Abstract
Interprofessional education within a team is a concept that is readily occurring within clinical dental practice, however, the theoretical underpinnings are rarely understood. Now more than ever, dental healthcare professionals are required to deliver holistic care planning for patients working collaboratively and synchronously with other healthcare professionals. This paper highlights the importance of understanding other team members’ ethics, values and beliefs as well as their remit to effectively communicate and collaborate to elevate a positive experience for both the patient and the clinician.
Learning Objectives
To critically evaluate current interprofessional education systems in place
To apply interprofessional education to a clinical setting and enable colleagues to work effectively as a team
To facilitate positive and effective communication within the dental team
Introduction
Interprofessional education (IPE) has been emerging on the forefront of healthcare education for several years. With the emergence of a holistic approach to patient care whereby all areas of patient care are encompassed in a single care plan, it has become increasingly paramount that all members of the healthcare team work together in the best interests of the patient. For this to occur, educational institutions and healthcare services have recognised the need for all members of the team to be educated together to deliver this holistic care to a patient.
A review of the literature in the context of dentistry highlighted a gap in the approach to educating several members of differing specialities and remits within the team. A literature search was done on Science Direct, PubMed, Taylor and Francis online and Wiley, and a review of the papers from 1991 onwards was conducted.
Buring et al (2009) 1 defined IPE as a pedagogical approach for enabling students within the healthcare professions to provide patient care using a collaborative team approach. The idea being that when all members of a team are utilised in a given healthcare plan, we gain maximum benefit for the patient concerned. In dentistry alone there are many members of the team that are critically involved in the care of a patient. Not only are there immediate contenders in a single treatment approach, for example dentist and dental nurse, there are also a lot of team members external to this situation who are highly involved in the care for a particular patient. A patient may attend a routine examination and be referred on to have hygiene treatment with a hygienist and extractions by an oral surgeon in hospital, all alongside continuing restorations with the general dental practitioner who first saw them. All these team members need to communicate with each other and work collaboratively for the patient to gain the best level of patient care.
As dental healthcare professionals, we must all abide by the General Dental Council’s Standards of Dental Practice. 2 The GDC is our governing body and as such sets out nine principles as a guidance to what is expected of us. Of the nine principles in question, principle six states that we must have the ability to work with colleagues in a way that is in the patient’s best interests. Principle six then goes on to elaborate that:
All dental professionals must work effectively with colleagues and contribute to teamwork
All dental professionals must communicate effectively with other team members so as to act in the best interests of the patient2
Hall (2005) 3 identified that although IPE aims to better patient care, what tends to happen is that two professions are thrown together without any prerequisite and are expected to collaborate without prejudice. What we as educators fail to see is that each healthcare profession has a different culture which includes values, beliefs, attitudes, customs and behaviours. When approaching other students, learners are already immersed in the knowledge and culture of their own professional beliefs and fail to adapt to the culture of their peers. This led to the realisation that different specialities in the same field can enter an IPE task of joint seminars with differing beliefs and attitudes. In the past, this has led to a reduced participation from one or both peers. This could be avoided if both team members were educated in the beliefs, attitudes and knowledge of each other prior to entering the integrated teaching session and can only be achieved if IPE is introduced earlier.
Hall and Zierler (2015) 4 state that with the increasing drive for IPE in the healthcare sector, many educators feel ill-prepared to face the challenges of this addition to the curriculum. A lack of tutor training on facilitating IPE means that tutors feel less able to mediate and/or direct. Hall and Zierler 4 advise that adaptation of the current curriculum within a school to fit local context may also aid in facilitating IPE. In other words, there is no point having a standard IPE module that we use to teach all professionals from any sector. It would make more sense to cater the module to each sector and teach it as a prerequisite to entering the integrated scenario. Furthermore, ongoing coaching/mentoring of both learners and tutors were key to the success of the activity. 4
Biggs (1993) 5 identified a three-stage model to visualise interactions between trainers and learners. The model identifies a three-stage process of presage, process and product, and identifies the expectations that trainers and learners have of the teaching and learning process. Presage refers not only to students learning in terms of prior knowledge, abilities, values, expectations and competence, but also the tutor’s (and institution’s) previous knowledge and beliefs. Both bring to the table their own values and beliefs which can affect the whole process. Biggs’ idea insinuates that presage will affect the process which, in turn, will affect learning and instigate either superficial or deep learning.
If we apply Biggs’ model to the co-education of two different professional students in a session, it becomes apparent that in the past, neither had a clear understanding of each other’s roles and beliefs. It would be beneficial to begin with IPE of students much earlier so that they can educate each other on their respective remits. In line with Biggs’ model, this will encompass identifying each other’s values and ethics. It will also demonstrate where roles and responsibilities lie and will hopefully open up avenues for improved and effective communication.
Steadman (2006) 6 found that simulation based learning was far superior to problem based learning in acquisition of management skills for a scenario. Further to training sessions on acquiring knowledge on each other’s roles and responsibilities, a simulation based IPE activity would ensure that all team members further understood each other’s roles and were able to practice working as a team before entering a professional setting.
Prosser and Trigwell (1991) 7 and Ramsden (2003) 8 have found that students’ approaches to learning are influenced by their prior experiences in teaching and learning. Ballard and Clancy (1997), 9 identified that ‘teachers, too, are shaped by their own cultural experience’. It therefore becomes apparent that it is the role of the facilitator to ensure a favourable team approach to IPE.
Ruiz (2012) 10 stated that facilitators should aim to encourage group discussion in IPE driven activities, whereby learners take ownership of the discussion. It is the hope that this encourages learning with, from and about each other. Sargeant et al. (2010) 11 elaborated that this interaction between learners in IPE is the key to a successful learning environment and it is the job of the facilitator to enable this. Sargeant goes on to say that fostering interaction between team members is crucial for knowledge gain about their roles, experiences, responsibilities and vales. 11 It would, therefore, have been valuable if the clinical tutors who are supervising IPE sessions on the clinic received some form of training on successful facilitation of such sessions. Furthermore, as Sergeant identified with the IPE facilitation scale, tutors can place themselves on the scale to see where they can improve their practice.
Thistlethwaite (2014) 12 further corroborates that health professionals need help and support to work in a collaborative practice team. There needs to be a common framework that both disciplines follow that enables them to understand and implement teamwork. There also needs to be a unified competency framework that is uniform to both disciplines for harmony to exist and progress to occur.
Biggs (1996) 13 highlighted that in order for teaching and learning to align so that there is a deep level of understanding from the students, there needs to be clear set outcomes at the outset which assessments should align with. Although it is hoped that both sets of students will learn together and also learn to work together, there needs to be universal learning objectives that are clearly set out for both sets of students to follow. This may help stop students feeling alienated in the team. If both sets of students have the same learning outcomes and the same assessment outlines to match these outcomes, irrespective of the treatment being carried out, then as per the Biggs model, there should be a deeper level of understanding and concurrently respect for peers.
Core competencies
Schmitt (2011) 14 identified core competencies that are required for learners to fulfil the learning outcomes in a team-based approach that produces the desired outcome for the patient. These are:
Values/ethics: Working together with members of other professional domains to maintain mutual respect and shared values.
To gain knowledge not only of your own role but roles of other members in the team so that all can work together in the patient’s best interests.
Interprofessional communication: To be able to communicate with staff, patients, families and communities to support a team approach
Teams and teamwork: To work as a team to support different roles in order to act in the patient’s best interests.
Schmitt outlined that if all members of the team are held accountable for these four competencies, it should improve teamwork and the dynamics of the team. It is the hope that this in turn will improve the care that is delivered to the patient. In line with Schmitt, the dynamics of the team could be improved, and trust gained, by conducting a few sessions beforehand whereby both disciplines could share their remit and values with each other. This could be done by working in small groups to provide a presentation to the rest of the group on how a set patient case scenario could be dealt with together. Similarly, another possibility would be to conduct simulation based scenarios whereby both disciplines simulate treating a patient together as it would be done in a clinical environment. This would encourage gaining knowledge on each member’s remit, valuing one another, communication between team members and ultimately, good teamwork.
Evaluation
As Kirkpatrick (2009) 15 identified, all training programmes should be evaluated in order to ensure success of the programme. Kirkpatrick identified a model of four levels which are designed to help course coordinators to plan training programmes to best deliver a successful programme whereby learning occurs on a deeper level.
The four levels of Kirkpatrick’s evaluation model are:
Reaction – this relates to students’ views on whether the training satisfied their needs of the module. This is done via feedback forms.
Learning – was there an increase in knowledge, skills and attitude as a result of the module? Usually done during the module in the form of a test.
Behaviour – Is there a change in behaviour as the result of the module? This evaluation is done six months post training while the student is implementing the training on the job. Evaluation usually occurs through observation.
Results – This is performance-based outcomes as a result of the module.
If we apply Kirkpatrick’s evaluation process to training courses, it becomes apparent that there needs to be formal evaluation of the activity. There also needs to be post-training evaluation and performance-based outcomes. If Kirkpatrick’s model for evaluation is used to evaluate the IPE activity involving both sets of students, a clearer understanding may occur, and changes can be made early on. Pinto et al. (2012) 16 found that students valued the knowledge and skills gained through the structured IPE clinical placement. This suggests that structured IPE clinical placements may provide learners with valuable collaborative learning opportunities, enhanced respect for other professionals, and insight into the value of IPE in healthcare delivery.
In conclusion, the ability to carry out an IPE activity with both sets of students working together is a great idea and should be hailed as such. However, at present there have been several oversights which have prevented the success of the activity. Further improvements are necessary to ensure the success of student learning and to ensure that these students continue to work as a team in the best interests of the patient, both when they are in university and, perhaps more importantly, when they go out into dental foundation training. It would perhaps be beneficial to roll out this activity earlier in the course rather than in the student’s final year. Proper training of facilitators needs to occur before such an activity is undertaken. It would be helpful to have at least a day of training whereby both sets of students could present roles, ethics, values and responsibilities to each other to ensure reduction of a negative attitude of each other when starting the activity. Finally, it would be useful to evaluate the module using the Kirkpatrick framework to ensure optimal results in the learning process and to facilitate behaviour change between the two groups of students.