Applying Landscapes of Practice Principles to the Design of Interprofessional Education

Abstract

Issue

Although interprofessional education (IPE) is acknowledged as a way to prepare health professions students for future interprofessional collaboration (IPC), there is a need to better ground IPE-design in learning theory. Landscapes of practice and its concepts of knowledgeability and identification are suggested as a framework that may help optimize IPE. This Observation paper provides an explanation of how these concepts might be used in IPE-design.

Evidence

We propose using three modes of identification, i.e., engagement, imagination, and alignment, described in this framework, for an IPE-design that fosters IPC skills, professional identity formation, and knowledgeability about a field and its actors. Identification and knowledgeability are through to enable successful collaboration across professional and practice boundaries.

Implications

Focusing on identification implies that students develop a sense of relevance to one another in solving complex problems (engagement), they become aware of their own roles and responsibilities in relation to others (imagination), and they gain awareness of the context in which the different professions align and collaborate (alignment). Altogether, this enables students to become knowledgeable in the landscape, which prepares them for successful interprofessional collaboration in practice.

Keywords:

• Interprofessional education
• landscapes of practice
• knowledgeability
• identification

Introduction

Contemporary health care faces complex problems which often require interprofessional responses. For example, care of aging populations,¹ reducing health inequalities,² or care of people with combined physical and mental health needs,³ extend across multiple social and health disciplines. Tackling such complex problems requires multiple perspectives and effective collaboration by various professionals in care teams. Our vision of health has shifted from the biomedical perspective to a biopsychosocial perspective, which takes into consideration health, disability, functioning, and quality of life and regards people as capable of adapting and managing their health condition themselves.⁴

To better prepare future health professionals for complexities in care, interprofessional education (IPE) has gained much interest.⁵ To enhance safe and effective health care, IPE aims to develop the necessary competencies for working in interprofessional teams that cross the boundaries of one’s own profession.⁶ There is a need to better embed IPE in theories that focus on how professionals work together in the workplace and develop their professional identity. In this Observations article, we explore how undergraduate IPE could be designed to enhance future interprofessional collaboration (IPC) skills in the workplace. To this purpose, we use an example of an interprofessional team intervention developed by Maastricht University and Zuyd University of Applied Sciences, The Netherlands.⁷ By applying the theoretical lens of landscapes of practice⁸ to this example we will demonstrate how combining authentic, complex learning tasks with principles of landscapes of practice can foster interprofessional collaboration skills and professional identity development.

Context and conceptual basis

IPE education

In IPE, “members of two or more professions learn with, from and about each other to enable effective collaboration and improve health outcomes.”^9(p.13) Many educational institutions have introduced elements of IPE in their curricula as it is seen as a means for undergraduates to practice and prepare for IPC.¹⁰ Oandasan and Reeves^11,12 previously identified factors contributing to the successful design and implementation of IPE interventions, but they also identified factors that can hinder IPE. One of these factors is professional stereotyping due to socialization in ones’ own profession, due to which faculty members might intend to insert their own beliefs and attitudes toward their own and other’s professions. In their proposed framework for IPE they acknowledge that professional stereotypes and professional beliefs are part of the system we are working in, and that these beliefs need to be addressed in future IPE interventions. Paradis and Whitehead¹³ point to the difficulty of successfully designing and implementing IPE because its organization is both complex and costly.

The IPE case: Collaboratively designing a care plan

In this IPE case,⁷ teams of undergraduate medical, physiotherapy, occupational therapy, and speech and language therapy students are asked to collaboratively develop a care plan for an elderly patient. This patient is considered by medical students on their family medicine rotation. The main learning outcomes of the IPE case are “to be able to learn how to make an effective contribution to an interprofessional team in the field of patient care, as well as how to develop a care plan for a patient in consultation with other healthcare professionals.”

The design principles behind this case are principles of constructivist learning.^14,15 meaning that students 1) activate prior knowledge and elaborate on what they learned triggered by a patient case; 2) work collaboratively on a care plan with students from different health care professions; 3) use real-life cases; and 4) are responsible for their own planning, monitoring, evaluation, and reflection on their learning process.⁷ During their rotation in family medicine, medical students select the patient cases and make provisional care plans. Then, in a student-led interprofessional team meeting facilitated by a teacher from one of the two involved institutions, students review the provisional plans together and subsequently reflect on their interprofessional collaboration, discussing such aspects as atmosphere, interaction, leadership, what they have learned about others, and whether respectful collaboration occurred. The facilitator guides the student-led interprofessional team meeting, but does not interfere too much. A lecturer in family medicine provides feedback on the care plan for medical students.

In evaluations of this IPE case, students usually report positive experiences that enabled them to learn with, from and about other health professions. Using real-life cases is perceived as beneficial for learning and enabling students to gain mutual respect for each others’ expertise.⁷ The strength of this IPE case lies in its authenticity, exemplified by an evidence-based educational activity that challenges students from various health care professions to collaboratively design a care plan for a real-life elderly patient and reflect on this plan in a workplace-based training program. However, we identified opportunities to further build on Van Lierop, et al.’s⁷ work regarding professional identity formation and to foster a more balanced input from the various health care professions in educational activities. These opportunities prompted us to explore next steps in our IPE design. We were inspired by the landscapes of practices framework which also addressed professional identity formation alongside IPC.

The choice for a new perspective on IPE

IPE has been undertheorized for a long time,^16,17 and has all too often been conceptualized as merely enabling contact between health care professionals, neglecting that this alone might not be enough, and could even reinforce professional stereotypes among students.¹³ Theories focusing on the social dimensions of interprofessional learning, in which building relationships between learners from different disciplines is stimulated, should be an explicit aim and starting point of IPE.¹⁸ This requires curriculum developers to facilitate learning at the boundaries of different professions and professional roles in order to enable learners to explore their own and others’ professions and how each can contribute to IPC.

Landscapes of practice⁸ theory simultaneously addresses identity (as it focuses on understanding one’s own identity and that of other professionals) and knowledgeability about a field and its actors, which is necessary for successful collaboration across professional and practice boundaries. The landscapes of practice framework distinguishes three consecutive modes of identification whereby professionals gradually increase their understanding of oneself, the other, and the systems in which they work and that might affect their view on collaboration. It poses that learning takes place at the boundaries of different professional landscapes. This framework enables the clarification of differences between professions as well as the complexity of relations and interactions between professionals; it describes crossing the boundaries of different landscapes as requiring ‘knowledgeability’ more so than competence.

Theories used to shape IPE often are based on competency-thinking, which emphasizes uni-professional contributions to collaboration, rather than knowledgeability and boundary crossing. For example, social capital theory¹⁹ contributes to interprofessional learning by illuminating the potential advantages of collaboration in interprofessional teams by uni-professional knowledge transfer via group members. (Occupational) Socialization theories²⁰ show the need for shared knowledge in IPE based on interdisciplinarity of learners. Cultural-Historical Activity Theory (CHAT)²¹ focuses on understanding collaborations between persons (or professionals) who temporarily cross boundaries in a network in order to collaborate in workplace environments. So, generally speaking, the above-mentioned theories take the functioning of the individual within an interprofessional context as a starting point for shaping IPE and its relation to collaboration, rather than interprofessional collaboration itself. In our view, landscapes of practice affords a more integrative perspective on IPE by combining the dimensions of identity formation, boundary crossing, and knowledgeability. The latter approach might do more justice to contemporary practice in which health care professionals work in interprofessional teams on complex problems.

Landscapes of practice

The landscapes of practice framework^8,22 is increasingly used in health professions education to understand workplace learning. It explains the complex system of multiple communities of practice (CoP), each containing three dimensions: 1) the domain; 2) the community; and 3) the practice.²² Each CoP has its own domain of competence consisting of a set of criteria and the experiences by which members recognize membership, and the boundaries between CoPs. In earlier work the focus was on single communities in which learners participate. However, this does not do justice to the multiple communities people belong to, and the complexity of current problems. The landscape is a metaphor for the several CoPs and the boundaries between them.²² Although we cannot be competent in all practices in a landscape, when we work in interprofessional teams we cross boundaries, which implies that we should be knowledgeable about what others do, what others mean to us and our work, and what place others have in the landscape.

Wenger-Trayner, et al.⁸ define the concept of knowledgeability as the combination of competence and identity; successfully engaging with the landscape of practice requires a clear understanding of one’s own identity and the identity of other professionals to effectively move between and across the boundaries of CoPs. This understanding is needed to be able to translate the complexity of the landscape into a meaningful service or delivery of care. In other words, those who can cross the boundaries of their own practice and question how the perspective of their own practice are or might be relevant for another practice, show knowledgeability. For these relations, competency in each particular community is not necessary, but identity is. Identity is shaped by the learner’s journey within and across CoPs in the landscape, resulting in an accumulation of different experiences that become part of who the learner is.⁸ However, identity development often is approached from a single professional perspective rather than an interprofessional perspective and is seldom defined as a specific aim of IPE. Wenger-Trayner’s theory on the landscapes of practice⁸ provides principles for an IPE design that facilitates becoming knowledgeable in the landscape or practice, which goes beyond being competent in only one’s own profession, but requires knowledgeability about other professions. The latter can be supported by giving specific attention to professional identify formation in IPE interventions.

Enhanced framework for IPE

In the following section, we explain the three modes of identification distinguished by Wenger-Trayner and colleagues⁸: engagement, imagination, and alignment. We elaborate on how these modes can be used to enhance IPE in the health context, assuming that in this situation professional boundaries will be crossed (see for example Refs.^1–3), and how this process contributes to professional identity development. Using our the IPE example of interprofessional student teams jointly developing a care plan, we will elaborate on how this educational design could facilitate professional identity formation from an interprofessional perspective. Disciplinary thinking, in contrast, is necessary for problem solving in one area of expertise, but will not produce a comprehensive care plan, nor will shaping one’s identity in relation to other professionals’ work occur simply by putting together students from different health professions.²³ What else could enhance professional identity development in IPE, beyond jointly discussing and reflecting on an authentic real-life case? The answer may lie in the three modes or principles of identification (engagement, imagination, and alignment) and how each could inform the design of IPE.

Engagement: How are we relevant to one another?

The first mode, engagement, is the most direct form of identification that enhances competence in the way we work, learn, do, talk, and debate in a particular practice. Engagement in IPE means engaging with different professionals within the landscape of practice and all its inhabitants. Becoming a member of the landscape then means that one knows oneself and the other - in other words how we are relevant to one another.²⁴ For example, medical, nursing, and physiotherapy students should know how they are relevant to one another to provide care for persons with complex health problems. For IPE, this relates to working on issues in one’s own practice through complex, authentic tasks that resemble real life. This can be done through meaningful activities that connect to the needs of the participating students.²⁴ In this stage of bringing students together, it is important that they can develop a sense of why they are relevant to one another and to guide them in learning about the different professional stakeholders in the problem at hand.

In our example, one student, not necessarily the medical student, presents a case:

Meet Mrs. Jones. She is 74 and suffers from Type II Diabetes and complex COPD. She was recently admitted to the hospital with a diabetic foot condition that required the amputation of several toes.

In discussing the care plan for Mrs. Jones, her transfer back home, and follow-up care, the team experiences that a comprehensive care plan requires input from and collaboration with various professions. A relevant task could be: “Describe how and what you can contribute to best manage Mrs. Jones’ transfer back home and aftercare. Listen to your fellow students and then describe what you and the others can contribute and how you can coordinate the contributions.” Van Lierop et al.’s⁷ work aligns well with the principle of enhancing engagement among students to make them aware that the different professions are relevant to one another to address the patient’s problem. However, landscapes of practice suggests that repeated engagement is needed; a single meeting to discuss a meaningful case will not be enough to become a knowledgeable member of the landscape. More cases, gradually increasing in complexity offered in a longitudinal learning trajectory are needed to enhance transfer for practice and to learn from, with, and about other professions.

Imagination: Who are we in our future professional context and in relation to one another?

The second mode, imagination, refers to how we see ourselves in our own role and how we orient ourselves to who we are in relation to each other. Imagination in IPE implies that by moving through the landscape and entering other practices that are affiliated but still unfamiliar, students learn to understand who they are in the landscape of practice or in their future professional context in relation to one another.²⁴ Consequently, within an IPE context, students should be stimulated to reflect on how they see themselves from the perspective of other health professionals. Students should become aware of who they are in the context of their own role and responsibilities in relation to others within their future professional practice; they need to be enabled to reflect on who they are in relation to another.

For example, how a ward nurse might approach Mrs. Jones might differ from how a physiotherapist would do so. To enhance imagination in IPE, educators might stimulate students to reflect on what they share and who they are in relation to each other, and how collaboration might enable them to learn from, with, and about each other. To stimulate imagination, students should be invited to reflect upon their role and responsibilities in a particular patient case. A subsequent IPE task could be to discuss: “What are my roles and responsibilities with regard to Mrs. Jones, and what are the responsibilities of other professionals and how do we matter or relate to one another?” For example, a physiotherapist would encourage Mrs. Jones to become physically active, a GP would monitor her blood glucose levels, and a dietician would help with her calorie intake. All three professionals need to collaborate and relate to one another in order to develop a comprehensive care plan that improves Mrs. Jones’ functioning without interfering with other aspects of the plan (e.g., not prescribing medication that enhances appetite because she does not need a high calorie intake, or increasing physical activity levels which will affect blood glucose levels). On the one hand, the intervention by van Lierop⁷ aligns well with this principle, given that students report becoming aware of what they can learn from each other. On the other hand, to offer high quality care to benefit the elderly, imagination requires an IPE learning trajectory that encourages students to deliberately reflect on how the different professions might matter to one another.

Alignment: How do we align our activities and collaborate?

The third mode of professional identity development is alignment. This is “a two-way process of coordinating enterprises, perspectives, interpretations, and contexts, so that action has the effect we expect.”^8(p.21)Alignment within the context of IPE refers to the diverse professions in practice that need to collaborate successfully, for instance in developing a care plan together, preferably involving the patient, while meeting the patient’s needs.

In our example, this means that students from different backgrounds collaborate successfully in helping Mrs. Jones transfer back home, in keeping her diabetes under control and in managing her COPD. All involved need to understand and speak the language of different professionals and the various systems in which fellow professionals work. All involved also need knowledge of the system and context in which professionals collaborate. This requires a safe environment in which students feel free to speak and ask questions and show respect for other perspectives.

So, collaboration requires coordination of activities that will result in better or safer care. This goes beyond the patient and into the healthcare system. Therefore, the whole of collaboration with other professionals and patients is more than the sum of its parts. This is not expected to be accomplished in one meeting between students of various professions, but requires exposure to a series of complex, authentic cases in a longitudinal learning trajectory that situates learning in students’ professional development in the context of health care practice and the workplace. In other words, students in an IPE setting collaborate with students from other professions in a real work context in which they gain understanding of how their different professions align with one another. They also need to learn to reflect on what might enhance or hinder alignment and collaboration among different professions. Van Lierop, et al.⁷ offers a first start but within the IPE learning trajectory it could be extended by enabling students to discuss their care plan with the patient and organize follow-up appointments. Besides this, students could participate in multidisciplinary care meetings in which various professionals discuss complex cases either with or without the patient or a relative present. Enabling students to attend these meetings and reflect on how (experienced) professionals align and collaborate might them make aware that building trust and respect among team members is crucial.²⁵

Finally, in comparison with single-professions education, a longitudinal IPE learning trajectory requires teachers to take on a different role. Teachers from different professions need to collaborate. In a study on co-teaching²⁶ it was found that successful collaboration between teachers depends on several factors: 1) mutual respect for each other’s contribution; 2) shared ideas with respect to learners and on how they should work; 3) shared knowledge and understanding on how their respective roles contribute to learning; 4) good communication skills; and 5) complementarity (e.g., in personalities that reinforce each other). For IPE this means that teachers need to get to know each other and develop trust to enhance effective collaboration, which often takes time to develop. Besides needing to engage longitudinally, they need to discuss how IPE interventions should to be designed, given their specific context, and also need to imagine how they relate to one another and how they might align with others to benefit the student. Teachers need to find ways to overcome the barriers to designing and implementing IPE learning trajectories. In general, research shows that facilitators of IPE are often ill-prepared for IPE because they are trained in their own profession and do not have much experience with a very diverse student population.^27,28 This requires more attention to staff development in the future, so that facilitators can serve as role models for students.²⁹

Discussion and implications: Knowledgeability as the goal of IPE

All three modes of identification in the landscape of practice are most effective when they co-exist in balance. A balanced combination would result in knowledgeability: A learner will not only be knowledgeable about their own profession, but also about other relevant professions and practices across the landscapes. In terms of identification, the goal is to achieve engagement within and across communities of practice, imagination of self in context, and alignment of activities within context. Therefore, IPE could strive to organize a series of meaningful learning activities centered on a series of authentic, ill-defined problems. In the case of Mrs. Jones, the students would know how the transfer from hospital to home works, what adapted footwear she would need, what kind and levels of physical activity would be advisable for her rehabilitation, and what diet she needs to keep her diabetes under control. In a later stage, students should also know what home care Mrs. Jones needs, how that is organized, and how Mr. Jones can be involved in helping her, for example in motivating her to adhere to her activity program.

Knowledgeability relates to the entire landscape of practice rather than a single community of practice. This also implies the lead is taken by the professional whose expertise is needed to direct care, depending on the situation, at hand.³⁰ So, professionals are sometimes in the lead, and sometimes follow a colleague.

Setting knowledgeability as the main goal of IPE has implications for learning outcomes, teaching and learning activities, and assessment. Learning outcomes could be geared explicitly to boundary crossing and professional identity development. In the example of Mrs. Jones this could mean that by participating in interprofessional teams in an IPE learning trajectory, students would develop a sense of relevance to one another and learn about the different professional stakeholders at hand in complex diabetes health care (engagement). Furthermore, in such a trajectory, students could show awareness of their own role and responsibilities in relation to others (imagination). Students could also be offered opportunities to gain an awareness of the healthcare system and context in which the different professions align and collaborate (alignment). A learning trajectory could include working on a series of poorly structured authentic cases of increasing complexity.

In this trajectory, teachers from different professions act as examples (engage, imagine, and align with each other) and offer students explicit support and guidance. Assessment should no longer solely focus on the development and assessment of discipline-specific knowledgeability and competencies in a specific profession and practice but should align with IPE principles.³¹ This includes a combination of reflections from students, teachers, and patients on how students engage with others, how they see themselves in the whole landscape rather than in their own profession and future practice, and how they re-align work in interprofessional teams that contribute to the broader vision of the landscape. Contrary to what is common, assessment of knowledgeability could be based on a mix of outcomes (competence, collaboration, crossing boundaries), triangulated with multiple sources (students themselves, their peers, teachers, and patients), and include multiple measurement and feedback moments during the learning trajectory as evidenced in a portfolio.

A potential limitation of the proposed approach concerns the implementation, which requires coordination between different curricula. This is often mentioned as a bottleneck for IPE (e.g., Ref.¹³). Furthermore, landscapes of practice was originally developed as a way to explain and guide workplace learning. The current manuscript is the first to propose use of its principles to develop undergraduate education. This approach requires further research and evaluation. Another concern is that not only students but also teachers/facilitators might resist working with interprofessional student teams.^27–29 They lack good examples, as they were also educated in ‘silos,’ and they have difficulties with their role. This implies that staff development should be part of the IP curriculum.

Considering this, to advance this developmental work, we recommend that:

1. Students from different professions are offered an IPE learning trajectory that features a series of authentic cases on which they can engage with their peers to enhance their understanding of how they are relevant to one another in the landscape of their future practice;

2. The design of the IPE learning trajectory ensures that students are deliberately enabled to reflect on their identity and are encouraged to imagine who they will be in their future professional context and in relation to other professionals;

3. The design of the IPE learning trajectory encourages students to collaborate with peers in other professions in the context of the health care system to gain a better understanding of the importance of building trust and respect for one another in order to align and collaborate successfully.

4. The design of the IPE learning trajectory includes a staff development program.

Conclusion

In this article we have addressed the need for an enhanced framework for IPE, based on the ideas of landscapes of practice. We have designed an IPE approach that extends the framework used by van Lierop et al.⁷ through the application of landscapes of practice theory. We propose that an integrated focus on engagement, imagination, and alignment will enable students’ identity formation and increase their knowledgeability as interprofessional practitioners across diverse health disciplines.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content of this article.