Dr. Deborah Craddock University of Southampton

1. LESSONS LEARNT FROM A NATIONAL STUDY OF PRE-REGISTRATION INTERPROFESSIONAL EDUCATION IN THE UNITED KINGDOM Dr. Deborah Craddock University of Southampton

2. Introduction • Crucial ability to learn and work in a multidisciplinary team (WHO 2008). • Interprofessional education (IPE) aims to reinforce inter-professional practice (DOH 2000a; DOH 2000b; Carpenter, 2005). • IPE is a mandatory requirement in the United Kingdom (UK) for pre-registration training in health and social care (DOH & QAA, 2006). • Varying models of IPE in undergraduate curricula(Roberts et al., 2000) • Evidence base for the effectiveness of such programmes is growing (Hammick et al., 2007; Hean, Craddock & O’Halloran, 2009).

3. Research Aim: To explore the potential influence of IPE at pre-registration level, using podiatry as an exemplar. Research Objectives: • To evaluate health and social work students’ awareness of podiatrists’ roles on two occasions1 across participating HEIs; • To explore health and social work students’ views of interprofessional learning (IPL) on two occasions1 across participating HEIs; 1 Sample 1: students at the start of their Level 1 IPE initiative; Sample 2: students on completion of their IPE Level 1 initiative

4. Methodology • Two prospective cross-sectional surveys • Ethical approval • Multi-stage sampling:- (1) sampling of HEIs & (2) sampling of students Questionnaires were administered to a volunteer sample of pre-registration health and/ or social work students in Higher Education Institutions within the UK at 2 separate time points. Inclusion criteria: Students registered on a health or social care programme participating in an IPE initiative that involved podiatry students.

5. Questionnaire Pack • Questionnaire pack- informed by (1) key informant interviews and (2) research evidence • Validated tools – Readiness for Inter-professional Education Scale [RIPLS] & Generic Role Perception Questionnaire • Face validity • Content validity • Pilot Study [test (i) n=67; test (ii) n=62] • Test re-test reliability • Internal consistency Key informant interviews

6. Sample 1: 1151 students participated in the Sample 1 phase [81.1% (933) female, 18.9% (218) male]: mean age 24.38 (SD=8.167) years in 6 HEIs Excluding students registered on a BSc (Hons) podiatry programme: Sample 1 sample size- 964 students [82.2% (792) female, 17.8% (172) male]: mean age 23.62 (SD=7.50) years in 6 HEIs Sample 2: 1060 students participated in the Sample 2 phase [81.2% (861) female, 18.8% (199) male]: mean age 24.32 (SD=7.84) years in 5 HEIs. Excluding students registered on a BSc (Hons) podiatry programme 967 students [81.7% (790) female, 18.3% (177) male]: mean age 23.82 (SD=7.46) years in 5 HEIs. Sample: Female : Male (Parsell and Bligh 1999; Cassidy 2007)

7. Objective 1 Evaluating health and social work students’ awareness of podiatrists’ roles on two occasions1 across participating HEIs; 1 Sample 1: students at the start of their Level 1 IPE initiative; Sample 2: students on completion of their IPE Level 1 initiative

8. Of these participants in Sample 1, only 20.4% (48) participants who claimed to be aware of podiatrists’ roles, perceived there to be no difference between chiropodists and podiatrists. In Sample 2: greater percentage number- 42.7% (180). 41.4% (399) participants in Sample 1 and 51.4% (497) participants in Sample 2 participated in an IPL group that included a podiatry student.

9. carrying out nail surgery for an ingrown toenail (Sample 1: 82.2%, 792; Sample 2: 80%, 774) manufacturing shoe devices (Sample 1: 54.5%, 525; Sample 2: 54%, 522) surgically removing bunions (Sample 1: 57.2%, 551; Sample 2: 57.5%, 556) At Sample 2 only, podiatrists were also identified as the key professional who treats verrucae (70.2%, 679). Other roles: Managing walking and mobility problems Assessment of patients/ clients for vascular disease Managing ulcerations Assessing children for gait or developmental anomalies Perceptions of podiatrists’ roles:

10. Only at HEI B did students have a greater understanding of podiatrists’ roles between Sample 1 and Sample 2 (Sample 1: Md=8, Sample 2: Md=10, U=7513, z=-5.294, p<0.001, r=-0.3) Note: Higher median score- Sample 2 Educational theory underlying IPE initiative

11. A Kruskal-Wallis Test highlighted a significant difference in students’ knowledge of podiatrists’ roles and their institution of origin- Sample 1: H=38.948, 5df, p<0.001, n=964; Sample 2: H=122.87, 4df, p<0.001, n=967. Sample 1: HEI D recorded the highest median knowledge score (Md=8.5) HEI K and HEI H recorded the lowest median knowledge score (Md=6) Sample 2: HEI D and HEI B recorded the highest median knowledge scores (Md=9) HEI K recorded the lowest median knowledge score (Md=6)

12. Students’ knowledge podiatrists’ roleswas better if they had participated in an IPE group that involved a podiatry student (Md=7) than students who did not or were unsure as to whether they had participated in an IPE group that involved a podiatry student (Md=6) (Sample 1: U=101791.00, Z=-2.596, n-964, p=0.009; Sample 2: U=72529.5, z=-10.272, n=967, p<0.001). Podiatry students’ awareness of their own profession’s roles was greater in Sample 2 than Sample 1 (Sample 1 Md=10, n=187; Sample 2 Md=12, n=93; U=4703.5, z=-6.301, p<0.001). A positive correlation was evident between age and knowledge of the podiatrists’ role (Sample 1: spearman’s rho= 0.097, n=964, p=0.001; Sample 2: spearman’s rho= 0.059, n=067, p=0.032 for a one tailed test) respectively.

13. GRPQ (MacKay, 2004) Scale with 20 items that has good internal consistency (Cronbach alpha=0.7; n=43) (MacKay, 2004) Principal Components Analysis with Oblimin rotation Sample 1- four components solution (Cronbach alpha=0.776) Sample 2- three components solution (Cronbach alpha=0.78) A Mann-Whitney U test revealed a significant difference between students’ perceptions of podiatrists’ roles in Sample 1 (Md=92, n=964) and in Sample 2 (Md=97, n=967) [U=404704.5, z=-5.012, p<0.001, r=-0.11]. In Sample 2 a significant difference was observed in students’ total GRPQ scores between health and social work students who participated in an IPE group that involved a podiatry student (Md=94, n=497) and students who either did not or were unsure as to whether they had participated in an IPE group with a podiatry student (Md=99, n=470) [U=101817.50, z=-3.451, p=0.001, r=-0.11]. Generic Role Perception Questionnaire

14. Objective 2 Exploring health and social work students’ views of interprofessional learning (IPL) on two occasions1 across participating HEIs; 1 Sample 1: students at the start of their Level 1 IPE initiative; Sample 2: students on completion of their IPE Level 1 initiative)

15. help health and/or social care professionals to be able to work more effectively together (Sample 1: 97.5%, 1098; Sample 2: 94.6%, 1003) enhance the quality of care given to patients (Sample 1: 95.4%, 1098; Sample 2: 92.8%, 984) Improve communication skills (Sample 1: 94.4%, 1086; Sample 2: 91.3%, 968) Increase confidence in professional roles (Sample 1: 87.3%, 1005; Sample 2: 82%, 869) NOT weaken the power of the professions (Sample 1: 82.7%, 952; Sample 2: 74%, 784) Increase cost effectiveness of patient care (Sample 1: 52.2%, 601; Sample 2: 57.5%, 610) Minimise the risk of any duplication of health service delivery (Sample 1: 45%, 518; Sample 2: 53.8%, 570) IPE has been introduced into pre-registration curriculum to:

16. Students’ Perceptions of IPE • Disagreement that campus based IPE opportunities were perceived as being more meaningful than placement based learning opportunities (Sample 1: 46.3%, 533; Sample 2: 51.1%, 542) • Rivalries exist in placement locations that expose students to stereotypical views of professions (Sample 1: 43.5%, 500; Sample 2: 47.2%, 501) Key Motivational Influence: - • use of clinical/ social scenarios in group-work activities (Sample 1: 81.6%, 939; Sample 2: 71.1%, 753) Campus SimMan

17. Commitment to IPE: • Positive correlation - age and level of commitment to IPE (Sample 1: spearman’s rho = 0.243, p<0.001; Sample 2: spearman’s rho = 0.165, p<0.001 for a one tailed test) • Modal response of 6 - the majority of participants were only fairly committed (Sample 1: 49.5%, 570; Sample 2: 46.9%, 497) to IPL. Commitment was strongly influenced by: • facilitators’ attitudes towards IPE (Sample 1:75.5%, 835; Sample 2: 74%, 784) • working practices of staff (72.4%, 833; Sample 2: 66%, 700); • Students induction to the IPE initiative (62.2%, 716; 56.2%, 596)

18. Commitment to IPE • Yet the majority of respondents had not read any information about IPE (Sample 1: 65.7%, 756; Sample 2: 60.8%, 644) Primary information sources accessed by students who had read information about IPE:

19. Students who had read information: • Developed a better appreciation of the need for multi-disciplinary team members to meet on a regular basis in order to plan and discuss issues (Sample 1: U=99499.5, z=-2.569, p=0.01, r=-0.08; Sample 2: U=82170, z=-3.704, p<0.001, r=-0.11). • Enabled students to gain an appreciation of the existence of rivalries in placement locations that may expose students to stereotypical views of other professions (Sample 2: U=87109.5, z=-2.223, p=0.026, r=-0.07).

20. Readiness for Inter-professional Learning Scale Principle Component Analysis • Kaiser-Meyer-Oklin value = Sample 1: 0.932; Sample 2: 0.938 • Bartlett’s Test of Sphericity (p<0.001) • Oblimin rotation with Kaiser Normalisation • Sample 1 and 2: 2 component solution • Comparisons with Parsell and Bligh (1998; 1999) & McFadyen et al. (2005) • Component 1 Teamwork and collaboration • Component 2 Professional identity and roles

21. RIPLS Subscale Comparisons

22. Cronbach Alpha Measure of Internal Consistency of Each Sub-scale

23. Pre-registration health and social work students’ perceptions of IPL Significant difference between: • Students’ total RIPLS scores in Sample 1 (Md=80, n=1151) and Sample 2 (Md=76, n=1060), U=498010.00, Z=-7.474, p<0.001, r=-0.16. • Findings echoed in relation to each sub-scale • Students’ total RIPLS scores in Sample 1 and Sample 2, for HEIs B, E, K and H. • Students at HEIs B and K had the highest RIPL and HEI F had the lowest.

24. Lessons Learnt Enhancing knowledge of professional roles

25. Lessons Learnt Key factors influencing students’ attitudes towards IPE

26. Lessons Learnt: • Value of placement based learning (Guest et al 2002; Lumague et al., 2006; Robson and Kitchen, 2007) Placement Based Learning not possible? • Stimulus materials in IPE initiatives linked to the practice setting. Recognised reservations: • practicability (Cook et al., 2001) • Lack of clinical experience (Young et al., 2007) • Existence of rivalries in practice (Robson and Kitchen, 2007)

27. Lessons Learnt: RIPLS (Parsell and Bligh, 1999) Role of reading about IPE > age of students > level of commitment • Timing of IPE • Target course materials where links are incorporated to key IPE websites • Target & engage younger students e.g. induction – (see, Stephens et al., 2007)

28. References • Carpenter, J. (2005) Evaluating the Outcomes of Social Work Education. London and Dundee: Social Care Institute for Excellence and Scottish Institute for Excellence in Social Work Education. • Cook, A., Davis, J. and Vanclay, L. (2001) Shared learning in practice placements for health and social care students in East London: A feasibility study. Journal of Interprofessional Care, 15(2): 185–190. • Department of Health (2000a) A Health Service of all the Talents: Developing the NHS Workforce. Consultation document on the review of workforce planning. London: Department of Health. • Department of Health (2000b) The NHS Plan: A plan for investment, a plan for reform. London: The Stationery Office Ltd. • Department of Health and QAA (2006) Department of Health Phase 2 Benchmarking Project – Final Report. London: Department Of Health; and Gloucester: Quality Assurance Agency for Higher Education. • Hammick, M., Freeth, D., Koppel, I., Reeves, S. and Barr, H. (2007) A best evidence systematic review of interprofessional education (Best Evidence Medical Education Guide No 9). Medical Teacher, 29(8): 735–751. • Hean, S., Craddock, D. and O’Halloran, C. (2009) Learning theories and interprofessional education: A user’s guide. Learning in Health and Social Care, 8(4):250-262. • MacKay, S. (2004) The role perception questionnaire: A tool for assessing undergraduate students’ perceptions of the role of other professions. Journal of Interprofessional Care, 18(3): 289–302.

29. References: (continued) • McFadyen, A.K., Webster, V., Strachan, K., Figgins, E., Brown, H. and McKechnie, J. (2005) The readiness for interprofessional learning scale: A possible more stable sub-scale model for the original version of RIPLS. Journal of Interprofessional Care, 19(6): 595–603. • Parsell, G. and Bligh, J. (1998) Shared goals, shared learning: Evaluation of a multi-professional course for undergraduate students. Medical Education, 32(3): 304–311. • Parsell, G. and Bligh, J. (1999) The development of a questionnaire to assess the readiness of healthcare students for interprofessional learning. Medical Education, 33: 95–100. • Roberts, C., Howe, A., Winterburn, S. and Fox, N. (2000) Not so easy as it sounds: A qualitative study of a shared learning project between medical and nursing undergraduate students. Medical Teacher, 22(4): 386–391. • Robson, M. and Kitchen, S.S. (2007) Exploring physiotherapy students’ experiences of interprofessional collaboration in the clinical setting: A critical incident study. Journal of Interprofessional Care, 21(1): 95–109. • Stephens, J., Abbott-Brailey, H. and Pearson, P. (2007) It’s a funny old game: Football as an educational metaphor within induction to practice-based interprofessional learning. Journal of Interprofessional Care, 21(4): 375–385. • Young, L., Baker, P., Waller, S., Hodgson, L. and Moor, M. (2007) Knowing your allies: Medical education and interprofessional exposure. Journal of Interprofessional Care, 21(2): 155–163. • World Health Organisation (2008) Now more than ever: The World Health Report 2008. Geneva: WHO.