Professional learning versus interprofessional learning: Evaluation of an interprofessional, cross-sectorial education concept for use in health professional bachelor degree programmes

The Danish healthcare system is undergoing changes optimising patient pathways leading to reduced length of hospitalisation. In the future, nursing as well as other health profession will become increasingly specialised and focus on transitions in patient pathways across professions and sectors. These demands will impact on the education programme for nurses.

Coherent patient pathways are a part of the strategy to improve quality in the Danish healthcare system (1). Cooperation between patients and professionals is challenged when patients are transferred between department, hospitals or sectors (2). Sharing and developing knowledge inter-professionally and in particular across sectors is inadequate (3-4). Establishing coherent patient pathways is a necessary goal and coordination and co-operation between professions, units and sectors is thus necessary.

Skills and framework to coordinate efforts in the healthcare system has become a theme in health professional education programmes to ensure that health professionals can meet the demands of tomorrow's health care system. According to D' Amour, a working relationship is based on the professional knowledge of each other's tasks, responsibilities and working conditions, and on the involvement of the patient's resources and needs (5-6).

Traditionally, the major part of clinical education in nursing and other health profession take place at somatic hospitals attached to one profession and in one unit. This is challenged by short-term contacts and fast discharge from hospital and when treatment and nursing care take place in the patients’ own home. In this way clinical education does not focus on interprofessional and cross-sectorial transitions in patient pathways.

Historically, nursing has evolved because of the need for care among ill people. The methods in nursing have developed to meet the demands of society. It is a current challenge for the nursing profession to balance maintaining a professional identity and to play a role in the cooperation across professions and sectors.

This Industrial PhD Project investigates the concept of InterTværs, which is an ongoing collaboration project between Aarhus University Hospital, Municipality of Aarhus, Aarhus University and VIA University College, Faculty of Health Sciences. The purpose of InterTværs is to strengthen the skills of students in education. The PhD-project will follow the InterTværs project, mapping out the field and use empirical data to generate knowledge about how students develop interprofessional competencies related to patient pathways across professions and sectors.

Background and context
In the Summer 2012 Aarhus University and Aarhus University Hospital launched the Project InterTværs to strengthen interprofessional and cross-sectorial collaboration skills of health professional students (8). In the spring 2013 a pilot project was conducted where teams consisting of a student from the physiotherapy, occupational therapy, and nursing bachelor degree programmes and a medical student underwent clinical education together focused on a patient pathway during hospitalisation. After discharge they followed the patient in their own home together with the primary care services in the municipality. The teams were supervised inter-professionally by clinical supervisors. Together they described the patient pathway and identified opportunities and weaknesses.

Lessons learned from the pilot project are collected in a report (9).

Research questions
This Industrial PhD Project will explore the embedded assumptions and challenges in InterTværs and examine how InterTværs influences the professional learning. The project focuses on how students develop interprofessional competencies and (inter)professional identity.

1. How do students in the InterTværs project learn to cooperate interprofessionally and across sectors concerning patient pathways?

2. How do the involved health education programmes and institutions interact in the InterTværs project?

3. How does participation in the InterTværsproject and collaboration interprofessionally and across sectors impact on the development of the professional identity of the student?


Methodology, Methods, Research Instruments or Sources Used:
This Industrial PhD Project is conducted as a research-based evaluation of an educational experiment. The methodological approach is described as a mix of evaluation research, ethnographic methods and action research similar to research by Dahler-Larsen, Borgnakke, Hammersley and Greenwood (10-15).
The project aims to explore InterTværs from concept to practice. The field and institutional levels will thereby be identified (11, 13). The aim of the project is to investigate the function of InterTværs as an educational concept and the influence this concept has on the health professional learning.
The empirical phase is scheduled from May 2014 to May 2015. The first empirical studies will be conducted with one month intensive field studies in May 2014.

Empirical studies:
When mapping the field is an empirical goal, multiple methods are necessary (11). Planning:
• Interviews with students and clinical and theoretical educators before participation in InterTværs
• Observational studies related to situations of professional learning
• Classroom research related to inter-professional meetings
• Participant logbooks, synopsis made on the case study as well as videos of presentations.

Theoretical framework:
Via InterTværs the project moves from vision into practical reality in the clinical training setting. The project is a movement between the political macro-level, the institutional meso-level and the practical micro-levels. These movements between different levels of importance influence the critical optics as well as the theoretical approaches.
Theoretically, the project ranges from organisational learning to health professional research and identity issue until professional learning from the students' point of view. The project seeks to cover the spectrum from organisational level to the individual level taking advantage of possible combinations between Yrjö Engeström and the orientation of company (16-17), Wolfgang Klafki and the orientation of critically-constructive didactic (18), Erling Lars Dale and the orientation of educational professionalisation (19) and finally, Etienne Wenger and the orientation towards practical learning and communities (20). The idea is to reinforce the theoretical discourse of (inter)professional learning in interaction with the empirical studies of InterTværs.

Conclusions, Expected Outcomes or Findings:
The Industrial PhD project aims to explore and describe how the perspective of InterTværs can help to strengthen and develop the individual, inter-professional and (inter)organisational learning, which is necessary for development of the future undergraduate health professional education programmes.

The PhD project intends to generate knowledge of:
- the contributions of InterTværs to the quality of future health professional education programmes and to the future healthcare system
- the cooperation between clinical and theoretical educators and students on development of the learning process.

The Industrial PhD Project is based on the ongoing InterTværs and the already gathered experiences (11). The gathering of experiences is based on logbooks from the students and interviews with both students and clinical educators.
The already gathered experiences (9) suggest three particularly sensitive areas:
1. The educator perspective where clinical educators and lecturers seem to be challenged by the inter-professional cross-sectorial meeting and guiding
2. The student perspective where students express the inter-professional cross-sectorial
learning as essential and unique, even though they express fear of losing mono-professional skills
3. The didactic perspective where the focus is methods of learning and how to collaborate towards common goals in transition concerning patient pathways. The transition challenges in the healthcare system do not seem to only affect patients and knowledge, but also the students and learning.

References:
(1) Institute for Quality and Accreditation in Healthcare. 2012. The Danish Healthcare Quality Programme. Accreditation Standards for Hospitals
(2) Siemsen IMD. 2011. Patientovergange. Et eksplorativt studie af faktorer der påvirker sikkerheden af patientovergange. PhD.-afhandling. DTU Management
(3) Gittell JH. 2009. High Performance Healthcare. Using the Power of Relationships to Achieve Quality, Efficiency and Resilience. New York: McGraw-Hill
(4) Vinge S, Strandberg-Larsen M. 2010. Kontinuitet og koordination i sundhedsvæsenet. Ugeskrift for Læger; 172(Videnskab):775-777
(5) D’Amour D, Oandasan I. 2005. Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care (Supplement 1):8-20.
(6) Reeves S, Hean S. 2013. Why we need theory to help us better understand the nature of interprofessional education, practice and care. Journal of Interprofessional Care; 27(1):1-3.
(7) Barr H. 2013. Toward a theoretical framework for interprofessional education. Journal of interprofessional care; 27(1):4-9.
(8) Kramer T, m.fl. 2013. Interprofessionelle, tværsektorielle studieforløb - En model. Aarhus Universitetshospital, Aarhus Universitet, Aarhus Kommune, VIA
(9) Kramer T. 2013. Erfaringsopsamling: Interprofessionelle, tværsektorielle studieforløb. Aarhus Universitetshospital, Aarhus Universitet, Aarhus Kommune, VIA
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