Do we need a signature pedagogy for interprofessional education?

KEYWORDS:

• Interprofessional education
• interprofessional practice
• interprofessional identity
• signature pedagogy
• collaborative care
• interprofessional care

Signature pedagogies in the professions

Professional training programs at both the pre- and post-licensure levels seek to endow graduates with not just knowledge, skills, and attitudes but also the values and identity of a profession. To do so, faculty must teach in ways that reflect these values and identity. These educational approaches have been termed signature pedagogies by Lee Shulman, President Emeritus of the Carnegie Foundation. He defined signature pedagogies as “the types of teaching that organize the fundamental ways in which future practitioners are educated for their new professions” (Shulman, 2005).

Signature pedagogies have three interacting dimensions: surface, deep, and implicit structures (Shulman, 2005). Surface structures are the most externally visible of the three dimensions. They represent the concrete and operational acts of teaching and learning, the ones that are apparent to an observer and could be described as learning activities such as a lecture, case discussion, simulation, or bedside instruction. Signature pedagogy characterizes learning as more than just these acts; it views learning as tied to more profound concepts of professional identity.

Beneath the surface structures are deep structures, a profession’s fundamental assumptions and beliefs about teaching and learning. Deep structures specify how knowledge, skills, values, and identity are communicated to learners and shape specific learning activities in the surface structure. While some deep structures are explicitly articulated (e.g., “see one, do one, teach one”), many are more subtly expressed by being embedded in professions’ historical approaches to training or by being reinforced and formalized through processes like accreditation requirements or faculty development programs. While deep structures are less obvious than surface structures, they are representations of how a profession fundamentally conceives of itself.

Underlying surface and deep structures is the most foundational level of signature pedagogy: the implicit structure. The implicit structure is the moral dimension of how a profession is situated relative to society and other professions This moral dimension reflects a critical set of beliefs about professional values, attitudes, and dispositions. These beliefs are the essence of professional identity. Importantly for interprofessional educators, they shape how professions interact with one another.

Through a profession’s signature pedagogy, learners become grounded in the identity of a profession and its moral relationship to society and other professions. Signature pedagogies are the central vehicle by which educators socialize individuals into a profession. They are the teaching handprint that conveys to learners: this is how we learn in our profession, and this is what we value.

Signature pedagogies of several professions have been described. Through the Carnegie Foundation’s Preparation for the Professions Program, (Colby & Sullivan, 2008) Shulman and collaborators published reports on medicine, (Cooke et al., 2010) nursing, (Benner et al., 2010) clergy, (Foster et al., 2006) law, (Sullivan et al., 2007) and engineering (Sheppard et al., 2007). Through a similar approach, Jensen and colleagues recently described the signature pedagogy of physical therapy (Jensen et al., 2019). Occupational therapy (Schaber, 2014) and psychoanalysis (Watkins, 2014) are other fields that have considered this concept. Table 1 provides examples of the three structures of signature pedagogy in medicine, nursing, physical therapy and law.

Table 1. Examples of Signature Pedagogies^a

Signature Pedagogy Dimensions	Medicine	Nursing	Physical Therapy	Law
Implicit Structure	Diagnostic acumen	Ethical comportment	Movement for health, well-being, and function	Desire for justice
Deep Structure	Learning in a community of practice with experts	Coaching during situated teaching	Learning through interaction with the human body as teacher	Analytical reasoning of established case law
Surface Structure	Clinical teaching during ward rounds	Teaching for salience	Honing skills of touch and observation	Classroom-based case dialogue

^aProfessions typically have multiple signature pedagogies. We provide one example of a signature pedagogy for each of these professions.

Consider an example of the three structures in medicine: one surface structure of medicine signature pedagogy is learning on the hospital ward via the Socratic method (i.e., being questioned about patient evaluations). A deep structure or teaching assumption embedded in this process is that diagnostic reasoning is best learned through an iterative process of evaluating patients with undiagnosed complaints, presenting this information to more clinically expert teachers, and receiving feedback from these practitioners about the diagnostic process. These assumptions stem from implicit structures formed from characteristics – perhaps thoroughness, perspicacity, and independence – necessary for a learner’s ideal professional identity. While learning about diagnosis is happening at the level of the surface structure, faculty are also instilling and reinforcing fundamental aspects of their professional identity.

Though many signature pedagogies have been around for decades, this concept is relatively newly defined and still evolving. A recent review focused mostly on nursing described the research around signature pedagogy and identified three challenges typical of a novel concept: 1) confusion around terminology, 2) uncertainty about how best to define signature pedagogy, and 3) the need for this concept to be more widely accepted and supported (Crookes et al., 2020). Signature pedagogies seem important for educators to contemplate with perhaps its most important implication being its unintended impact.

Shulman described several ways in which deep-rooted signature pedagogy can be negative (Shulman, 2005). For example, the Socratic method, a common teaching habit in some professions, can be problematic. Questioning can turn malicious, creating a deleterious learning climate and undercutting individual performance as well as and psychological safety (i.e., the willingness to take an interpersonal risk) (Kost & Chen, 2015). For interprofessional learning, this approach may set a poor example of collaborative practice and inadvertently discourage future collaborative work. Shulman articulated this duality more broadly and the challenge of what signature pedagogies do or do not convey, noting that signature pedagogies:

… involve a choice, a selection among alternative approaches to training aspiring professionals. That choice necessarily highlights and supports certain outcomes, while usually unintentionally failing to address other important characteristics of professional performance. (Shulman, 2005, p. 55)

While these choices can be nuanced, they may have lasting influence on learners and their patients.

Unintended consequences of signature pedagogies may have enduring, historical roots dating back generations. Some of these foster the development of unanticipated impacts on learners and their work while others simply cause curricular methodologies to remain static, even in the face of societal changes and shifts in professional values. Consider: as professions carved out their roles in society in the early years of licensed medical practice, signature pedagogies emerged as a set of teaching strategies and a professional blueprint, reinforced by structures like licensure and certification, representing a profession’s value to society (Starr, 1982). When Abraham Flexner documented and defined the idealized medical curriculum early in the twentieth century, for example, (Flexner, 1910) he set in motion a process that to this day defines medicine’s signature pedagogies of hospital-based clinical education yet also devastated the Black physician workforce (Campbell et al., 2020). Similarly, nursing’s signature, dating back to the Winslow-Goldmark Report (Goldmark, 1923), and public health’s signature from 1915 (Petersen & Weist, 2014) may need review within today’s context and the evolving social and moral missions of these professions. While signature pedagogies should transmit the ideal moral foundation that shapes professional identity, signature pedagogies are resistant to change and may not evolve as the needs of society and our understanding of justice change.

Signature pedagogies are then a necessary yet fraught concept. Over the past hundred years, our society has become globalized and technology-driven. Causes of death have shifted from infections and malnutrition to chronic cardiovascular disease and cancer. Recognition of social determinants of health has expanded our understanding of health and added layers of complexity to care delivery. In response, the Carnegie reports on the signature pedagogies of medicine and nursing education emphasized the need for “reform” (Cooke et al., 2010) and a move toward “radical transformation,” (Benner et al., 2010) suggesting it was past time to reevaluate and implement substantive change. Yet, when change is necessary, reformers face barriers not just from educational leaders but also from faculty who have learned to teach only within the approaches of specific signature pedagogies.

Newer approaches to professional education may struggle as they adapt signatures from other learning contexts. For interprofessional education, authors have noted that “the pedagogy of medical education is not geared to team learning” (Morrison et al., 2010, p. 256). Important concepts for collaboration like power and conflict may be unexplored and, if ignored, may magnify adverse experiences during single-profession and interprofessional education (Paradis & Whitehead, 2018, Appelbaum et al., 2020). Inadequately considered, interprofessional education can lay the wrong foundation for the desired interprofessional identity and hinder future interprofessional collaboration. The transformation of modern health professions education – including the implementation of interprofessional education – should include reexamining signature pedagogies to address the evolving needs of populations and to mitigate the harms of antiquated signature pedagogies.

Applying signature pedagogy to interprofessional education

The increasingly complex care of today demands that all health professionals exit their pre-licensure education with the knowledge, skills, values, and professional identity supportive of interprofessional care (Health Professions Acceditors Collaborative, 2019; National Collaborative for Improving the Clinical Learning Environment IP-CLE Report Work Group, 2019). The goal of preparing a more collaboration-ready workforce should spur us to explore the application of signature pedagogy to interprofessional education. While we have made significant strides in achieving consensus around interprofessional competencies (Interprofessional Education Collaborative, 2016) and incorporating them in accreditation recommendations (Health Professions Acceditors Collaborative, 2019), there is limited evidence that students graduate with entry-level competence in these domains (Institute of Medicine, 2015). One reason is that learning activities for interprofessional education are viewed as successes if they simply overcome the increased logistic barriers inherent in this arena (Lawlis & Greenfield, 2014). However, if a goal of interprofessional education is to instill an interprofessional identity, these learning activities may fail to inculcate this identity if they are not linked to the moral foundation of interprofessional collaboration. What may be lacking is a coherent interprofessional pedagogy that supports the formation of a collaborative professional identity through learning activities that advance health outcomes.

Applying the framework of implicit, deep, and surface structures to interprofessional education may demonstrate that many activities appear to only address the surface or, possibly, deep structures. For example, ongoing efforts to involve other professions in medicine ward rounds typically do not integrate the deep and implicit structures underlying the professional identities of all participating professions. Because each profession’s implicit structure may not be embedded in the learning activity, learners may experience professional or moral conflict (Barr, 1998). Non-medical students may passively watch rounds, feel marginalized, and contribute little to improve interprofessional collaboration and patient care. These interactions may reinforce hierarchy and negative professional stereotypes and further undercut interprofessional collaboration (Garman et al., 2006).

An alternative to this approach is to incorporate the implicit structures of each profession into the deep and surface structures of existing interprofessional learning activities. In our example, if students from nursing and physical therapy students were included in medicine rounds, could the holistic approach of nursing or the functional emphasis of physical therapy be melded with the implicit structure underpinning the teaching of diagnostic acumen? Potentially, but an entirely different teaching and learning approach may be needed to better include the implicit structures of all involved professions. Here, the concept of signature pedagogy helps us critique our current approaches and identify where we fall short.

Embracing signature pedagogy lead us to this conclusion: we must start anew. Because building on current learning activities may be challenging and may not lead to the “radical transformation” espoused by Carnegie and needed by society, we may need to co-create new signature pedagogy for interprofessional learning – one that reflects shared values about collaboration and is unencumbered by implicit structures that undermine efforts to work together in meaningful and effective ways. Creating new, transdisciplinary signature pedagogies must go beyond merely blending several professional pedagogies (Gray, 2008; Lingard, 2016; National Research Council, 2015). Rather, we need signature pedagogy that, as Barr described, includes overlapping areas of profession-specific and interprofessional competence (Barr, 1998). These “common competencies” may be representations of the implicit structures for interprofessional learning. By articulating the underlying implicit structures, we might be able to establish more effective teaching assumptions as deep structures and pedagogical approaches at the surface structure.

Next steps for interprofessional education

Considering signature pedagogy forces us to define the “why” of the implicit structures and moral foundation for interprofessional education as we build the “how” of the deep and surface structures for interprofessional curriculum. Signature pedagogy is a powerful concept for understanding professional identity formation by connecting learning activities and teaching assumptions to moral foundations and common competencies. Current signature pedagogies from individual professions may hinder interprofessional learning. As such, signature pedagogies for interprofessional learning may be essential to boost interprofessional education and the development of interprofessional professional identities.

One next step to advance the concept of signature pedagogy for interprofessional education is to examine the concept of signature pedagogy within each of our own professions and identify how these approaches support or hinder the ideals of interprofessional collaboration. We may discover instructional approaches built on moral foundations that are not consistent with our current conceptualization of optimal care. For example, many entities that oversee educational programs such as accreditors or licensing boards require that students be taught by their own profession even as we have realized the value of learning from other professions. This intraprofessional work may be best facilitated by existing professional societies, and interprofessional scholars and leaders may be the best advocates within their own professions to examine these signature pedagogies and identify where change is necessary.

Another next step is to define the foundation of implicit structures for interprofessional practice and the desired interprofessional identity (Khalili et al., 2013), (Tong et al., 2020), (Thistlethwaite et al., 2016) (McGuire et al., 2020). This work could be done by the community of interprofessional practice and scholars to help solidify the underpinnings of our educational programs. While our current moral foundations across professions appear to share values – quality, safety, patient-centeredness, access to care, and mutual respect, these are not always be well-articulated or demonstrated in teaching, especially as we struggle to overcome logistical challenges. Solidifying this moral foundation is essential to ensure our interprofessional education is grounded in purpose and that new signature pedagogies for interprofessional education are based on collective assumptions about how future practitioners should learn in order to become collaboration-ready. Otherwise, we risk providing education via surface structures that are untethered from the aspiration of developing long-lasting interprofessional professional identities. From this solidified foundation, we can reach consensus on the assumptions about learning inherent in the deep structures and the most fitting approaches to teaching and learning as surface structures.

For over a decade, our field has been guided by the definition of interprofessional education as being “with, from, and about” (World Health Organization, 2010). Competencies have provided us endpoints (Interprofessional Education Collaborative, 2016). Signature pedagogy pushes us to consider the “because”. We educate our interprofessional learners with this approach because we hold these assumptions about how best to learn because we have a shared interprofessional moral foundation. Answering this question of “why” at the implicit, moral level is critical as we develop the surface and deep structures of “how” across both interprofessional and single-profession education. To graduate the collaborative healthcare practitioners needed for our modern world, we must ask these questions and create signature pedagogies for interprofessional education.

Declaration of interest

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

Previous presentations

Initial ideas underlying this manuscript were presented at the “Collaborating Across Borders” conference, October 23^rd, 2019 Indianapolis, IN.

Additional information

Notes on contributors

Alan Dow

Alan Dow, MD is the Seymour and Ruth Perlin Professor of Medicine and Health Administration and Assistant Vice President of Health Sciences for Interprofessional Education and Collaborative Care, Virginia Commonwealth University, Richmond, VA.

Andrea Pfeifle

Andrea Pfeifle, EdD, PT, FNAP is Associate Vice Chancellor for Interprofessional Interprofessional Practice and Education; The Ohio State University and Wexner Medical Center; Columbus, Ohio.

Amy Blue

Amy Blue, PhD is Associate Vice President for Interprofessional Education, Clinical Professor, College of Public Health and Health Professions, University of Florida; Gainesville, FL.

Gail M. Jensen

Gail M. Jensen, PhD, PT, FAPTA, FNAP is Professor of Physical Therapy and Vice Provost for Learning and Assessment and Dean, Graduate School; Creighton University; Omaha, NE.

Gerri Lamb

Gerri Lamb, PhD, RN, FAAN is professor in the College of Nursing and Health Innovation and Founding Director for the Center for Interprofessional Practice, Education and Research at Arizona State University, Phoenix, AZ.