Design and evaluation of a team-based interprofessional practice placement: A design-based research approach

Abstract

Introduction

Team-based Interprofessional Practice Placements (TIPPs) are innovative training practices. Evidence to substantiate the design of TIPPs is limited. This study explores the design and evaluation of TIPPs to support undergraduate students in gaining a better understanding of the complexity of patient problems in primary care settings and of collaboration within interprofessional teams.

Method

We implemented TIPPs at a University of Applied Sciences, Belgium based on three principles: (1) authentic tasks with real clients, (2) students collaborated in small interprofessional teams, and (3) students were supported by teachers. TIPPs were evaluated using focus groups (N = 5) that explored teachers’ (N = 13) and students’ (N = 22) experiences. Data were analysed thematically.

Results

Three themes were constructed. First, TIPPs enhance students’ understanding of the complexity of clients’ problems and what matters to the client. Second, TIPPs support students to value the expertise of interprofessional team members. Finally, to enhance students’ learning, TIPPs must strike an appropriate balance between teacher support and student autonomy.

Conclusion

The three design principles used to underpin the TIPPs were viable. Although students reported to receive sufficient support, they also felt this support should have been gradually withdrawn to offer more opportunities for autonomous learning. Teachers reported difficulties in balancing their support.

Keywords:

• Team-based interprofessional practice placement; design-based research; interprofessional education; interprofessional collaboration; authentic learning

Introduction

Practice points

• A Design-Based Research approach was used to design a Team-based Interprofessional Practice Placement (TIPP) to support undergraduate students to gain a better understanding of the complexity of patient problems in primary care settings and of collaboration within interprofessional teams.

• The TIPP enhances students’ understanding of the complexity of clients’ problems and what matters to the client.

• The TIPP supports students to value the expertise of interprofessional team members, but it is important to strike an appropriate balance between teacher support and student autonomy.

Interprofessional collaboration (IPC) is a central theme in today's healthcare if we are to meet the challenges of an ageing society in primary healthcare effectively. The ageing population will increase the complexity of medical problems, which calls for an interprofessional approach across professions (Reeves et al. 2017a). The World Health Organization (WHO 2013) has also endorsed the importance of IPC between the current actors in primary care to cope with these complex health problems and the literature has shown that IPC benefits patients (Oeseburg et al. 2013; Mertens et al. 2018; Schapmire et al. 2018). The challenges of IPC do not only apply to the clinical setting, but also to healthcare student preparation before graduation (Castro et al. 2019).

Today’s healthcare education faces a major challenge given that students are mainly trained in professional silos (Tran et al. 2018). If we want to prepare students in healthcare education for IPC at work, we need to look for new and innovative ways to design interprofessional education (IPE) for the different curricula (WHO 2013; O'Keefe et al. 2017; Castro et al. 2019). IPE is defined as the process whereby professionals from two or more different professions learn with, from and about each other to enhance collaboration and the quality of care (Barr et al. 2006). As a step towards IPC in the workplace, healthcare students should be offered IPE before graduation so that they can experience working with students of other health professions (Thistlethwaite 2012; Al-Qahtani and Guraya 2016; Reeves et al. 2017b; Zechariah et al. 2019). This is where the problem lies for education: How can we design interprofessional learning activities that contribute to the competencies that students must acquire to work interprofessionally in the workplace?

So far, little is known about the design of IPE interventions. Although the literature on IPE is increasing, with various studies pointing to its potential importance, the question which curriculum design principles might fit with IPE remains unanswered. Thistlethwaite (2012) has argued that, to design IPE, evidence should be collected in situ through empirical studies in the workplace. This, however, begs the question: How to design a Team-based Interprofessional Practice Placement (TIPP)?

We utilized three instructional design principles when designing our Team-based Interprofessional Practice Placements (TIPPs). These TIPPs support healthcare students to develop a better understanding of patient complexity in primary care settings and collaboration within interprofessional teams.

First of all, when students have to learn competencies in a complex domain, the learning tasks should be meaningful and authentic (Frerejean et al. 2019). In other words, students should preferably be confronted with professionally relevant problems ordered from simple to complex. Learning from real-world and ill-defined problems enhances the integration and application of knowledge, skills and attitudes and promotes the transfer of learning to new situations or practice (van Merrienboer et al. 2002; van Merrienboer et al. 2003; Vandewaetere et al. 2015; Frerejean et al. 2019). To boost the effectiveness of IPE, authenticity is considered key (Hammick et al. 2007; Fitch 2011). Learning in an authentic environment is perceived to stimulate the transfer of theory to practice (Housley et al. 2018).

Second, since our aim is to support undergraduate students in gaining a better understanding of the complexity of patient problems in primary care settings and of collaboration within interprofessional teams, students’ learning should preferably take place in interprofessional teams. Interprofessional learning is a trend that is gaining more and more attention within various healthcare curricula and the available literature offers clear evidence for the positive effects interprofessional learning on interprofessional collaboration (Barr et al. 2006; Reeves et al. 2016). Furthermore, participation in IPE and experiencing being part of an interdisciplinary team is perceived to promote interprofessional collaboration (Hammick et al. 2009).

Third, current instructional design models have emphasized the importance of scaffolding students’ learning, for instance by offering them teacher support. When students are confronted with a complex task for the first time, a lot of support should be offered in the beginning to be gradually withdrawn over time. Once the student is able to deal with the task independently or with very limited support, the student should be offered a more complex task, again with a lot of support and scaffolding at the start (Van Merrienboer et al. 2002; Frerejean et al. 2019). This phenomenon is called ‘scaffolding’ and encapsulates three important elements that should be taken into account when designing education. First of all, teachers should adapt their support to students’ level of competence. Next, teachers should gradually reduce this support. Finally, by reducing the level of support, students are encouraged to take more responsibility (van de Pol et al. 2014). Scaffolding of undergraduate students can be designed in different ways. One way is to offer students just-in-time information. This allows students to receive support from peers when performing the whole task in the interprofessional teams (West et al. 2017). Another way is to provide students with literature resources or other supportive information to help them better understand the materials (Van Merrienboer et al. 2002; Frerejean et al. 2019).

In this study, we designed a TIPP based on the three principles explained above. In addition, we implemented and evaluated the TIPP to address the following overall research question of this paper:

How does a TIPP support undergraduate students in gaining a better understanding of the complexity of patient problems in primary care settings and of collaboration within interprofessional teams from the perspective of students and teachers?

Methods

Design

To design and evaluate a team-based interprofessional workplace-based education intervention, we used a Design-Based Research (DBR) approach. In a DBR approach, the advancement of theories is intertwined with the maturing of practice because both theories and stakeholders’ opinions are used to design and evaluate interventions. Studying educational practice through DBR offers a unique approach to bridge the gap between theory and practice (Dolmans and Tigelaar 2012).

Setting

The VIVES University of Applied Sciences in Belgium aims to prepare healthcare students for their future professional practice by offering workplace-based learning environments. IPE is one of its spearheads. Students are offered various interprofessional learning activities over a three year time period. During the final phase of this interprofessional learning trajectory, a Team-based Interprofessional Practice Placement (TIPP) is offered, named Agora 1. This four-month project was organized in the community of Houthulst, Belgium, in the fall of 2018. During this project, students learnt by completing authentic tasks in which they interacted with a real client in inter- and uni-professional student teams in the workplace and on campus, while being supported by a teacher.

Participants

Participants of the Agora 1 Houthulst project were seven teachers, seven elderly clients and 44 students who were divided into teams. In total seven teams participated, each consisting of 6–7 students, one teacher and one elderly client. Students had a background in speech therapy (n = 7), dietetics (n = 5), nursing (n = 15), occupational therapy (n = 5), and social work (n = 12). A representative sample of students from each discipline was involved in the different interprofessional teams, further details are given in Supplemental Appendix A. Teachers from the same range of professions were involved as coaches; speech therapy (n = 1), dietetics (n = 1), nursing (n = 3), occupational therapy (n = 1), and social work (n = 1). The elderly clients were volunteers who were recruited from the local social services of Houthulst community. Although preference was given to their home environment, the elderly client could decide where to host the students, so an encounter could also take place in the community service centre of Houthulst if they preferred.

The TIPP

During the TIPP, students’ learning was centered around authentic professional tasks. Students started working with problems of the elderly in the personal setting of these people. For example, during the TIPP the student team met the elderly client and, if applicable, the partner and caregiver. By letting healthcare students work together with the client in a real-life situation, we created possibilities to learn in a real-life setting and apply the knowledge and skills acquired in earlier years. The aim of the TIPP was to support undergraduate students in gaining a better understanding of the complexity of patient problems in primary care settings and of collaboration within interprofessional teams.

A second unique feature of the intervention was that students from different professional training programmes collaborated in small interprofessional teams. Students from speech therapy, dietetics, nursing, occupational therapy and social work participated in the TIPP. Since the number of students differed per programme, it was impossible to compose uniform interprofessional teams. Consequently, in some teams not all professions were represented, while in others they were represented twice, further details are provided in Supplemental Appendix A. Students had varying experiences with primary healthcare and interprofessional teamwork, depending on the training in their past years of education. By grouping students from the various healthcare programmes together in this TIPP, we aimed to educate them in interprofessional teamwork in primary healthcare.

A third principle was that students received support from teachers. The teachers involved in the project were randomly assigned to the interprofessional teams. This resulted in teachers coaching not only students from their own discipline, but also those from other professions. Teachers attended the meetings in which the interprofessional team met the elderly client with the aim to guide and assist the interprofessional teams with the necessary scaffolding as a facilitator. While the TIPP was organized around interprofessional teams, students were also offered the opportunity to consult with students from their own background. The TIPP was organized in such a way that off-campus moments were followed by on-campus moments. In these on-campus moments, students also studied together in teams within their own profession or educational programme, with the support of a teacher to find the information necessary to solve the problems of the elderly client. In this way, students had the opportunity to enlist the support of students from their own profession, beyond meeting in interprofessional teams.

Interview guide

Focus groups were semi-structured, based on an interview protocol, guided by the first author and observed by a team member of VIVES. Interview guides were designed for both students and teachers and topics were structured around the design principles of the educational intervention (for the interview guides, see Supplemental Appendix B & C. Participants were asked to think about their experiences and about the extent to which particular characteristics of the intervention enhanced or hindered their learning. Before reporting orally in the focus group, teachers and students were asked to write these experiences down. This approach allowed participants to reflect on their own experiences and ensured that each participant was able to voice their own experiences with the project.

Procedure

Focus groups were held two months after the end of the project. We organized separate focus groups for students and teachers to evaluate the educational intervention from different angles. Participants were recruited by email and participation was voluntary. Participants gave informed consent and could withdraw from the study at any time. We randomly assigned participants to a focus group.

Analysis

Themes were constructed through a process of inductive and deductive analyses and guided by principles of thematic analysis (Braun and Clarke, 2021). The discussions were recorded and transcribed verbatim. In the first stage, inductive coding was used to generate the first level of themes by TC and EVDW, TC and EVDW. These themes were discussed and reviewed within the larger research team including JdN and DD. In the second stage of coding we used a combined inductive and deductive analysis approach in which the design principles underlying the intervention, being the use of authentic tasks, interprofessional teams and teacher support or scaffolding were used as lenses or sensitizing concepts to study the data. The process was carried out using Microsoft^® Excel^® for Mac, 2011 (Ronan and Gallagher 2016).”

Ethical approval

Ethical approval was obtained from the Ethical Review Board of AZ Delta in Roeselare, Clinical Trial no.: B117201938923.

Results

In the end, we held five focus groups in total, two with teachers and three with students. Of the 44 students who had completed the project, 22 participated in a focus group (3 speech therapy, 1 dietetics, 10 nursing, 3 occupational therapy and 5 social work students). Both focus groups with teachers consisted of seven participants from different professional backgrounds, while the focus groups with students were attended by seven, seven and eight participants with different specialties of training, respectively. Only one teacher and one student could not attend the focus groups.

There were three main thematic areas identified after the analysis: 1) TIPPs enhanced the students’ understanding of the complexity of clients’ problems and what matters to the client; 2) TIPPS supported students to value the expertise of interprofessional team members; and 3) to enhance student learning, there must be an appropriate balance between teacher support and student autonomy on TIPPS.

TIPPs enhanced the students’ understanding of the complexity of clients’ problems and what matters to the client

Students indicated that the TIPP experience helped them understand how important it was for them as health professionals to gain insight into the client’s perspective and what mattered to the client, rather than starting from their own expectations. Meeting the client in his or her personal setting was perceived to be beneficial to gain a better understanding of the problems experienced by the client as well as what mattered most to the client. Contact with the client motivated students to take the assignment seriously and teachers confirmed this. Furthermore, students discovered that practice is unpredictable and that they needed to adjust to the clients’ needs to set priorities during the consultation. They learnt to apply theory in practice, although, according to teachers, this was difficult for them in the beginning. Teachers also pointed to the difficulties that students experienced in capturing their client's little hints signalling underlying, more serious issues or concerns in a conversation. These findings are illustrated with the following quotes:

… in nursing we learn about patient-centred care, but what does this really mean? In this project you can use this theory because you can apply existing knowledge in practice. You have to find out what is important to the client, what do they really want? … this is a real context with real people …. (PS 6).

I also liked the fact that it was in a home setting … You see how they act in that environment …. (PS 7).

… besides the integration of theory in this project, you get to know the client as a person and find out what is important to him. This project is for real and you can discuss the different possibilities from the client’s perspective … (PS 6).

They [students] are dealing with a real problem that is ill-defined … (PT 1).

The elderly [person] tells only a few little things and often does not express exactly what he means. That’s what I found so challenging for students (PT 2).

TIPPs supported students to value the expertise of interprofessional team members

Students indicated that, by learning in interprofessional teams, they discovered each other's profession and developed respect for the other members of the interprofessional team. They also learnt to trust different stakeholders. As they explained, after having completed the TIPP, they would more easily seek help from other healthcare professionals in a new situation. Students learnt that they could not always rely on existing expertise within their own discipline when dealing with the complex problems of the elderly client. Students and teachers both agreed that a TIPP added value in terms of learning to appreciate the expertise of team members from different professions. The following quotes clearly demonstrate the above:

I also think that this is a very good … learning situation on a social, communicative level because you really interact with the different disciplines . I also find it of added value that you do not only stay in your own disciplines but that you also start to look more broadly and, in doing so, you actually get to better understand the other professions (PS 6).

… you learn to interact with each other and you will take that with you in the future. You dare to ask for advice from other disciplines because you know they will help you. And you know that they can broaden your understanding (PS 5).

… especially during my internship, for example when I have an elderly person and I see he has trouble eating, I go to the nursing department to discuss … I’m no longer afraid because I know they [colleagues] are willing to help me and I can help them (PS 4).

I have learnt a lot, from nursing, from OT, from everyone (PS 4).

I think that they have not only learnt from each other interprofessionally, but they have also learnt that everyone [all team members] with their own characters and personalities, regardless of their profession, determines what teamwork is like (PT 7).

To enhance student learning, there must be an appropriate balance between teacher support and student autonomy on a TIPPS

Students felt they received sufficient support from their teachers during both the uni-professional on-campus team meetings as well as during the off-campus interprofessional team meetings in which they met the client. They received feedback and guidance not only from their teachers, but also from their peers during all meetings. On occasions, but especially at the start of the TIPP, teachers offer help to students and show them how to communicate with the client. Students appreciated this support. Teachers had difficulty in finding the right balance between offering students support and giving them autonomy, because they felt responsible for student learning and the client. Students indicated that they would have learnt to work more autonomously, had the teacher not been present during some meetings with the client:

… our teacher did a very good job because she never really jumped to the foreground … if we didn’t know how to handle a problem, she would say it subtly … it was interesting to hear her feedback, what we did well, what we could do differently (PS 8).

I also think it’s important to have some kind of freedom to grow … but you know there is still someone you can rely on if things don’t go well (PS1).

I think it was also important for me to get a confirmation from my own profession that we were doing well (PS 1).

I guess, if the teacher hadn’t been there, things might have been a little more difficult at first, but I’m convinced, with all the different characters and with the expertise we had in the group, that it was going to work (PS3).

I believe if there were no coaches during the visits, that yes, independent work would be stimulated even more. But I do think that we would still need support to check what we are doing. For example, during the uni-professional meetings, with our own discipline (PS2).

Yes, I also found that, you really did bump into yourself at times … reflecting all the time, how much distance should I take, how many suggestions can I give, how far am I allowed to go or will I just observe. Constantly balancing those options (PT4).

Discussion

This study offers insight into and an understanding of how TIPPs in primary care can be designed based on current instructional design principles to enhance student learning.

Our results showed that the encounter with clients made students more aware of the complexity of the client's problem and of the contextual factors that influence health and quality of life, i.e., the situation in which the elderly person lived. These findings fit well with the study of Brewer and Barr (2016), who implemented and evaluated an interprofessional learning activity organized around an encounter with a real patient, showing that students became more aware of the importance of contextual factors and of how these might impact the patient’s health.

Furthermore, our results revealed that TIPPs with complex client problems were perceived as meaningful by students and teachers, since they support students to value the expertise of interprofessional team members. Similar findings were reported in other studies, for instance Neill et al. (2007) and Kassutto et al. (2020).

Finally, our study showed there must be an appropriate balance between teacher support and student autonomy on TIPPS to enhance student learning. Students reported that they received sufficient teacher support and felt this support should have been gradually withdrawn to offer more opportunities for autonomous learning. Teachers reported to struggle with offering an appropriate level of support to the student teams. We also found that students appreciated and valued the support from expert teachers during the TIPP which is consistent with Anderson and colleagues’ study (Anderson et al. 2016). van de Pol et al. (2014) reported in a study in which they investigated teacher scaffolding, that providing adaptive support by teachers is key to excellent teaching. It is very difficult for teachers to tailor their support to the students’ needs. The contingency between the teachers’ support and the students' needs is difficult to achieve but crucial for teaching and learning.

We found that the use of authentic tasks in which students meet with real patients, interprofessional team learning and a well-balanced level of teacher support were perceived as valuable by students and teachers. Students and teachers reported that students gained a better understanding of the complexity of the patient problem and of what matters to the patient and that students learnt to value the expertise of interprofessional team members. Overall, we conclude that the three design principles used to underpin the TIPP in primary care were viable.

As a step towards IPC in the workplace, healthcare students should be offered IPE before graduation so that they can experience working with students of other health professions to effectively design IPE based on three current instructional design principles.

A strength of this study is that we designed a TIPP based on three instructional design principles that fit well with the aims of IPE, implemented it and evaluated it from the stakeholders’ perspective, that is, the perspective of students and teachers. As such, our study adds evidence on and insight into how to effectively design IPE based on three current instructional design principles. These principles offer guidelines that can be used to design and evaluate TIPPs in different contexts in close collaboration with teachers, students and researchers.

Although the findings of this study provide rich insights, the study also has some limitations. First, the TIPP was studied in a specific context, i.e. an educational training in which students participated in interprofessional learning activities before they encountered a real client in a team-based interprofessional practice placement, which makes it difficult to generalise the results to other contexts. Nevertheless, the instructional design principles offer guidelines when implementing TIPPs in another context. Second, this study has looked at IPE from the angle of a single course instead of IPE as a longitudinal learning trajectory. Third, this TIPP focused on the perceptions of students and teachers only.

We suggest that future studies explore TIPPs in various real-life contexts to enable further extrapolation of understanding and insights gained from the design principles applied. To this end, we invite researchers to design IPE for different authentic settings. Additionally, we encourage longitudinal research into a learning trajectory on IPE for students consisting of a coherent set of relevant learning tasks ordered from simple to complex. Another recommendation for further research is to include the clients in studying TIPPs to gain insight into their perspectives. Finally, an observational study could add more specific information regarding what actually happens during IPE interventions.

What are the practical implications of this study? The findings of this study underscore the importance of teachers providing support to students which should be gradually decreased to enhance student autonomy when designing and implementing IPE in primary care. We conclude that teachers and students should be supported in finding this balance. Scaffolding provided by teachers should be included in the design. Support from teachers is just one of the possibilities. Students can also support each other, and the client can offer support during the learning process as well.

Overall, our results demonstrate that offering TIPPs are perceived to be effective by both students and teachers to prepare students to gain a better understanding about the value of interprofessional collaboration at the workplace.

Glossary

Team-based Interprofessional Practice Placements (TIPPs): Is a workplace-based intervention in which students from different professions learn by interacting with real clients in the workplace and on campus while being supported by teachers.

Acknowledgements

The authors thank all students and teachers who participated in this study. The authors also thank Angelique van den Heuvel for the language editing and Els Van De Walle for transcribing the recordings and for supporting the first author with conducting the focus group interviews.

Disclosure statement

The authors report no conflict of interest. The authors alone are responsible for the content and the writing of the article.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Tony Claeys

Tony M. I. Claeys, is a PhD student at the School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands and a researcher at Vives University of Applied Sciences, Centre of Expertise for Care Innovation, Belgium.

Diana H. J. M. Dolmans

Diana H. J. M. Dolmans, PhD, is a Professor of Innovative learning arrangements and educational scientist at the School of Health Professions Education (SHE) and the Department of Educational Development & Research, at the Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands.

Jascha de Nooijer

Jascha de Nooijer, PhD, is a Professor of Interprofessional Teaching and Learning at the School of Health Professions Education (SHE) and the Department of Health Promotion, at the Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands.