LESSONS LEARNT FROM A NATIONAL STUDY OF PRE-REGISTRATION INTERPROFESSIONAL EDUCATION IN THE UNITED KINGDOM Dr. Deborah Craddock University of Southampton

Introduction Crucial ability to learn and work in a multidisciplinary team (WHO 2008). Interprofessional education (IPE) aims to reinforce inter-professional practice (DOH 2000a; DOH 2000b; Carpenter, 2005). IPE is a mandatory requirement in the United Kingdom (UK) for pre-registration training in health and social care (DOH & QAA, 2006). Varying models of IPE in undergraduate curricula (Roberts et al., 2000) Evidence base for the effectiveness of such programmes is growing (Hammick et al., 2007; Hean, Craddock & OHalloran, 2009).

Research Aim: To explore the potential influence of IPE at pre-registration level, using podiatry as an exemplar. Research Objectives: 1.To evaluate health and social work students awareness of podiatrists roles on two occasions1 across participating HEIs;1 2.To explore health and social work students views of interprofessional learning (IPL) on two occasions1 across participating HEIs;1 1 Sample 1: students at the start of their Level 1 IPE initiative; Sample 2: students on completion of their IPE Level 1 initiative

Methodology Two prospective cross-sectional surveys Ethical approval Multi-stage sampling:- (1) sampling of HEIs & (2) sampling of students Questionnaires were administered to a volunteer sample of pre-registration health and/ or social work students in Higher Education Institutions within the UK at 2 separate time points. Inclusion criteria: Students registered on a health or social care programme participating in an IPE initiative that involved podiatry students.

Questionnaire Pack Questionnaire pack- informed by (1) key informant interviews and (2) research evidence Validated tools – Readiness for Inter-professional Education Scale [RIPLS] & Generic Role Perception Questionnaire Face validity Content validity Pilot Study [test (i) n=67; test (ii) n=62] Test re-test reliability Internal consistency Key informant interviews

Sample: Sample 1: 1151 students participated in the Sample 1 phase [81.1% (933) female, 18.9% (218) male]: mean age (SD=8.167) years in 6 HEIs Excluding students registered on a BSc (Hons) podiatry programme: Sample 1 sample size- 964 students [82.2% (792) female, 17.8% (172) male]: mean age (SD=7.50) years in 6 HEIs Sample 2: 1060 students participated in the Sample 2 phase [81.2% (861) female, 18.8% (199) male]: mean age (SD=7.84) years in 5 HEIs. Excluding students registered on a BSc (Hons) podiatry programme 967 students [81.7% (790) female, 18.3% (177) male]: mean age (SD=7.46) years in 5 HEIs. Female : Male (Parsell and Bligh 1999; Cassidy 2007)

Objective 1 Evaluating health and social work students awareness of podiatrists roles on two occasions1 across participating HEIs;1 1 Sample 1: students at the start of their Level 1 IPE initiative; Sample 2: students on completion of their IPE Level 1 initiative

Of these participants in Sample 1, only 20.4% (48) participants who claimed to be aware of podiatrists roles, perceived there to be no difference between chiropodists and podiatrists. In Sample 2: greater percentage number- 42.7% (180). 41.4% (399) participants in Sample 1 and 51.4% (497) participants in Sample 2 participated in an IPL group that included a podiatry student.

Perceptions of podiatrists roles: carrying out nail surgery for an ingrown toenail (Sample 1: 82.2%, 792; Sample 2: 80%, 774) manufacturing shoe devices (Sample 1: 54.5%, 525; Sample 2: 54%, 522) surgically removing bunions (Sample 1: 57.2%, 551; Sample 2: 57.5%, 556) At Sample 2 only, podiatrists were also identified as the key professional who treats verrucae (70.2%, 679). Other roles: Managing walking and mobility problems Assessment of patients/ clients for vascular disease Managing ulcerations Assessing children for gait or developmental anomalies

Only at HEI B did students have a greater understanding of podiatrists roles between Sample 1 and Sample 2 (Sample 1: Md=8, Sample 2: Md=10, U=7513, z=-5.294, p<0.001, r=-0.3) Note: Higher median score- Sample 2 Educational theory underlying IPE initiative

A Kruskal-Wallis Test highlighted a significant difference in students knowledge of podiatrists roles and their institution of origin- Sample 1: H=38.948, 5df, p<0.001, n=964; Sample 2: H=122.87, 4df, p<0.001, n=967. Sample 1: HEI D recorded the highest median knowledge score (Md=8.5) HEI K and HEI H recorded the lowest median knowledge score (Md=6) Sample 2: HEI D and HEI B recorded the highest median knowledge scores (Md=9) HEI K recorded the lowest median knowledge score (Md=6)

Students knowledge podiatrists roles was better if they had participated in an IPE group that involved a podiatry student (Md=7) than students who did not or were unsure as to whether they had participated in an IPE group that involved a podiatry student (Md=6) (Sample 1: U= , Z=-2.596, n- 964, p=0.009; Sample 2: U= , z= , n=967, p<0.001). Podiatry students awareness of their own professions roles was greater in Sample 2 than Sample 1 (Sample 1 Md=10, n=187; Sample 2 Md=12, n=93; U=4703.5, z= , p<0.001). A positive correlation was evident between age and knowledge of the podiatrists role (Sample 1: spearmans rho= 0.097, n=964, p=0.001; Sample 2: spearmans rho= 0.059, n=067, p=0.032 for a one tailed test) respectively.

Generic Role Perception Questionnaire GRPQ (MacKay, 2004) Scale with 20 items that has good internal consistency (Cronbach alpha=0.7; n=43) (MacKay, 2004) Principal Components Analysis with Oblimin rotation Sample 1- four components solution (Cronbach alpha=0.776) Sample 2- three components solution (Cronbach alpha=0.78) A Mann-Whitney U test revealed a significant difference between students perceptions of podiatrists roles in Sample 1 (Md=92, n=964) and in Sample 2 (Md=97, n=967) [U= , z=-5.012, p<0.001, r=-0.11]. In Sample 2 a significant difference was observed in students total GRPQ scores between health and social work students who participated in an IPE group that involved a podiatry student (Md=94, n=497) and students who either did not or were unsure as to whether they had participated in an IPE group with a podiatry student (Md=99, n=470) [U= , z=-3.451, p=0.001, r=-0.11].

Objective 2 Exploring health and social work students views of interprofessional learning (IPL) on two occasions1 across participating HEIs;1 1 Sample 1: students at the start of their Level 1 IPE initiative; Sample 2: students on completion of their IPE Level 1 initiative)

IPE has been introduced into pre- registration curriculum to: help health and/or social care professionals to be able to work more effectively together (Sample 1: 97.5%, 1098; Sample 2: 94.6%, 1003) enhance the quality of care given to patients (Sample 1: 95.4%, 1098; Sample 2: 92.8%, 984) Improve communication skills (Sample 1: 94.4%, 1086; Sample 2: 91.3%, 968) Increase confidence in professional roles (Sample 1: 87.3%, 1005; Sample 2: 82%, 869) NOT weaken the power of the professions (Sample 1: 82.7%, 952; Sample 2: 74%, 784) Increase cost effectiveness of patient care (Sample 1: 52.2%, 601; Sample 2: 57.5%, 610) Minimise the risk of any duplication of health service delivery (Sample 1: 45%, 518; Sample 2: 53.8%, 570)

Disagreement that campus based IPE opportunities were perceived as being more meaningful than placement based learning opportunities (Sample 1: 46.3%, 533; Sample 2: 51.1%, 542) Rivalries exist in placement locations that expose students to stereotypical views of professions (Sample 1: 43.5%, 500; Sample 2: 47.2%, 501) Key Motivational Influence: - use of clinical/ social scenarios in group-work activities (Sample 1: 81.6%, 939; Sample 2: 71.1%, 753) Students Perceptions of IPE

Commitment to IPE: Positive correlation - age and level of commitment to IPE (Sample 1: spearmans rho = 0.243, p<0.001; Sample 2: spearmans rho = 0.165, p<0.001 for a one tailed test) Modal response of 6 - the majority of participants were only fairly committed (Sample 1: 49.5%, 570; Sample 2: 46.9%, 497) to IPL. Commitment was strongly influenced by: facilitators attitudes towards IPE (Sample 1:75.5%, 835; Sample 2: 74%, 784) working practices of staff (72.4%, 833; Sample 2: 66%, 700); Students induction to the IPE initiative (62.2%, 716; 56.2%, 596)

Yet the majority of respondents had not read any information about IPE (Sample 1: 65.7%, 756; Sample 2: 60.8%, 644) Commitment to IPE Primary information sources accessed by students who had read information about IPE: Sample 1N (21%; 242) Sample 2n (21.8%, 231) Websites47.5%, 115Course materials 40.7%, 94 Course materials 47.1%, 114Websites30.3%, 70 Books18.6%, 45Books27.3%, 63 Discussions17.8%, 43Journals22.5%, 52

Students who had read information: – Developed a better appreciation of the need for multi- disciplinary team members to meet on a regular basis in order to plan and discuss issues (Sample 1: U= , z= , p=0.01, r=-0.08; Sample 2: U=82170, z=-3.704, p<0.001, r=-0.11). – Enabled students to gain an appreciation of the existence of rivalries in placement locations that may expose students to stereotypical views of other professions (Sample 2: U= , z=-2.223, p=0.026, r=-0.07).

Readiness for Inter-professional Learning Scale Principle Component Analysis Kaiser-Meyer-Oklin value = Sample 1: 0.932; Sample 2: Bartletts Test of Sphericity (p<0.001) Oblimin rotation with Kaiser Normalisation Sample 1 and 2: 2 component solution Comparisons with Parsell and Bligh (1998; 1999) & McFadyen et al. (2005) Component 1 Teamwork and collaboration Component 2 Professional identity and roles

Factor AnalysisSub-scale 1 Teamwork and collaboration Sub scale 2 Professional Identity (1999) and Negative Professional Identity (1998) Subscale 3 Roles and Responsibilities (1999) + Roles (1998) Parsell and Bligh (1999) (n=120) 42% variance explained Items 1-9Items 10-16Items Parsell et al., (1998) (n=914) 48% variance explained Items 1-9 Item 11 Items Item 12 Item 17 Item 19 Item 18 McFadyen et al (2005) (n=308) (n=308) 44% variance explained Items 1-9; 10, 11 Items Item 12 Item 17 Items Craddock Sample 1: n= % variance explained Craddock Sample 2: n % variance explained Items 1-9 Items Items Items RIPLS Subscale Comparisons

StudySub-scale 1 Teamwork and collaboration Sub scale 2 Professional Identity (1999) and Negative Professional Identity (1998) Subscale 3 Roles and Responsibilitie s (1999) + Roles (1998) Parsell and Bligh (1999) (n=120) Parsell et al., (1998) (n=914) McFadyen et al (2005) (n=308) Craddock (n=1151) Craddock (n=1060) Cronbach Alpha Measure of Internal Consistency of Each Sub-scale

Pre-registration health and social work students perceptions of IPL Significant difference between: Students total RIPLS scores in Sample 1 (Md=80, n=1151) and Sample 2 (Md=76, n=1060), U= , Z=-7.474, p<0.001, r= – Findings echoed in relation to each sub-scale – Students total RIPLS scores in Sample 1 and Sample 2, for HEIs B, E, K and H. Students at HEIs B and K had the highest RIPL and HEI F had the lowest.

Lessons Learnt Assessment Task Make- up of IPE groups Formal & informal learning opportunities Focus of learning outcomes Student Preparation Enhancing knowledge of professional roles

Lessons Learnt Key role of facilitators- staff training Working practices of staff Induction process Key factors influencing students attitudes towards IPE

Lessons Learnt: Value of placement based learning (Guest et al 2002; Lumague et al., 2006; Robson and Kitchen, 2007) Placement Based Learning not possible? Stimulus materials in IPE initiatives linked to the practice setting. Recognised reservations: practicability (Cook et al., 2001) Lack of clinical experience (Young et al., 2007) Existence of rivalries in practice (Robson and Kitchen, 2007)

Lessons Learnt: RIPLS (Parsell and Bligh, 1999) Role of reading about IPE > age of students > level of commitment Timing of IPE Target course materials where links are incorporated to key IPE websites Target & engage younger students e.g. induction – (see, Stephens et al., 2007)

References Carpenter, J. (2005) Evaluating the Outcomes of Social Work Education. London and Dundee: Social Care Institute for Excellence and Scottish Institute for Excellence in Social Work Education. Cook, A., Davis, J. and Vanclay, L. (2001) Shared learning in practice placements for health and social care students in East London: A feasibility study. Journal of Interprofessional Care, 15(2): 185–190. Department of Health (2000a) A Health Service of all the Talents: Developing the NHS Workforce. Consultation document on the review of workforce planning. London: Department of Health. Department of Health (2000b) The NHS Plan: A plan for investment, a plan for reform. London: The Stationery Office Ltd. Department of Health and QAA (2006) Department of Health Phase 2 Benchmarking Project – Final Report. London: Department Of Health; and Gloucester: Quality Assurance Agency for Higher Education. Hammick, M., Freeth, D., Koppel, I., Reeves, S. and Barr, H. (2007) A best evidence systematic review of interprofessional education (Best Evidence Medical Education Guide No 9). Medical Teacher, 29(8): 735–751. Hean, S., Craddock, D. and OHalloran, C. (2009) Learning theories and interprofessional education: A users guide. Learning in Health and Social Care, 8(4): MacKay, S. (2004) The role perception questionnaire: A tool for assessing undergraduate students perceptions of the role of other professions. Journal of Interprofessional Care, 18(3): 289–302.

References: (continued) McFadyen, A.K., Webster, V., Strachan, K., Figgins, E., Brown, H. and McKechnie, J. (2005) The readiness for interprofessional learning scale: A possible more stable sub-scale model for the original version of RIPLS. Journal of Interprofessional Care, 19(6): 595–603. Parsell, G. and Bligh, J. (1998) Shared goals, shared learning: Evaluation of a multi- professional course for undergraduate students. Medical Education, 32(3): 304–311. Parsell, G. and Bligh, J. (1999) The development of a questionnaire to assess the readiness of healthcare students for interprofessional learning. Medical Education, 33: 95–100. Roberts, C., Howe, A., Winterburn, S. and Fox, N. (2000) Not so easy as it sounds: A qualitative study of a shared learning project between medical and nursing undergraduate students. Medical Teacher, 22(4): 386–391. Robson, M. and Kitchen, S.S. (2007) Exploring physiotherapy students experiences of interprofessional collaboration in the clinical setting: A critical incident study. Journal of Interprofessional Care, 21(1): 95–109. Stephens, J., Abbott-Brailey, H. and Pearson, P. (2007) Its a funny old game: Football as an educational metaphor within induction to practice-based interprofessional learning. Journal of Interprofessional Care, 21(4): 375–385. Young, L., Baker, P., Waller, S., Hodgson, L. and Moor, M. (2007) Knowing your allies: Medical education and interprofessional exposure. Journal of Interprofessional Care, 21(2): 155–163. World Health Organisation (2008) Now more than ever: The World Health Report Geneva: WHO.