Complexity: A model for interprofessional education with medical and social work students

1. Complexity: A model for interprofessionaleducation with medical and social work students Dr Julia Stroud Principal Lecturer, School of Applied Social Science, Faculty of Health and Social Science, University of Brighton Dr Jim Price Senior Lecturer, Institute of Post Graduate Medicine, Brighton Sussex Medical School

2. Outline • The practice environment for social workers and doctors • Example ... • Interprofessional education: definition, drivers and theory • Complexity theory. Key concepts: relevance for IPE • Case study example

3. The Practice Environment ‘Many of the problems professionals face are neither predictable nor simple. They are unique and complex. Arising from environments characterised by turbulence and uncertainty, complex problems are typicallyvalue laden, open ended and multi-dimensional, ambiguous and unstable ... Complex problems are not in the book but in the ‘indeterminate zones of practice’ ... Furthermore they are not solved once and forever. They must be continuously managed’. Klein J.T (2004)

4. Example … Climbié Inquiry • 3 Housing authorities • 4 Social Services Departments • 2 Metropolitan Police Child Protection Teams • 1 Specialist NSPCC centre • 2 different hospital admissions with a range of doctors, nurses and hospital social workers

5. Example … • The ward round on the morning of 3rd August was carried out by Dr A. He noted that Victoria was ‘better’ and ‘medically fit for discharge’. However, Victoria had yet to provide a satisfactory account of what had happened to her and he considered that a proper history was still required. • Dr A did not take the history himself, apparently because he thought Nurse T would do so. However, Nurse T said that nobody ever asked her to take a history from Victoria. • Dr A considered it was necessary to ensure that it was safe for her (Victoria) to return home. This would have required some formal investigation or case conference at which the ‘specific details of further care were discussed’.

6. Example … • Later that morning Ms A the social worker responsible for Victoria’s care telephoned the hospital and spoke to Nurse Q. • Their…accounts of the conversation differ in a number of critical respects. • Nurse Q said that her conversation with Ms A lasted about 10 minutes, during the course of which she told her all the concerns of the medical staff felt regarding Victoria.

7. Example … • Ms A made a detailed note at the time which said: ‘Hospital are satisfied with the explanation given by Anna’s mother re. her burns. Explanation was that Anna, who had been suffering from scabies had poured hot water from a kettle over her head. She did this to relieve the itching’. • Despite considerable contact between the hospital & social services during the course of the day, little in the way of clear information demonstrating that Victoria was the victim of serious physical abuse was provided Laming (2003) The Victoria Climbié Inquiry. London. HMSO

8. Interprofessional education: definition used ‘Interprofessional education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ Centre for the Advancement of Inter Professional Education 2002 http://www.caipe.org.uk/

9. Interprofessional education: purpose Interprofessional Education is – ‘A patient/ service user centred, team-based approachthat maximises the strengths and skills of each contributing health and social care worker, thus increasing the quality of the patient/ service user’s care’(CAIPE)

10. The importance of students developing an ‘interprofessionally informed’ professional identity • The paradoxical need in training for students to develop a strong professional identity – with collaborative attributes • An ‘interprofessionally informed’ professional discourse (Whittington 2005) • Importance of overcoming established and durable stereotypes of other health and social care professionals (Hean et al 2006) • Significance of modelling good collaborative practice in ipl(Hill, Gray, Stroud et al 2009)

11. Interprofessional Education and Theory It is suggested that interprofessional education is under- theorised ... • That IPE is not undertaken because of, or informed by, theory in relation to either collaborative practice or learning • Rather, that IPE is driven by the reality of integrated service delivery in all arenas in health, social care and education policy, AND • By professional training requirements ...

12. Interprofessional education: Training requirements as drivers ... Social Work • GSCC Code of Practice (2002) ‘Recognising and respecting the roles and expertise of workers from other agencies and working in partnership with them’ (6.7) • QAA Benchmark for Social Work (2008) ‘act co-operatively with others, liaising and negotiating across differences such as organisational and professional boundaries and differences of identity and language’ • National Occupational Standards for Social Work (2003) ‘Work within multi-disciplinary and multi-organisational teams, networks and systems’ (Key Role 5: Unit 17) • DH Requirements for SW Training (2002): Requirement L – Specific Learning and assessment on ‘Partnership working and information sharing across professional disciplines and agencies’

13. Interprofessional education: Training requirements as drivers ... Medicine Currently: GMC (2006) Good Medical Practice ‘Most doctors work in teams with other colleagues’ Doctors must – (a) respect the skills and contributions of colleagues and (b) Communicate effectively with colleagues within and outside the team GMC 2006 Para 41

14. Interprofessional education: Training requirements as drivers ... GMC.Tomorrow’s Doctors 2009. A Draft for Consultation Outcomes 3 The Doctor as Professional ‘Learn and work effectively within a multi-professional team’ ‘Understand the roles and expertise of health and social care professionals, in including doctors, in the contexts of working and learning as a team, as well as in policy and practice development....’

15. Recent Key Policy drivers • Kennedy Report (2001) re. Bristol Royal Infirmary • Laming Report (2003)re. Victoria Climbié • 2nd Laming Report The Protection of Children in England: A Progress Report (March 2009) ‘co-operative working is increasingly becoming the normal way of working. However, good examples of joint working too often rely on the goodwill of individuals’ (Laming 2009: 36) • Voices of patients/ service users and their input into health and social care policies • DarziReport (2008) partnerships between NHS and other agencies – e.g. PCT’s and LA’s re. Preventative strategies for obesity, alcohol, drug addiction, smoking sexual health, mental health.

16. Complexity Theory: A Model for Interprofessional Education Complexity Theory Concerns the behaviour of complex systems and processes. Complex systems contain many discrete elements which may be similar to each other and which interact with other elements of the system. From this, interactions arise, or patterns of order or behaviour emerge which are not seen in, nor can be understood from, the individual elements.

17. Complexity theory: an evolution from chaos theory • Chaos is often thought to represent disorder, but new order can be emerging. ‘Chaos and order are always interconnected’ in any system (Urry 2003:14) • Evolution of chaos (or disorder) into a new form of order (self organisation) is better thought of as complexity • ‘Complexity theory is the study of complex systems and is concerned with transformations – positive and negative...it understands that links between the whole system and its constituent parts is not easily made’ (Warren Adamson 2009) • Distinguish complex systems which are irreducible (e.g. weather, the brain) from complicated ones (e.g. motor car, computer) – which can be disaggregated and reassembled to the same state

18. A Complex Adaptive System … “a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that the action of one part changes the context for other agents” Zimmerman et al 1998

19. Complexity theory: some key concepts

20. Chaos Zone of Complexity Surprise Far from agreement Close to agreement of Process Structure Simple Close to Certainty of Outcome Far from Certainty

21. A working definition of complexity thinking: ‘the study of learning systems’ Davis et al 2008

22. Concepts from complexity theory applied to interprofessional education

23. IPE Case study: Year 1, Term 1 Medical and Social Work Students Case Study Lisa is 22 years old. She has never known her father and her mother died in a car crash, which she survived, when she was 6 years of age. She was then cared for by her aunt, who supported her when she was diagnosed with diabetes aged 9 years: Lisa is insulin dependent. From age of 13 years Lisa was in the care of a Local Authority, as her aunt, to whom she was deeply attached, died of a heart attack. Lisa had many different placements with foster parents and in Children’s Homes while in care. She presented then, and continues to present, as deeply troubled, frequently cutting her arms to the extent that suturing is necessary. Lisa neglects her diabetes and often doesn’t take her insulin. She has been treated in A&E for alcohol poisoning and drug overdoses. Lisa left school at 16 years; she had some short-lived temporary jobs, but says she sells sex for money. Lisa in now 30 weeks pregnant: her pregnancy wasn’t planned and she does not know who the father is. Lisa has a changing and ambivalent attitude to her pregnancy. She has continued to cut her arms and has been treated for one overdose since becoming pregnant. In the last few weeks she has engaged more with services. Since the overdose she has seen a psychiatrist and described how she has wanted to die since her aunt died and how she doesn’t take insulin to punish herself for being so unlovable. She has attended the diabetic clinic because of trouble with her vision, linked to the neglect of her diabetes. Over the last month she has, for the first time, kept her appointments at the ante-natal clinic, but the midwife is concerned about whether Lisa will provide consistent, stable care for, and safeguard, her baby – and indeed herself, and has referred her to Social Services.

24. IPL Case study: Year 1, Term 1 Medical and Social Work Students  SMALL GROUP TASKS In small mixed professional groups please consider your responses to the following questions: Having read the case study carefully, please discuss and identify: 1. What factors in the case do you think DOCTORS should be concerned with? What factors should SOCIAL WORKERS be concerned with? 2. What BENEFITS are there in professions working together support Lisa? What DIFFICULTIES might there be? 3. What SKILLS will be necessary for successful work for other professions? FINALLY… How do you think Lisa might FEEL meeting the professionals involved? Please identify THREE things you have learnt from this morning and doing this exercise together  PLEASE NOMINATE ONE MEMBER OF YOUR SMALL GROUP TO FEED BACK TO THE WHOLE GROUP

25. And some comments on the learning ... • Learnt more about the role of a social worker • Importance of negotiating • Respecting difference of opinion • Good communication • Holistic approach to care and support • Bio-psychosocial concerns – but with different emphasis • Factors that doctors and social workers look at overlap • Team work important to meet needs • Diverse range of responsibilities social workers have • All professionals and specialities are important • Respect for others roles • Being clear about each other’s roles and responsibilities • For social workers to be concerned about the doctor’s concerns and vice versa • Being alert to potential for duplication and omissions in interprofessional teams • Working together and appreciate each other’s views and priorities • Each professional may have different parts of the story • All essentially have the same concern

26. References Byrne D. (1998) Complexity Theory and the Social Sciences. An Introduction. London: Routledge. Davis B., Sumara D. and Luce-Kapler R. (2008) Engaging Minds: Changing Teaching in Complex Times. New York: Routledge. Hean S. et al (2006) ‘Will opposites attract? Similarities and difference in students perceptions of the stereotype profiles of other health and social care professional groups’. Journal of Interprofessional Care. 20(2) pp162-182 Hill L., Gray R., Stroud J. and Chiripanyanga S. (2009) ‘Interprofessional learning to prepare medical and social work students for practice with refugees and asylum seekers’. Social Work Education. 28 (3) pp.298-308 Klein J.T (2004) ‘Interdisciplinarity and complexity: An evolving relationship’. Complexity, Emergence and Organization. 6:1-2, pp.2-10 Laming (2003) The Victoria Climbié Inquiry. London. HMSO Urry J. (2003) Global Complexity. Cambridge: Polity Press Warren Adamson C. (2009) ‘Collaborative practice and its complexity’. In , Ruch G. (Ed.) Post qualifying Child Care Social Work. Developing Refelcive Practice. London: Sage. Whittington C (2005) ‘Interprofessional education and Identity ‘. In, Colyer H. et al (Eds). The Theory-Practice Relationship in Interprofessional Education. Health Academy Occasional Paper No.7. November 2005. http://www.health.heacademy.ac.uk/publications/occasionalpaper/occp7.pdf Zimmerman B., Lindberg C. and Plsek P. (1998) Edgware. VHA Inc. Irving,Texas