This paper outlines the response of pre-clinical medical and pharmacy students to their first formal interprofessional education. We assessed the students’ perception of the value of IPE, learning gains and attitudes toward collaboration. We designed the conference using principles of contact theory, and employed pedagogical approaches that required balanced, collaborative input from both medical and pharmacy students. Students reported that the conference helped them to develop profession-specific knowledge and skills relevant to their future roles; in particular, medical students highlighted the acquisition of skills-based prescribing competencies while the pharmacy students highlighted that they learned about diseases and the diagnostic reasoning process. There was evidence that students had gained from the opportunity for interprofessional socialisation, learning about the roles and expertise of other healthcare professions (37), and they reported that the conference had demonstrated to them the importance of effective team work, collaboration and communication in ensuring patient safety.
We found contact theory to be an effective framework for the development of our IPE activities (30). Many of the positive findings from our evaluation came from consideration of the four core conditions proposed for effective interprofessional learning (see Table 1). Another common framework used in the analysis of IPE events is Biggs’ 3P (presage, process, product) model of learning and teaching (38). Biggs’ original model has been developed more recently for analysis of IPE (39, 40). This systems model approach explores the contextual factors that facilitate and hinder effective IPE. Presage factors include the learning and teaching context (e.g., institutional support and resource allocation), and teacher and learner characteristics including prior learning and beliefs. Process factors include the approach to learning and teaching, such as selection of teaching methodologies and facilitation style. Product is the outcome of the IPE initiative; the knowledge and skills acquired, or modification of attitude or behaviour. Principles of contact theory map onto the various components of the 3P model. We discuss our findings below within the context of these theoretical frameworks.
3P framework and contact theory
The contact theory condition of institutional support for the programme and activities (Table 1, condition 4) is part of presage. In a previous evaluation of the logistics and feasibility of the IPE conference, developed in advance of this study for timely feedback to stakeholders, we noted local institutional support as being vital to the success of the event (27). Regional and national support for the IPE conference, through involvement of professional bodies and senior NHS staff strengthened this support from authorities beyond the institutional level. Reeves and colleagues applied the 3P framework to an IPE project for community mental health teams. They identified presage factors, including lack of institutional support, as a key problem hindering the roll out of their pilot IPE initiative (41).
We considered equal status between groups in matching the year groups of the students and selection of LOs (see Table 1, condition 1). Learner characteristics are presage elements. Our approach to selection of LOs was constructivist, based on the belief that learners build new knowledge based on the foundation of what they have previously learned (42). Thus, we mapped outcomes onto the students’ stage of development and current knowledge. The approach to interprofessional learning developed was both explicit and implicit, with LOs focussed on the clinical subject matter and on IPE. The creation of explicit and implicit curriculum content was a key recommendation of Shrader and colleagues in their Interprofessional Education and Practice Guide (33). Learner expectations as well as learner knowledge are presage factors that can contribute to IPE success (41). Students generally enter IPE programmes with positive expectations, with younger students reported to be more positive in their interprofessional attitudes (43). This was our students’ first IPE experience, and our results support previous findings of initial positive attitudes towards IPE (see Table 3) (40, 44). The majority of students felt ready to engage at this pre-clinical phase of their development. Previous research has highlighted the potential benefits of early exposure to IPE (45, 46).
Students were keen to see an increase in IPE events in the curriculum (see Table 3). The conference format was developed for our pilot early-years IPE initiative, in part, as a mode of bringing together large and geographically separated cohorts of students (27). However, in line with this student feedback, the evidence ‘supports the needs for multiple exposures to maximise sustained learning and change’ (32). We need to develop frequent, smaller scale events that run longitudinally through the curriculum. In this study, we did not map our outcomes against an IPE competency framework (47). However, as our curricula develop, it will be important to do so to ensure all IPE competencies are adequately addressed (33).
In many IPE events students, participation is voluntary, which may bias towards participants already more open or amenable to IPE (40, 48, 49). Our event was compulsory, as all small group sessions in our programmes are, which should reduce this bias, although not all students chose to participate in the evaluation. We aimed to achieve equal numbers of students in each workshop. However, around 15% of medical students did not attend on the day, unbalancing numbers. Absences were presumed to be due to the conference being on the last day of term, and the day after the hand in of the last piece of in-course assessment for the year. This highlights the importance of considering all presage factors such as the timing of events in the development stage. Low numbers of medical students in some small group sessions, and a lack of engagement from others who were present was noted in the evaluation as an area for improvement. This, together with a feeling from some pharmacy students that they did not have sufficient medical knowledge before the conference, may in part explain why pharmacy students responded less positively to three of the statements evaluating the value of the interprofessional nature of conference (see Table 3).
IPE can reinforce negative stereotypes if these are enacted in the sessions (50), and negative attitudes towards medical students from non-medical healthcare students can remain unchanged or be reinforced following IPE exposure (48). Overall, our data indicate that the conference did help the students to understand the value and expertise of other professionals. However, since our study did indicate some negative experiences due to lack of engagement by a minority of students, we propose explicit teaching in advance on professional identity formation and the potential for IPE to reinforce or ameliorate negative stereotypes. This could be in the form of an online IPE tutorial that is embedded within the curricula and a prerequisite to attendance at the first shared IPE event.
Workshop tasks were designed for students to work collaboratively not competitively, on common goals (see Table 1, conditions 2-3). This co-operative approach to learning is a process factor (40). The two cohorts came to the conference with different levels of skills and knowledge; pharmacy students with knowledge of prescribing and the medical students with basic knowledge of antimicrobials. The CRA session in particular was specifically designed to require balanced but differing input from the two cohorts, such that the tasks were beyond the capabilities of an individual cohort but achievable when subject-specific skills and knowledge from each profession were combined. The success of this approach is illustrated in Figure 1, where medical students more frequently stated they learned practical skills from the pharmacy students (e.g., how to use the BNF) and the pharmacy students more frequently stated they had gained knowledge from the medical students around the diagnosis and management of infections.
The use of simulation, applied clinical cases, video-based learning and facilitation are all process factors that evaluated positively in our study. There is evidence that positive outcomes for IPE depend on students regarding activities as authentic experiences which replicate the clinical workplace and interactions (50). The SimMan Sepsis workshop was a combination of simulation, role play and interactive team voting activities; these were designed to elicit maximum engagement with the scenario and imitate the pressures and complexities of managing an acutely unwell patient (26). A review of simulation-based IPE found that most studies revealed positive outcomes related to student satisfaction and their perceptions of learning, which our study supports (24). There is evidence that simulation is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals (22). However, most studies, including ours, did not assess knowledge and skills pre- and post-intervention, nor compare these to a control group, so were unable to determine whether the perceived learning gains were achieved and were related specifically to the simulation intervention (21, 24) .
3P framework and Kirkpatrick’s educational outcomes model
The outcomes of our IPE event, the product, map to levels 1 and 2 of Kirkpatrick’s educational outcomes model (40, 51). We evaluated the participants’ reaction to the workshops, assessing their views on the content, teaching methods and organisation (Kirkpatrick Level 1). Analysis of the specific aspects of the workshops that most helped or hindered their learning is informing future development of the sessions. Specifically, we have built in more elements explicitly exploring interprofessional teamwork, and have simplified some of the clinical elements of the scenarios. We assessed students’ attitudes toward the value of interprofessional collaboration in education and patient care (Kirkpatrick Level 2a) (40). Development of an understanding of other healthcare profession roles, the importance of interprofessional communication and effective interprofessional collaboration to ensure patient safety were major themes that arose from our evaluation. We argue that this could not have been achieved as effectively in a uni-professional intervention or through solely didactic teaching.
We assessed students’ perceived acquisition of knowledge and skills (Kirkpatrick Level 2b). Students reported acquisition of problem solving and critical evaluation skills, and a wide range of knowledge including concepts and procedures related to infection management and antimicrobial prescribing. When teaching prudent antimicrobial prescribing, educators are advised to adopt a competency-based approach that develops practitioners who are knowledgeable, skilful and reflective (52, 53). Davenport and colleagues suggest that outcomes include the ability to carry out practical procedures, undertake patient investigations, handle and communicate information and facilitate the development of decision-making and clinical reasoning skills (53). These were all themes that emerged from our student evaluation, suggesting that our simulation and interprofessional workshops are appropriate approaches for teaching antimicrobial prescribing.
The major strength of the study was in the design of the interprofessional intervention. It incorporated positive contact principles and many of the features that underpin effective IPE activities as outlined by Teodorczuk and colleagues in their Toolbox article (19). These include oversight of the intervention by an interprofessional collaborative steering group, development of common learning items, focussing on authentic learning activities, training of the facilitators and coupling simulation with IPE. In addition, learning was comprehensively evaluated across both cognitive psychomotor and affective domains. A further strength of the evaluation was the use of the 3P framework which enabled a systematic exploration of factors that facilitate and hinder IPE activities.
A limitation of our evaluation is the self-perceived nature of learning and changes in attitude; we did not conduct a pre- and post-test to evidence the learning that took place. We also did not use a control group of students covering the same material in a non-simulation and non-IPE context, thus, we cannot conclude that these approaches are more effective that other traditional or uni-professional teaching approaches (24). However, for an event of this magnitude, it was unlikely that students would be accepting of being randomised to a control group for fear of missing out and issues of equity would likely arise. We did not use an established validated measure such as the Readiness for Interprofessional Learning Scale (RIPLS) to assess interprofessional learning because this study already included a large-scale evaluation of the conference format and workshops, so we developed a shorter quantitative survey on the value of IPE. This survey was informed by the RIPLS and had been developed iteratively over previous IPE evaluations at our institutions. The evaluation only assessed students’ attitudes at the time of the conference. A follow up evaluation, after they had entered the clinical years, would have enabled us to assess any impact of the conference on changes in attitude and behaviour in practice, but was beyond the scope of this study (40, 54).
Pharmacy students felt they lacked sufficient clinical knowledge before some of the workshops. Although we had designed the workshops to draw on the different strengths of the cohorts, we did not brief the student about this sufficiently. We need better signposting of professional roles in the session or more previous teaching of the clinical concepts for pharmacy students. Early IPE events before the conference, on explicit IPE themes such as teamwork or professional roles, should help integration of students at the conference.
The conference and workshops have been developed in format and content in subsequent years, due to results from this evaluation, a programme merger and curriculum renewal in the medical programme, and addition of a pharmacy programme at Newcastle University. As indicated above our study afforded learning at Kirkpatrick levels 1 and 2. The next step is to demonstrate learning at Kirkpatrick level 3. However, achieving such learning at scale is traditionally challenging. Moreover, our learners were at prequalification level. Such an approach will need to be carefully designed to achieve demonstrable, reliable and valid results in a randomised controlled trial or other experimental setting. Arguably the conference would need to be repeated to sustain learning, embedded within an IPE framework of both ‘CAIPE compliant’ (19) and non-compliant learning activities that progressively builds collaborative capabilities and underpinned with sound educational theory as described previously. Such an approach could lead to IPE success that later demonstrates changes to prescribing behaviour and potentially health benefit.