  The context of interprofessional learning. T, L & A = teaching, learning and assessment; IPL = interprofessional learning; ‘Wicked’ competencies from Knight21

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Different areas of expertise and complementary skills, knowledge and disciplinary perspectives are needed to deliver to these stakeholders the increasingly complex health services they require as a result of their more and more convoluted clinical and social problems. The stories of patients, clients and consumers in health care reveal that cohesive team practices do not naturally follow from health workers achieving clinical expertise and knowledge.9

Several powerful influences on both undergraduate and postgraduate education are beginning to realise the potential of IPL. Professional bodies endorse the need for teamwork and collaborative practice, but do not consistently and formally include IPL in their accreditation and CPD requirements, thus missing the opportunity to drive tertiary education to formally assess IPL as a standard element within curricula. The media are undoubtedly responsible for many of the stereotyped images of certain health workers and could help to redress this stereotyping through a fairer portrayal of all health workers.10 Government policy is recognising the potential of increasing the capability of all health workers and national registration presents another opportunity to embed IPL within health worker credentialing.

The effect of policy on promoting a culture of IPL can be powerful and positive. A risk management approach to health care is reflected in Australia’s policy writing and is inevitably affecting the Australian tertiary education system. A recent review of the Australian tertiary education system11 reinforces the need to develop graduates who have skills and attributes suited to effective team-working and communication skills relevant to changing health care practice. This affords a direct link between IPL and generic skills, graduate attributes, professionalism and employability skills. Employers often want some indication of how well their potential employees measure up in terms of these capabilities and health undergraduate recruitment could also benefit from this insight.

A study from Israel presents an innovative approach to the recruitment of medical students and in so doing produces some potential tools for IPL assessment.12 It is interesting to note that health professional students who fail because of inappropriate attitudes and behaviour are few and far between, despite some flawed recruitment practices.13 If this were not the case, health services might witness less malpractice.

Assessment in IPL

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context
  5. Assessment in IPL
  6. Conclusions
  7. Acknowledgments
  8. References

Figure 2 offers a more detailed vision of IPL assessment. Personal capability domains (rather than ‘competencies’) have been so named as the conceptualisation of work-ready attributes. The term ‘capability’ more readily accounts for the many-layered and multiple processes that health professionals are expected to perform in real-life work contexts.14 These capabilities are best taught in context alongside other clinical skills and knowledge, as modelled by the mixing of IPL with resuscitation teaching.8 Examples of appropriate assessment tools and teaching methods which are more likely to deliver authentic learning are offered in Figure 2.

image

Figure 2.  A more detailed examination of assessment of interprofessional learning. CPD = continuing professional development

Download figure to PowerPoint

Simulation is the ‘new frontier’ in health education as governments, health services and the tertiary sector seek a solution to the clinical placement shortage throughout Australia. In trialling a simulated ward environment, one study endorses the need to formally assess simulations in order to highlight them as important learning tools when used in IPL.15 The Israeli study cited earlier used a simulation-based assessment centre to measure interprofessional qualities in potential medical students.12 Their combined assessment model used three assessment tools to rate candidates on capabilities such as interpersonal communication. This scoring methodology is probably too complex for day-to-day assessment purposes, but the study does provide a range of assessment tools which could be adapted.

The model of formal interprofessional assessment presented in Figure 2 suggests an interactive facilitation of IPL rather than didactic teaching methods. Simulation provides such an interactive facilitation tool. The introduction of formal assessment after a simulation is made easier if video equipment and debriefing space are available; however, these are not essential. Simulation assessment could have several component parts, as illustrated in Table 1, becoming a collaborative venture in itself.

Table 1.   Example of a set of assessment tools for a simulation* designed to integrate interprofessional learning domains with technical skills
Timeline for simulationAssessment toolContentAssessment styleMark/grade
  1. * The scenario. A 52-year-old man presents to the emergency department suffering from shortness of breath and chest pain (standardised patient, briefed on history and presenting details). These symptoms were noticed as the patient participated in a community group exercise activity. The man is accompanied by his wife (facilitator, who is in possession of further information and the contact numbers of the patient’s general practitioner and community group activity organiser). Five months earlier the patient underwent a coronary artery bypass and graft and has been recovering well.

  2. The assessing team (nursing and medical staff) have access to consultation expertise via telephone, including to an exercise physiologist, pharmacist, physiotherapist and cardiologist. Telephone numbers are not volunteered by the simulation facilitators unless they are requested

  3. † Moderated result calculated for each individual team member out of 100%

Introduction and preparation of team1 hourMultiple-choice questionnaireClinical facts and management of heart disease Who is the ‘treating team’ and how do they collaborate? Risk management systems in place within the emergency departmentFacilitator marked with input from cardiologist and other clinicians20%
Simulation30 minutesObserver behind screen and facilitator roleplaying wifeUse of standardised tools to monitor interaction, communication, teamwork, participation, peer support and adherence to correct clinical proceduresVideoed for debrief Facilitator and observer complete standardised marking tools15%
Debrief after simulation1 hourFive long-answer questionsGroup discussion and viewing of video Critical reflection of self-participation and learning Individual behaviour and learningSelf-assessed10%
DebriefTwo long-answer questionsCritical reflection of a peer’s participationParticipant marks for Peer 110% (to peer 1)
DebriefTwo long-answer questionsCritical reflection of a peer’s participationParticipant marks for Peer 210% (to peer 2)
Re-run of same simulation30 minutesObserver behind screen and facilitator role-playing wifeUse of standardised tools to monitor interaction, communication, teamwork, participation, peer support and adherence to correct clinical proceduresVideoed for debrief Facilitator and observer complete standardised marking tools15%
Debrief after simulation re-run1 hourFive long-answer questions – repeat of initial questionsGroup discussion and viewing of video Critical reflection of self-participation and learning Individual behaviour and learningSelf-assessed10%
DebriefQuestionnaire administered to standardised patientPerformance of team overall from the perspective of the ‘patient’ (respect, dignity, rights, information, inclusion)Patient assessed10%

In this example the reflection and peer-assessed components are weighted to imply greater importance to collaborative practice and self-insight. The peer assessments could be cross-matched to the participant’s self-assessment for consistency. Written reflections can be assessed using an analysis of language. A recent study on reflective practice proposes a full coding framework for such a linguistic analysis.16

Collaborative study through group work has the potential to enhance a sense of responsibility engendered during learning which could carry over into the workplace where team members need to take team responsibility for patient outcomes.17Figure 2 highlights the links between group work, clear learning objectives and activities which are designed to replicate or simulate the workplace, to make the learning authentic and to encourage collaborative skills. This clear alignment and relevance can overcome the frustrations sometimes experienced by groups undertaking group work.17 Group learners are sometimes concerned that they will not be fairly assessed on their individual contributions, and this again can be overcome by the suggested combined approach to marking, utilising observer, self- and peer assessment.18 Peer assessment, in the context of IPL, should be approached as a learning exercise in itself, encouraging cooperative, rather than competitive, learning.17

Students and health workers who lack insight into their own capacity are seen as representing risk within health care. Self-assessment can develop the discipline of reflection, equipping health professionals with skills to assess their own and others’ performance sensitively and appropriately.19 Feedback on self-assessment can be particularly powerful because it represents feedback not only on a learner’s performance, but also on his or her thinking about that performance.19

It is important to distinguish IPL from problem-based learning (PBL). As illustrated in a recent in-depth analysis of PBL,20 there are now many different interpretations and practical applications of PBL. Essentially PBL was originally designed for pre-clinical medical students, for whom the presenting ‘patient problem’ formed the core learning focus.20 Interprofessioal learning applies to all health workers, at all levels of qualification, and, although the patient focus is important, has teamwork, communication and collaboration skills as its learning focus. Whereas PBL aims to apply clinical knowledge, skills and attributes to understand and evaluate individual clinical problems, IPL seeks to develop interdisciplinary communication, integration of services and sound collaborative practice.

Formal assessment allows for CPD points to be awarded, for learning pathways to be recognised and credit points towards further recognised qualifications to be gained. This process provides motivation for individual health workers. Incentives for health services lie in the accreditation process which demands evidence of quality improvement and innovation in health service delivery. Formal assessment of IPL stands as proof of increased organisational capacity and can be linked to patient safety and satisfaction. Formal assessment of IPL may help to raise awareness of the desired generic skills and create a more solid foundation for an otherwise abstract academic concept. Professional bodies, driven by the impetus to improve patient safety and quality, should also welcome an opportunity to measure and assess the capabilities of their members. By making IPL specific in terms of it becoming a formally assessed requirement, health workers will be provided with an incentive to seek out IPL in a format which is authentic to them.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context
  5. Assessment in IPL
  6. Conclusions
  7. Acknowledgments
  8. References

Many drivers already in place within both the health services (patient safety and quality initiatives) and tertiary education (employability skills and industry-required core competencies) offer opportunities to integrate the teaching, learning and formal assessment of IPL into existing curricula. This paper argues that many of the conditions needed to move IPL forward are already in place and instigating the formal assessment of IPL may provide the impetus to initiate a domino effect and lead to the embedding of IPL into learning, teaching, policy and curriculum frameworks.

Interprofessional learning assessment practices should allow for deep, rich learning experiences that encourage divergent abilities. A culture change is needed within health education, at both postgraduate and undergraduate levels, to align the teaching, learning and assessment of IPL within the workplace and tertiary education institutions. If a diverse and appropriate range of assessment methods is used, learning can be enhanced and adapted to suit the needs of both students and qualified health workers. Thoughtful design and skilful facilitation will influence the success of all IPL, but formal assessment is necessary to develop and validate IPL within health education.

Formal assessment of IPL is complex and difficult; however, this paper argues that communication, teamwork and collaborative care skills are as important as those involved in sound clinical practice. From a patient’s perspective, collaborative practice is a learning domain worth the effort of recognising and endorsing through health education and formal assessment. Interprofessional learning takes health workers out of their comfort zone and highlights the potential risks to patients unless collaborative care is delivered.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context
  5. Assessment in IPL
  6. Conclusions
  7. Acknowledgments
  8. References

Acknowledgements:  the author thanks Jo Travaglia, Centre for Clinical Governance Research, University of New South Wales, for assistance with figures and general encouragement, and Peter Donnan, Teaching and Learning Centre, University of Canberra, for comments, suggestions and general encouragement.

Funding:  none.

Conflicts of interest:  none.

Ethical approval:  not applicable.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context
  5. Assessment in IPL
  6. Conclusions
  7. Acknowledgments
  8. References
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