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The application and
future of key learning
theories in
interprofessional
education
Sarah Hean, ([email protected])
Bournemouth University
Deborah Craddock,
University of Southampton
Cath O’Halloran,
University of Huddersfield
www.bournemouth.ac.uk
Current theory
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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
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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.
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)
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.
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 19642001
• Hand search JIPC, Learning in Health and Social care
Selection
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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.
Reviewer extracted information
on:
• learning theory applied;
• application to curriculum design or evaluation
• unit of analysis: micro or macro level of learning
Our overview of contemporary learning
theories (used in IPE)
MICRO
ADULT LEARNING
Self directed, experiential,
problem based,
discovery
interprofessional, collaborative
B-1-1
BEHAVIOURISM
interprofessional competencies
A
CONSTRUCTIVISM
B
MACRO
Expansive learning
B3
Social
Social conflict theory
Socio-cultural learning
Situated learning
Collaborative learning
Interprofessional learning
B2
Cognitive
Developmental/stage theory
Self directed, experiential,
problem based,
discovery
B-1
Overview of Behaviourism
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Early version of behaviourism described by Thorndike’s early
experiments with hungry cats.
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Learning occurs through experiencing the consequences of
one’s own behaviour.
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Trial and error may be part of such learning.
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Less interested in thought processes and how learning has
occurred, but focus on learning outcomes.
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.
Application to IPE
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“..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
• 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;
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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
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.
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.
Overview of Constructivism
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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.
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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)
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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).
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
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.
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).
Application to IPE of
developmental theories
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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;
Contribution of Social
constructivism
Socio cultural learning theory
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Developed mainly through work
of Vygotsky
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Student Learning is mediated
by through socio cultural tools
such as language
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Description of Zone of Proximal
Development
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Scaffolding
How have theories been applied in
IPE
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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.
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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:
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• 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
Gaps
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Move adult learning theory theories from a “how to” to a “ a
why to”?
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Need to develop ideas of stages of IPE development beyond
theoretical applying this to curriculum development and
evaluation.
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Need to increase prevalence and develop ideas of
scaffolding, ZPD into curricula design and evaluation, e.g. elearning as a scaffolding, an exploration of peer lead or tutor
lead discussions.
Criticism
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Concentrated on individual as unit of analysis
Macro level of analysis:
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Communities of Practice (CoP): situated learning
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Activity theory: expansive learning
CoP and Situated learning
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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.
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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.
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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.
Greater complexity
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An evolution of Vygotsky’s triangle of individual activity
(mediated by cultural tools) into a description of collective
human activity (2nd and third generation).
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Expansive learning takes place within these collective activity
frameworks.
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Expansive learning takes place when contradictions in activity
system occur.
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Knowledge is unstable, unidentifiable and not understood. Is
generated by joint activity
Application to IPE
• Curricula:
• Moving away from issues of curricula as no longer about
individual learning;
• Engestrom (2001) (Child care in Helsinki)
Examples of situated learning and
expansive learning
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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.
Criticism
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Ignores processes within the individual
Over simplistic (CoP).
Cop does not look at dimensions of Power
Practice learning can be idealised
Conclusions
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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.
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Should guide curriculum design as well as evaluation
Overall conclusions
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Understanding of evolution and connectedness of theories
helps position ourselves as practitioners.
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Lack of theoretical underpinning limits potential of educational
interventions (e.g. assessment opportunities) and their
evaluation (see Mikkelson Kyrkebo et al., 2007)
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Contemporary learning theories in education are being
reflected in interprofessional education also
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Theory as a political tool
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Theories are not mutually exclusive but have a different
emphasis
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Much overlap between theories: learning by doing, student
centeredness are key
Cont….
• IPE evaluation focussed on measurement of stereotype
change
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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.
Specific conclusions
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Interprofessional competencies not translated into curriculum design
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Need to increase and improve measurement of interprofessional
behaviours and competencies
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Adult learning can be subsumed under constructivism:
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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.
And finally…
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After some neglect, theory is moving towards socio cultural and
more meso level stages of analysis but this is changing.
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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;
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Greater application of issues of expansive learning and third
generation activity systems to IPE curricula and evaluation
(see Payler et al., 2007)