Students’ perceptions of interprofessional learning through facilitated online learning modules

Abstract

Background: Asynchronous e-learning is an appealing option for interprofessional education (IPE) as it addresses the geographic and timetabling barriers often encountered when organizing activities across educational programs.

Aim: This study examined the extent to which pre-licensure students were able to learn with, from, and about each other through completion of innovative online IPE learning modules.

Methods: Seventy-seven students completed e-learning modules developed through a consortium of educational institutions. Evaluation was primarily qualitative through focus groups, interviews, analyses on off-line discussions and an online feedback form.

Results: Qualitative analyses of the discussion fora revealed that students were able to solve problems collaboratively, clarify their professional roles, and provide information from their professional perspective. Focus groups and interviews reinforced that students recognized the importance of working together and implicate clinical education as an important venue to reinforce learning about collaborative practice. Analyses of the online feedback form suggest the need for clear processes related to group assignments and deadlines.

Conclusion: Students learned about each other's role, solved problems together and had positive perceptions of the online modules as a venue for interprofessional learning. Results are encouraging to those interested in using e-learning in IPE as part of an overall curriculum.

Introduction

Enhancing interprofessional learning among health professional students is a laudable goal for educational institutions. However, logistics such as geography and scheduling of interprofessional education (IPE) curricular events remain a challenge for educators trying to organize activities across health professional programs. Scheduling IPE events outside of students’ profession specific timetable is an option, but can also send a hidden message that these activities are less important. An asynchronous online learning curricula has appeal as it can circumvent timetabling barriers.

The body of literature examining online interprofessional learning is only starting to emerge. Much of the literature is descriptive; for example, Walsh (2007) described feedback from nurses and physicians who had participated in online learning modules developed by the British Medical Journal. Connor (2003) presented an example of virtual learning that enabled students to learn about interprofessional collaboration and proposed some recommendations related to the experience.

Others have attempted a more rigorous approach. Carbonaro et al. (2008) examined whether team process skills taught in a traditional classroom format could be taught successfully in a blended learning setting. They found no differences between student scores on team process between the two formats; however, students who participated in the blended learning situation had more positive perceptions of their interprofessional course achievements. Miers et al. (2007) examined student experiences with online interprofessional learning through qualitative analysis of discussion boards and student interviews. While students shared professional knowledge, their discussions were superficial and showed limited evidence of reflective analysis and evaluation. Recently, Casmiro et al. (2009) highlighted the importance of a theoretical framework to guide development of interprofessional online learning and noted a shift to constructivist views of learning to underpin these courses.

The Institute of Interprofessional Health Sciences Education (IIHSE) was developed to design and evaluate a novel approach to IPE. It is a virtual e-learning center funded by Health Canada's IPE for Collaborative Patient Centered Practice initiative. It consists of a consortium of four universities, McMaster University, University of Western Ontario, University of Ottawa, and Laurentian University and the Council of Ontario Universities, a provincial coordinating body. This article reports on the extent to which health professional students are able to learn with, from, and about each other through completion of innovative online IPE learning modules.

Table

Practice points

Asynchronous online learning can overcome timetable barriers, a significant barrier to IPE. Students are able to engage in collaborative problem-solving and learn about each other's roles in an online learning environment. Online faculty facilitators are important to role model interprofessionalism and make collaboration more explicit.

Methods

Development and implementation of the modules

Each university took the lead in development of modules which aligned with specific areas of content expertise (Table 1). A total of eight modules were developed for pre-licensure learners in the health professions; the curriculum of each module was based on the philosophy of IPE of the IIHSE. Initially, the consortia partners developed a philosophy and the principles of education which guided the design of the curricula. The philosophy reflected a constructivist approach to learning which was then operationalized through an agreement that each curricular module be developed by interprofessional teams to ensure relevance to all students within the participating institutions. Additionally, the modules were planned for flexible delivery to be used as a stand-alone educational event, integrated into the existing curricula or a combination. The modules ranged in length from 3–12 weeks.

Table 1.  Institute of interprofessional health sciences education: student modules

Communication 1: Establishing and understanding groups	McMaster University
Communication 2: Making the most of groups and teams	McMaster University
Interprofessional health care ethics	McMaster University
Interprofessional stroke care: An evidence based approach	McMaster University
Culturally informed aboriginal health care	Laurentian University
Promoting the health of the community	University of Western Ontario
Palliative care/total pain	University of Ottawa
Interprofessional health care in rural areas	University of Ottawa

All curricular modules adopted use of problems or case scenarios as a stimulus for learning to support the authenticity of learning, an important component in successful interprofessional learning (Hammick et al. 2007). In addition, the use of problem-based learning (PBL) was intended to encourage interaction, collaboration and to engage learners (Solomon 2005). As some of the nuances of face-to-face PBL (e.g., ability to react to body language and tone of voice) are not possible in an online venue, the modules provided direction in the form of prompting questions throughout. Questions were also purposeful in their attempts to promote interprofessional learning. In order to foster collaboration, students were expected to complete some of the assignments in small interprofessional groups (e.g., develop a patient care plan). Students were expected to share their opinions and findings through an online discussion forum. Additionally, module developers attempted to integrate many innovative and engaging elements such as video clips of patient interactions, patient narratives, and progressive disclosure of patient histories using the patient's voice into the modules. Detailed reports on the design and unique features of individual modules are available elsewhere (Carter & Rukholm 2009; Hall et al. 2009; Luke et al. 2009, Solomon & Geddes 2009; Solomon & Baptiste in press).

The modules were intentionally designed to be facilitated by an experienced faculty member. Facilitators varied with respect to their experience with online learning, however, all were knowledgeable about IPE. Use of facilitators was deemed essential to role model collaboration and make interprofessional learning explicit to the students. For example, if a profession was not represented, the facilitator could prompt students to assign someone to play the role of that profession. Another example relates to students who have comparatively little clinical experience; the facilitator can help dispel feelings of inadequacy and ask questions which stimulate discussions by the entire group. Facilitators are also important for building and strengthening online group process (ELF 2006) and can help students make the link between concepts and encourage reflection. There was some variation in how each module unfolded as this was dependent on the ground rules that were established and the composition of each group. Typically, there was a period of initial socialization in which students introduced themselves and their professional role. Students who ran into technical difficulties were provided with an e-mail contact though this was not always immediately available given that students were often online during the evening hours.

Participants

Student volunteers were recruited from each participating institution through advertisements on student websites and posted fliers. All students enrolled in health professional programs at each of the participating universities were eligible to participate. Students were from a variety of professions as noted in Table 2. Upon completion of a module, students were invited to participate in either a focus group or individual interview depending on their availability. Students were provided with an honorarium of $50 in recognition of the time spent on the evaluative component of the modules.

Table 2.  Demographic characteristics of students

	n	%		n	%
Gender			Health profession program
Male	10	13.0	Occupational therapy	23	29.9
Female	67	87.0	Medicine	15	19.5
Age			Nursing	14	18.2
≤20	5	6.5	Physiotherapy	7	9.1
21–30	47	61.0	Social work	5	6.5
31–40	5	6.5	Spiritual care	4	5.2
≥41	4	5.2	Speech language pathology	3	3.9
Missing	15	20.8	Health promotion	3	3.9
			Dietetics	2	2.6
			Pharmacy	1	1.3
University attending			Year within program
University of Western Ontario	24	31.2	First year	29	37.7
University of Ottawa	24	31.2	Second year	17	22.1
McMaster University	21	27.3	Third year	12	15.6
Laurentian University	4	5.2	Fourth year	11	14.3
St. Paul University	2	2.6	Missing	8	10.4
Other	2	2.6

Note: n = 77.

Evaluation

Qualitative methods were used to assess students’ learning using three types of data. The online discussion text from all modules allowed for direct insight into actual “conversations” and collaborative problem-solving. The discussion fora were downloaded directly into NVivo (2007) for qualitative analysis. Focus groups and individual semi-structured interviews of students at completion of the project were conducted to gain further insight into students’ perceptions of learning that had occurred. The focus of the student interviews and focus groups was to learn about their values, attitudes, and perceptions of IPE and collaborative practice and to reflect on their experiences. The interviews and focus groups were audiotaped and transcribed verbatim and entered into the NVivo software program. The analysis followed a conventional content analysis according to Hsieh and Shannon (2005). This began with reading the text line by line and assigning a code to capture key meanings or reactions expressed by students. Two of the investigators (PS and SK) and a research assistant independently developed codes and then met to refine the coding list. Following development of the codes, the research assistant analyzed the remainder of the discussions with periodic reviews by the investigators to confirm the coding assignment, reconcile any discrepancies, and adding new codes if necessary. Once all discussions had been coded, the final step consisted of the investigators reviewing all data within a specific code, combining, and forming new codes to form themes.

In addition, at the completion of each module, students completed an online feedback form so that we could gain insight into their perceptions immediately following their experiences. The form had items in the form of statements related to educational content (15), online discussions and teamwork (7), online facilitation (4), and online support (3). Students were asked to rate their level of agreement with the statements on a 5-point scale ranging from strongly disagree to strongly agree.

This study received ethics approval from each of the educational institutions participating in this project.

Results

Of the 156 students who agreed to participate, 83 (53%) completed the entire module. Six students took more than one module, resulting in a sample of 77. Thirty students participated in individual interviews while 34 students participated in one of the 10 focus groups, leaving a total of 64 students who completed the follow-up components of the program evaluation. Table 2 outlines the characteristics of the students. Sixty-six percent (66%) reported previous experience with online learning, 66% with online discussions, and 60% working with students from other professions. Sixty-seven students completed the online module feedback form.

Discussion forum

Seven themes emerged from the discussion: importance of communication strategies, clarifying professional roles, problem solving together, recognizing and valuing collaboration, providing information from own professional perspective, positive attitudes to IPE, and moving the process forward. These will be described in the following sections with representative quotes.

Importance of communication strategies

Students demonstrated awareness of the centrality of communication in collaborative practice and the importance of developing communication strategies as a team. This entry from a physiotherapy student summarizes her perceptions:

“It is amazing how we are all from different work places, maybe different cultures. We all were able to focus on the importance of communication and its importance to the effectiveness of an outcome for a client. We all agreed on the importance of the introduction, active listening and effective communication. … we really all thought that involving the daughter with those meetings or another meeting will be a great step …., the agreement really tells us we are one step ahead and we understand better PCC [patient-centred care] …. ” [Physiotherapy student].

Clarifying professional roles

Students developed team management plans in several of the modules. In doing so, they reflected on their case scenarios or patient problems and noted their need to be able to clarify their professional roles within teams. At times, students also had to advocate for their professional involvement in patient care:

“As a social worker, I would listen to everything that [the patient] wished to share with me. I would use an non judgmental and non biased approach. I would possibly try to obtain further information on the history of the family dynamics. I would assist him in obtaining help in areas that he wished. If he wished to obtain medical help, I would provide him with contacts. If his physical well being is affected, other areas of well being can also be at risk. Through out all of the sessions with him I would be respectful upon all of his wishes” [Social work student].

Problem-solving together

Students learned to build on each other's ideas and solve problems together as an outcome of their shared work. Not unexpectedly, as the modules evolved the students became more familiar with each other and often became more candid in their responses. This posting from a student not only illustrates problem-solving but also shows how the student was able to provide positive feedback to another student:

“Your observations help me to really zone in on the heart of what's wrong … namely, this interview was not client centred (how could it be when she was on the periphery, not asked to tell her story and discuss issues) and there was no probing or discussion to help everyone understand issues and other's perspectives more fully. Therefore they could not move into a solution phase, because they remained stuck in their own positions” [Occupational therapy student].

Recognizing and valuing collaboration

Students developed the ability to identify when collaboration was occurring and often discussed the value of a collaborative approach. A spirit of camaraderie evolved, which reflected a view of students seeing themselves as a “team” of learners:

“I find it interesting to read other professional comments throughout our discussions because we all have similar goals, even though we are all educated in different areas of healthcare. I think that is a good sign towards interprofessional collaboration” [Dietetics student].

Providing information from own professional perspective

The students learned the importance of declaring their professional perspective as they proceeded through the modules. They would provide information but at times overtly took ownership of the information from their professional viewpoint:

“In medicine, clinical practice guidelines are the most common and direct medium in which evidence based practice is used. As the article by the GRADE working group pointed out, clinical guidelines are only as good as the evidence they are founded on (Atkins et al. 2004). This points out the importance of being able to critically evaluate research” [Medical student].

Positive attitudes towards IPE

Throughout the module, there were indications of the enthusiasm with which the students approached their tasks and for the collaboration that emerged as they worked together.

“Wow, this is a real teamwork! Thank you for your wonderful ideas, guys. You provided some excellent suggestion and strategies of team effectiveness. I like [OT student's] ideas of shared leadership and ongoing prof development. Also I think [PT student's] strategies of make it mandatory is an effective way” [Nursing student].

Moving the process forward

It was also apparent that students were aware of their learning process and content. Various strategies were used to move discussions and decision making forward. including supportive comments by students towards other students:

“I really like the idea of encouraging each other to participate with leading questions. It makes the task of coming up with something to say a bit easier” [Medical student].

Students were comfortable asking for other's opinions and perspectives:

“I agree that all concerns of the team and the family should be expressed and dealt with as soon as they arise, but it should be done by the whole team as a unit. What do you think guys?” [PT student].

Interviews and focus groups

As the themes that emerged from the analyses of the interviews and focus groups were similar, the data are jointly presented in the following sections. Themes emerging from the transcripts were the importance of working together, reflecting on clinical experiences, impact on the patient, and positive learning.

The importance of working together

Students recognized the importance of interprofessional collaboration and the value in problem-solving and working together:

“There's things that I can do that perhaps someone else can’t do but there's things that someone else can do that I can’t do … You have to inter-depend on one another to sort of reach whatever you’re trying to do or solve a problem inside a case … that's what I think about interprofessional collaboration” [Medical student].

Students grew to appreciate the need to communicate and behave in a manner which respected each other's professional roles:

“I … learned about the importance of respecting the role of the different professions and that they do have a role and just because you don’t know about it very well doesn’t mean that it's not justified and especially when on placement too like just each … like people have to respect OT as much as the OT's respect them. I think that's … one of the most important things for interprofessional collaboration. I think that's probably what's missing right now in health care too, is a lot of the respecting each other” [Occupational therapy student].

Reflecting on clinical experiences

Many students reflected on their clinical experiences from both positive and negative perspectives. Positively they observed role models for collaborative practice. However, many also discussed situation in which they had seen little collaboration and examples of disrespectful communication:

“When I’m in the hospital setting doing my clinical I don’t see a lot of interprofessional teamwork at all to be honest … The doctors are doing their own things, the PTs are doing their own things. I never see them as a team together, talking or collaborating. It's usually through notes or through records … not actual[ly] let's get together and talk about the patient or … have the team members with the patient. It's usually the Nurse and the patient, the Doctor and the patient, the PT and the patient and … ” [Nursing student].

Impact on the patient

Students perceived that ultimately collaborative efforts would result in better patient care. Through their interactions and increased understanding of the roles of others, they learned that patient problems are often complex and that by working together, they could provide better patient care:

“But it's really important that you’re able to communicate with different types of health care providers just because a patient isn’t one dimensional. They’re three dimensional. You need to know … if they’re going to have OT care or PT care. You need to know what the Doctor's reports are. If you can’t communicate … if you don’t have effective communication between team members and the patient, you won’t be able to provide the best possible care for the patient and that's something we learned too during the module. Like we all incorporated our own ideas and it's one really, really good patient care plan” [Nursing student].

“There's so many different dimensions to a person's health and so when everyone gets training in different areas then we can give the patient the best quality care when we’re getting everyone's basic instincts to the table” [Physiotherapy student].

Positive learning

Students identified many positive aspects to their learning including the challenging of stereotypes of roles or prevalent attitudes of and towards other health care professions:

“It was good that way … especially before you get out there and practice and go in with these stereotypes, it's nice to see that they aren’t true” [OT student].

In reflecting on their learning, students expressed their belief that IPE would be helpful as they anticipated their future careers:

“As it is, we are all learning some of the same skills, yet in different ways because we all get our separate educations, but if we were to combine some of our education, get to know each other earlier in our careers, then it would be a lot easier for all of us to learn and work together in a lasting relationship” [Medical student].

Student module feedback form

The results from the Student Module Feedback Form are presented in Table 3. For ease of reporting, the number of students who indicated that they agree or strongly agree with the statements has been combined to form an overall percentage of student who agreed with the statement. Results generally support those of the qualitative analyses with all students agreeing that learning from students of other professions would help them better understand clinical problems and 98.5% agreeing that interprofessional learning would help them become a better health professional. Items related to the online discussions and team work demonstrate that only half the students (49.2%) agreed that guidelines for forming groups were clear and even fewer (35.6%) agreed that deadlines were specified. Approximately two-thirds of the students (67.2%) felt that the facilitator provided excellent guidance. The response to the items related to online support shows that there were mixed feelings about the technical support as while only 32.3% agreed that the technical support was “great”, a smaller percentage (18.4%) agreed that it took a long time to get technical support or answer technical questions.

Table 3.  Student module feedback form results

tems related to educational content	Percentage of students who agreed/strongly agreed with statement*
Shared learning with students from different health professions will help me better understand clinical problems	100%
Interprofessional learning will help me become a better health care professional	98.5
I was able to learn about other students’ perspectives on the subject matter of the module	95.6
I was able to learn about other students’ roles and responsibilities	92.5
This module provided me with opportunities to work with students from other professions on identifying and defining problems	91.1
Compared to the beginning of the module, I have a better knowledge of other students’ perspectives on the content of this course	91.1
Shared learning with students from other health professions will increase my ability to manage clinical problems	91.1
This module taught me about working collaboratively within a team for better patient outcomes	86.6
Compared to the beginning of this module, I am better able to identify shared tasks that require joint solutions	83.6
This module provided me with opportunities to work with students from other health professions on finding solutions to joint problems	82.1
The course content was directly related to the learning objectives	80.6
This module taught me about IPE	78.7
Compared to the beginning of this module, I have a better knowledge of the specific tasks of professionals from other disciplines	74.7
Compared to the beginning of this module, I have better skills in coordinating actions with other health care professionals in pursuing joint solutions to problems	67.1
Because of this module, I now have better skills in joint planning and decision making with other health professionals	62.7
Items related to online discussions and team work
Team based assignments were relevant to learning	77.6
Guidelines for online discussion (such as netiquettique) were provided and were helpful	76.1
Expectations were clearly specified for participation in team-based activities	74.6
I enjoyed online discussions	74.3
After completing this module, I am confident about working as part of a collaborative team	71.6
The guidelines for forming groups were clearly provided	49.2
Deadlines were specified and the consequences of missing deadlines were clearly stated	35.9
Items related to online facilitation
The availability of the instructor was clearly specified	83.6
The facilitator provided excellent guidance on assignments or content	67.2
I was often confused about where to submit assignments that were due	27.3
The facilitator took a long time to answer questions or get back to me	22.7
Items related to online support	*
The availability of technical support was stated	59.7
Deadlines were specified and the consequences of missing deadlines were clearly stated	35.9
The technical support for the web-modules was great	32.3
It took a long time for me to get technical support or for someone to answer my technical questions	18.4

Discussion

The qualitative analyses reveal that students learned about each other's roles and solved problems together and that they had positive perceptions of the modules as a venue for interprofessional learning. The discussion forum provides direct insight into actual “conversations” and examples of processes guiding development of collaborative problem-solving. Throughout these online conversations, positive feedback and awareness of processes to move their learning teams forward were evident. A consistent outcome was the development of students’ learning of what constituted interprofessional learning and collaborative group work. Although the students were from different institutions and the modules addressed different content areas, our results demonstrate that students were able to solve problems collaboratively, clarify their professional roles, and provide information from each of their professional perspectives.

A comprehensive review of IPE literature revealed that authenticity of learning is important to facilitate interprofessional learning (Hammick et al. 2007). Arguably, an online environment is neither a realistic nor an authentic environment. However, problem-based scenarios incorporating patient narratives and video clips of patient interactions were used to promote realism. While interacting face to face, in a real clinical environment would promote a higher fidelity learning experience, the online environment is safe and the asynchronous design overcomes the geographical and timetabling barrier of implementing IPE. Health professionals are increasingly interacting online via e-mail, personal digital assistant, and text messaging, and as electronic health records and other technologies evolve this mode of learning may start to reflect current practice to a greater extent.

There is little in literature to help determine the optimal length of time required for students to develop online relationships and to learn with, from, and about each other. Our shortest module was 3 weeks in duration. Students who completed this module reported that they were engaged and learned knowledge and skills of each other. Dufner et al. (2002) found that 2 weeks was insufficient for accomplishing a group task; however, in this study, the intent of the learning experience was neither interprofessional learning nor related to patient decision making. We intentionally used facilitators to guide learning processes and designed health care problems that would promote interprofessional interactions. The quality and design of the curriculum and the experience and role of the facilitator will be key factors in determining the breadth and depth of learning.

Ideally, a facilitator would have expertise in the content area of study, online learning, and in IPE. Not unsurprisingly, it was difficult to find faculties with this combination of experience. All the faculties were experienced educators familiar with the goals of IPE. An orientation to facilitating online was provided and all had access to support for advice on both the content and process of learning. “On the job” learning for online facilitators appears to be common (ELF 2006) and we felt it was more feasible for experienced faculty committed to IPE to learn online teaching skills then for experienced online faculty to learn about IPE. Our findings differ somewhat from Miers et al. (2007) who found little evidence of analytical and evaluative skills in their online course for health and social science students. From our perspective, the role of the facilitator is essential to foster critical analysis through the use of stimulating and challenging questions and observations (Solomon & King 2010).

The student discussion fora illustrated that the students enjoyed reflecting on their experiences and that direct application of their learning to practice would be an ideal reinforcement of their learning. Students were also eager to share their practice experiences in which they observed lack of collaboration or disrespectful communications. This speaks of the need to allow students’ opportunities to reflect, debrief, and learn from “negative” as well as “positive” experiences. E-learning is reported to allow students to take more time to formulate their thoughts and promote reflection (Dufner et al. 2002). Without opportunities to discuss discomforting situations they have observed, there is a risk that students will not buy into the philosophy or may perceive that collaborative practice is an unattainable ideal.

The perceptions of the students immediately following the completion of the modules as assessed through the module feedback form is generally positive and supportive of the qualitative data. Student assessment of the more pragmatic processes suggests that the online modules need to have clear processes related to forming groups to complete assignments and state clear deadlines for posting for online discussions and assignment. The majority of students had prior experience with online learning; this may account for the mix in perceptions related to online support. It is important to note that issues related to usability of the modules did not emerge as a theme in the qualitative measures.

There are a number of limitations to this study, the primary one relating to the fact that this evaluation was limited to assessment of students’ immediate online interactions and their perceptions of learning. As with numerous evaluations of IPE, the long-term influence on students’ attitudes, behaviors, and actual clinical practice are unknown (Hammick et al. 2007). Others have written about the inherent difficulties in attempting to conduct a longitudinal evaluation of the effectiveness of IPE curricula. If an intervention cannot, at a minimum, influence students’ immediate perceptions, then it is unlikely to have any lasting effect. This study can also be criticized for the poor completion rate of the participant learners. Given that participation was totally voluntary, without credit and many of the courses occurred in the summer months, we were actually pleased with the completion rate. This does not negate the possibility that this was a biased group of students that were predisposed to positive attitudes towards collaboration. An additional limitation is related to the fact that we aggregated data across modules. Although the modules were developed based on similar pedagogical principles, they varied in design, use of innovation, and in content and facilitator, and one could query the wisdom of combining these data. Finally, these modules were developed and implemented across a consortium of universities, each with their own idiosyncrasies. This is arguably an advantage in that successful implementation in a variety of contexts suggests that the online modules were adaptable to the context. Our intent was to design modules that were highly adaptable and useable. However, we recognize that this makes it difficult to identify contextual details from a specific institution that may have impacted upon the students’ learning.

In spite of these limitations, we feel that the results of our study are encouraging to those interested in using e-learning in IPE. Students clearly enjoyed their online learning and interactions. Analyses of the online interactions demonstrated that the students went beyond simply presenting their information to building on each other's ideas to work towards a common goal. In addition to learning the collaborative process foundational to interprofessional practice, students shared knowledge and content about their respective professions. Given the limited literature on online interprofessional learning, this study provides an important foundation for future research.

As noted in a recent article, the understanding of how learners acquire knowledge in an online environment is still evolving (Casimiro et al. 2009). Arguably, how students learn interprofessional knowledge, skills, and attitudes in an online setting is a more complex question worthy of further study given the potential of this mode of learning. Studies which examine whether online learning is superior or equal to face-to-face interprofessional learning are also warranted.

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