Learning Theories and Interprofessional Education: An Overview ESRC Seminar Series: 26th June 2009

Background Research evidence underpinning the drive for IPL is still growing (Payler et al., 2007; Thistlewaite, 2008) Descriptive, anecdotal & atheoretical? (Freeth et al., 2002; Barr et al., 2005; Clarke, 2006) Few interventions identify the educational theory underpinning the development & delivery of IPE initiatives (Cooper et al., 2001; Freeth et al., 2002; Barr et al., 2005) Kolb’s (1984) experiential learning cycle, adult learning theory & psychological theories of group behaviours and teamwork approaches (Cooper et al., 2001; Barr et al., 2005) and learning organisations (Freeth et al., 2002) Theory needed to guide IPE curriculum development (Eraut, 2003; Clark, 2006) It is widely accepted that… Much of the IPE literature has been described as… resulting in insufficient theory-driven guidance for growth needed in this field. It is therefore unsurprising following several systematic reviews that… in the description of the method or in the choice of outcome measures. Of the few IPE interventions that made reference to an educational theory, most were primarily based around… (andragogy & problem solving approaches) Theoretical frameworks should guide IPE programme structures and processes…to become better informed about effective learning methods.

Families of Learning Theory Behaviourism Constructivism -cognitive - social Use in IPE? This presentation will focus on the learning theories used in IPE…

Behaviourists consider that: Learning outcomes are important as opposed to the processes underpinning this learning; All behaviour is learned and all learning involves an observable change in behaviour; Adopt a positivist approach; Students’ own activity in achieving outcomes is pivotal to learning. (Jarvis et al., 2003; Armitage et al., 2003) *Bahaviourism is a psychological theory based upon objectively observable, tangible and measurable data. *It adopts a positivist stance, in which behaviourists believe that only that which can be empirically measured can be regarded as learning. Key focus of behaviourist curricula is outcome or competency driven.

Behaviourism in IPE IPE curriculum developers create an outcome based curriculum; Interprofessional competencies (Arredondo et al., 2004; Norris et al., 2005) -learning outcomes assessed and evaluated No clear reference to IPE competencies in curriculum design IPE evaluations- Kirkpatrick’s (1967) model *No publication of the use of competencies beyond HEI course approval documentation.

Modified Kirkpatrick's Model of Educational Outcomes for IPE 1 Reaction Learner's views on the learning experience and its interprofessional nature. 2a Modifications of attitudes/perceptions Changes in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude towards the value and/or use of team approaches to caring for a specific patient group. 2b Acquisition of knowledge/skills Including knowledge and skills linked to interprofessional collaboration. 3 Behavioural change Identifies individuals' transfer of interprofessional learning to their practice setting and changed professional practice. *Self report (Kilminister et al., 2004; Pollard et al., 2005; Pollard and Miers, 2008) 4a Change in Organizational practice Wider changes in the organizational and delivery of care. 4b Benefits to patients Improvements in health or well-being of patients. (Barr et al., 2000; Freeth et al, 2002; Hammick et al., 2007) *The modified version differentiated between outcomes that related to people and those that impacted upon service delivery. *These outcomes are not hierarchical; and have been used in IPE since 2000. *The majority of evaluations have evaluated changes in levels 1 & 2 of Kirkpatrick’s (1967) four level model of educational outcomes however, few studies have explicitly measured changes in level 3. In fact at each level it was considered to be progressively harder to gather reliable data related to the educational intervention. Hammick et al (2007) highlighted that owing to the time gap between students’ IPL and pre-registration qualification evaluating outcomes associated with levels 3 and 4 is challenging. *Of the few studies that have measured students’ behavioural changes, these were via students’ self report adversely affecting the validity of inferences made. *Extending the definition of competencies to include changes in attitudes towards other professions or interprofessional teamwork (see, Carpenter, 1995; Tunstall-Pedoe et al., 2003; Hind et al., 2003; Hean et al., 2006) or knowledge and attitudes towards others in relation to certain patient groups (see, Barber et al., 1997; Crutcher et al., 2004). Outcomes have been reported in levels 1, 2a, 2b

Cognitive Constructivism Concerned with the process of how learners learn; Adult learning- self directed learning Learning is within the learner’s control (Spencer and Jordan, 1999; Kaufman, 2003; Wood, 2003) Application and use of developmental theories (Paiget, 1973) *… in relation to development stages and learning styles A key component of cognitive constructivism in adult learning is… Self directed learning facilitates the integration of new knowledge and understanding into the personal and professional context of the individual to enable the development of life long skills. *Highlights the key role of IPE curriculum developers to organise learning and teaching so that… learning is within the learner’s control. *Few authors have overtly applied and used developmental theories; of the few that have Dahlgren (2006) and Clark (2006) are amongst Dahlgren (2006) drew on the Piaget’s notion of decentering’ –which mirrored the notion of ‘metacognition competence’- enabling students to become conscious of viewpoints other than one’s own.

Clark (2006) applied Perry’s (1970) theory: Ultimate Goal Accepting of the range of complementary professions required to provide holistic care; Students recognise the presence and nature of other professions. Via IPE students are offered an opportunity to expand beliefs beyond own profession *Expand beliefs beyond the supremacy of one’s own profession *Through these developmental stages it was hoped that students could reach the ultimate goal of becoming completely aware of the complexities of professional working- valuing the perspectives and contributions of their own and other professions.

IPE Curriculum Developer’s Role: Consider ways to develop students’ knowledge by activating and building on existing knowledge bases- transformative learning Consider key assumptions underlying the constructivist origins of adult learning theory (ALT) or androgogy (Knowles, 1990; Kaufman, 2003) ALT- key mechanism for well received IPE (Hammick et al., 2007) *The processes of assimilation and accommodation to acquire knowledge were fundamental in Piaget’s stage development. *Assimilation involves students taking in and filtering contextual information which subsequently interacts/ conflicts with the individual’s existing knowledge base. *In the IPE field cognitive processes Assumptions Underlying the Adult Learning Theory or ‘Andragogy’ 1 Adult learners need to know the relevance of what they need to learn before undertaking to learn it; 2 Adults prefer responsibility for their decisions and desire to be viewed as capable of self direction; 3 Adults accumulate a greater volume of experience, which represents a rich resource for learning and necessitate individualisation of learning strategies; 4 Adults become ready to learn things when they need to know them in order to cope effectively with real life situations; 5 Adults have a task centred orientation to learning and like to feel free to focus on the task or problem; 6 Students can work collaboratively and in dialogue with others with mutual trust and respect, both peers and lecturers, to shape, elaborate and deepen understanding; 7 While adults are responsive to some external motivators, their most potent motivators are internal. (Knowles, 1990; Kaufman, 2003) * Transformative learning (Mezirow, 1997; 2004) – highest potential for understanding; This emphasises the importance of curriculum developers developing learning opportunities to enable students to become more reflective and critical; more open to the perspectives of others; less defensive; and more accepting of new ideas.

Teaching methods used to facilitate adult learning: Self-directed learning (Kaufman, 2003) Problem based learning (Newble, 2002; Wood, 2003); Discovery learning (Spencer and Jordan, 1999; O’Halloran et al., 2006); Case based learning; Portfolio based learning; Project based learning; Peer evaluation; Use of learning contracts (Kolb, 1984; Brown and Atkins, 1988; Spencer and Jordan, 1999). Use reflective practitioner theory (Schon, 1984; Goosey and Barr, 2002) and experiential learning (Moon, 2004; Roberts et al., 2000). Promotes active learning grounded in learners’ past experiences: *To facilitate transformative learning an emphasis was placed on the importance of reflection in learning via the use of reflective practitioner theory…

Social Constructivism – Vygotsky (1978; 1986) D’Eon (2005): Use of IPE tasks could become progressively more complex from, for example simple paper case-based scenarios with two disciplines to very complex cases in real life settings with many disciplines Learning- mediated via socio-cultural instruments e.g. language Support systems In contrast to cognitive constructivists, social constructivists emphasise how learning is mediated by the environment where social meetings are believed to shape learners’ knowledge and comprehension (Atherton, 2005; Hean et al., 2009). IPE curriculum developers adopt a social constructivist approach via collaborative, interprofessional and situated learning. This was considered fundamental as it is this socio-cultural approach in preference to more cognitive constructivist approaches that differentiates IPL from uni-professional learning (Hean et al., 2009). *Socio-cultural instruments- language or peers; support systems (scaffolding)- IPE facilitators, e-learning etc. *students complete tasks that enables them to go beyond the ‘actual developmental level’ and into the ZPD (Jarvis et al., 2003). This enables students to develop their existing knowledge base and ‘internalise’ new information (Hean et al., 2009). As students develop a comprehensive understanding and develop into independent learners, these scaffoldings systems are removed (Vygotsky, 1978; Jarvis et al., 2003; Hean et al., 2009). *In the IPE field however, Hean et al (2009) highlighted that only a few authors (D’Eon, 2005; Hughes, 2004) had explicitly applied Vygotsky’s ZPD in the curriculum development of IPE initiatives; and no evidence was found of its use in IPE evaluations.

Social constructivism & macro level thinking: Used to inform evaluations of IPE (see, for example Robinson and Cottrell, 2005; Payler et al., 2007); Why has it not been used to inform IPE curriculum development? -HE curriculum developers- focus on micro level of learning (Hean, Craddock and O’Halloran, 2009) -Critics of activity theory (Fuller et al., 2005; Payler et al., 2007) Communities of practice (Wenger, 1998) Activity systems (Engestrom, 1999; 2004). Expansive learning –to create new knowledge & practice *Critics of constructivism and behaviourism may censure these learning approaches as they principally focus on learning within an individual or at the micro level (Hean et al., 2009). Social constructivism however, provides an opportunity to explore macro level thinking within the field of IPE via communities of practice in which learning takes place (Wenger, 1998) and activity systems (Engestrom, 1999; 2004). This enables curriculum developers and evaluators to explore students’ learning within or by a practice organisation. *At the macro level, the term ‘communities of practice’ describes groups of individuals engaged in a collaborative, mutually recognised activity that binds them together where common cultural resources are shared (Wenger, 1998). Within the IPE field this is considered to be the social environment where students learn (Hean et al. 2009). However, by subsuming this concept within activity systems it is possible to develop a macro level description of collective human activity and the learning that takes place within these. Within an IPE context, the elements included in the model of activity are represented in Figure 2 (Engeström, 1987) and are relational to each other in triangular formation. These include the subject (individual participant on an IPE programme or an IPE group); the object (the aim of interprofessional collaboration or focus of the activity); and the tools (the student-centred task completed during the IPE programme, facilitator or context specific signifiers of the placement) (Payler et al., 2007). The subject is part of a community (e.g. IPE group) from which knowledge is derived from interactions. Such interactions are shaped by rules; and a division of labour influences the way subjects act (ibid). Students’ learning of knowledge within activity systems was described by Engeström (1987) as ‘expansive learning’, particularly when contradictions between and within elements in the system act as catalysts for change and are resolved (Engeström, 2004). To create new knowledge and practice students, in a collective movement, must work through ‘expansive learning processes of openly articulating differences, exploring alternatives, modelling solutions, exploring an agreed model and implementing activities (Robinson and Cottrell, 2005). *HE curriculum developers focusing on the micro, individual level learning with explicit learning outcomes. *Critics of social practice theories- owing to the lack of analytical attention given to power relations, access, public knowledge and accountability within communities of practice (Tennant, 1997; Fuller et al., 2005; Payler et al., 2007). There is also a risk that insufficient emphasis is placed on the psychological processes and the individual (Engestrom, 1990). *Nevertheless, the notion of community of practice with an equal emphasis in the workplace (Lave and Wenger, 1991) and classroom may create conditions favourable to IPL.

Summary Insufficient rigorous research identifying the theoretical underpinning of IPE initiatives; Implications of overlooking IPE theorising; Benefits of IPE theorising Catholic approach to a whole range of theoretical doctrines is needed (Meads et al, 2003). *To overlook IPE theorising, means that no IPE curriculum model can be explained; … clearly to enable practices to be judged and/ or shared. *will improve the quality of IPE curriculum development and evaluative practice; (2) explain the curriculum & evaluation to sceptics We needs to adopt a… to enable an understanding of the complexity of IPE

Time for Reflection How can learning theory be used to inform your own work? How can you evaluate its use in practice? How can we work together to advance knowledge in this field?

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 To help understand the IPE curriculum development process, a summary of learning theories used in IPE is presented: No one particular theory is favoured over another – but it is hoped that an overview and description of the context in which different theories might be useful. (Hean, Craddock and O’Halloran, 2009)