Learning theories and interprofessional education: a user's guide
Contents
1. Acknowledgements This work originated from a seminar series Evolving theory in Interprofessional Education 2007 2009 funded by the Economics and Social Research Council in the United Kingdom References Armitage A Bryant R Dunhill R Hayes D Hudson A Kent J amp Et Al 2003 Teaching and Training in Post Compulsory Education Open University Press Buckingham Arredondo P Shealy C Neale M amp Lapearle L W 2004 Consultation and interprofessional collaboration modelling for the future Journal of Clinical Psychology 60 787 800 Atherton J S 2005 Learning and teaching constructivism in learning 722 2222 222 Barr H 1998 Competent to collaborate towards a com petency based model for interprofessional education Journal of Interprofessional Care 12 181 187 Barr H Koppel I Reeves S Hammick M amp Freeth D 2005 Promoting Partnership for Health Blackwell Publishing and CAIPE London Bigge M L amp Shermis S S 1999 Learning Theories for Teachers 6th edn Longman New York Biggs J amp Tang C 2007 Teaching for Quality Learning at University 3rd edn Open University Press Maidenhead Bleakley A 2006 Broadening conceptions of learning in medical education the message from team working Medical Education 40 150 157 Burns R 1995 The Adult Learner at Work Sydney Busi ness and Professional Publishing Sydney Carpenter J Barnes D amp Dickinson C 202. or even understood ahead of time Engestr m describes learning of this knowledge in this context as expansive learning Expansive learning takes place within these collective activity frameworks most often when contradictions in the system occur and are resolved Engestr m 2001 A search of the literature for the use of activity theory in curriculum development was not suc cessful However this was not unexpected as cur rent HEI curriculum development especially if based outside practice focuses on the micro indi vidual level learning with predictable and defin able outcomes The systems activity theory in which expansive learning takes place is less pre dictable and hence does not lend itself to use in curriculum development as readily It was there fore not unexpected that activity theory has not been used to underpin any known IPE curricu lum models The search for use of activity theory in the evalua tion of IPE was more successful Two examples of the use of activity theory to underpin evaluations of interprofessional learning rather than IPE were identified Robinson amp Cottrell 2005 in an evalua tion of decision making and knowledge sharing in multi agency teams explored the ways in which professional knowledge was generated in these teams how learning took place as well as the ways of working created as a result of being part of this activity system Similarly Payler Meyer amp Humph ris 2007 app
3. between peers and a peer review activity within a virtual IPE programme using these interactions as a means by which Vygotsky s ZPD can be tran scended However D eon 2005 provided by far the most comprehensive utilization of socio cultural learning and specifically the concept of scaffolding This arti cle provided clear and practical guidance on how the concepts of scaffolding could be applied to IPE via a range of student tasks of ever increasing com plexity These become progressively more complex in two ways 1 From working on paper based scenarios to those set in real life practice settings 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd 2 From simple interaction between two profession als to a case in which a range of professionals are involved They maintain that when the scaffolding of these guided tasks is removed i e the tasks are com pleted students should be able to apply or transfer their interprofessional learning independently to novel cases and situations There was no evidence in the search of concepts of scaffolding and ZPD being used as a means of evaluation Future work in IPE development would therefore benefit from an increase in the applica tion of ideas of ZPD and scaffolding and explora tion of this can be applied to peer led or tutor led discussions Macro level thinking Constructivist and behaviourist approaches may be criticized as focusing overly
4. context appears as a collection of ped agogical approaches and is described variously as E Learning theories and interprofessional education 7 e g self directed Kaufman 2003 experiential Puliyel Piliyel amp Puliyel 1999 Moon 2004 prob lem based learning Newble 2002 Wood 2003 and discovery based learning Spencer amp Jordan 1999 Some of these theories have a particular emphasis on the process of reflection in learning e g transfor mative learning Mezirow 1997 2004 the reflective practitioner Schon 2004 experiential learning Kolb 1983 Moon 2004 Fig 2B 1 In order to make meaning of the wide number of adult learning theory applied to IPE it is important to recognize that many adult learning theories experiential learning Kolb 1983 inquiry based learning Clev erly 2003 are constructivist in their origins This is reflected in some of the key assumptions of adult learning theory that holds that adults 1 are independent and self directing 2 have accumulated vast experiences which are rich resources for learning 3 value learning that integrates with the demands of their daily lives 4 are more interested in immediate problem cen tred approaches than in subject centred ones 5 are more motivated to learn by internal as Wiopposed to external drivers Knowles et al 1984 Knowles 1990 Kaufman 2003 However a failure in the IPE literature to recog nize the constructivist origins
5. expected assessed and evaluated Such a clear cut structured approach has its appeal However if chosen to underpin an IPE evaluation or curriculum design it must be acknowledged that in focusing exclusively on the outcomes or products of IPE the developer ignores the processes that have under pinned this learning Furthermore if a behaviourist curriculum approach emphasizes learning by doing learning by trial and error and the consequences of one s own behaviour then there is the danger that students become involved in practicalities of experi ence and fail to reflect on their actions during this process Students may also become overly focused on the assessment and achieving the stated behavio ural objectives Bigge amp Shermis 1999 Armitage et al 2003 These problems however are not limited to interprofessional learning Constructivism In contrast to behaviourist theory constructivism takes account of the process of learning The con structivist family encompasses both cognitive con structivist and socio constructivist approaches to learning Fig 2 Cognitive constructivism Cognitive constructivism is concerned with the pro cesses experienced by learners The creation of cog nitive structures and higher order skills such as problem solving and the development of insights are key Dewey 1966 Piaget 1973 Burns 1995 Atherton 2005 as too are student activity in learning and self direction in his her own de
6. in Atherton 2005 AUTHOR If there are fewer than 3 author names for Reference X XXXX please supply all of their names If there are 11 or more author names please supply the first 3 author names then et al Also provide journal name vol ume and page span AUTHOR Arrendo et al 2004 has been changed to Arredondo et al 2004 so that this citation matches the Reference List Please confirm that this is correct MARKED PROOF Please correct and return this set Please use the proof correction marks shown below for all alterations and corrections If you wish to return your proof by fax you should ensure that all amendments are written clearly in dark ink and are made well within the page margins Instruction to printer Leave unchanged Insert in text the matter indicated in the margin Delete Substitute character or substitute part of one or more word s Change to italics Change to capitals Change to small capitals Change to bold type Change to bold italic Change to lower case Change italic to upright type Change bold to non bold type Insert superior character Insert inferior character Insert full stop Insert comma Insert single quotation marks Insert double quotation marks Insert hyphen Start new paragraph No new paragraph Transpose Close up Insert or substitute space between characters or words Reduce space between characters or words Textual
7. of adult learning the ory means these theories are often used simply to describe how the IPE curriculum was delivered e g as a form of group work and fail to recognize or articulate the constructivist theories that underpin why the curriculum is being delivered in this way This study takes the stance as illustrated in Fig 1 that adult learning applied to IPE should not be seen as a theory on is own but is instead a context in which constructivist learning theories are applied Social constructivism Learning is not a purely individually constructed process and social constructivists view individual learning as being mediated by the environment Curriculum developers and evaluators in IPE who discuss collaborative interprofessional and situated learning take this perspective Fig 2B 2 Mediating artifact N p E O 0 E0 Fig 3 Triangle depicting a subject s or learner s mastery or learning about an object as through an external and mediating artefact such a peer or tool such as language Engestr m 2001 Social constructivism in contrast to cognitive constructivism emphasizes how social encounters influence learners meanings and understanding Atherton 2005 The learner is more actively involved in constructing new meaning in a collab orative enterprise particularly with the facilitator Atherton 2005 This approach is best character ized by the theory of socio cultural learning the ory develo
8. s 1990 theory emphasizes social reality within which learning and expansion occurs there is a risk that insufficient emphasis is placed on the psychological processes and the individual Furthermore Tennant 1997 is concerned that communities of practice are roman ticized and that in their eagerness to debunk testing formal education and formal accreditation they do not analyse how this af fects power relations access public knowledge and public accountability Tennant 1997 p 79 The push to move IPE into practice and the increased interest in activity theory and communi ties of practice need to bear this in mind Potential use of the framework The overview of learning theories used in IPE and presented as Fig 5 attempts to explain the relation ship between the range of available theories and how ideas have evolved one from another An under standing of these relationships can help researchers and practitioners form a mind map of the learning theories and their uses and compile a theoretical toolbox for use in IPE curriculum design and evalu ation For example the relationship between micro level thinking of socio cultural learning and its appli cation leads into the more complex macro level thinking of activity theory and expansive learning in which ideas of community practice may be linked is one example of how the range of theories can pro vide clarity where a single theory cannot An understanding o
9. 03 Making a Modern Mental Health Care Force Evaluation of the Birmingham University Interprofessional Training Programme in Community Mental Health 1998 2002 Centre for Applied Social Studies University of Durham Durham Carpenter J Barnes D Dickinson C amp Wooff D 2006 Outcomes of interprofessional education for commu nity mental health services in England the longitudinal evaluation of a postgraduate programme Journal of Interprofessional Care 20 145 161 Clark P 2006 What would a theory of interprofessional education look like Some suggestions for developing a theoretical framework for teamwork training 1 Journal of Interprofessional Care 20 577 589 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd Clarke B Lapthorn C amp Miers M 2005 Study 2 Student Learning in Interprofessional Modules Evidence from Student Interviews and Assignments University of West of England Bristol Cleverly D 2003 Implementing Inquiry Based Learning in Nursing Routledge London Colyer H Helme M amp Jones I 2006 The Theory Prac tice Relationship in Interprofessional Education Higher Education Academy Health Sciences and Practice London Cooper H 2004 Complexity and interprofessional edu cation Learning in Health and Social Care 3 179 189 Craddock D O Halloran C Borthwick A amp McPherson K 2006 Interprofessional education in health and social care fashion or info
10. 3 A key question for the IPE practitioner is to con sider the part behaviourist approaches have taken in the understanding the nature of interprofessional learning IPE curriculum development and evalua tion Taking the above description of behaviourism this approach is one in which an IPE curriculum developer creates an outcome based curricula This is in line with current trends in most curriculum development in Higher Education in the UK where establishing key learning outcomes is central Biggs amp Tang 2007 Curriculum developers should ques tion whether their designs of IPE curricula should follow this same trend i e borrow from the same behaviourist tradition as that of the uniprofessional curriculum The key question remains is this a nat ural and appropriate progression or one that is taken pragmatically when IPE curriculum develop ment is often conducted in circumstances in which time and human resources are limited Although the search of the literature showed no reference to behaviourist models of learning explic itly some evidence was found of reference to the learning outcomes of IPE although these were rephrased as interprofessional competencies Using the latter as a keyword in the search strategy identified only three key references Barr 1998 Arredondo et al 2004 Norris et al 2005 that specifically mentioned interprofessional competencies Some of these competencies identified in these articles are summ
11. Author Received Dispatch 26 5 09 alee alee Original article No of pages 13 PE Shyamala DOI 10 11 11 1473 6861 2009 00227 x Learning theories and interprofessional education a user s guide Sarah Hean PhD Deborah Craddock Ma Bsc Hons DPodM amp Cath O Halloran php I Senior Lecturer Research Methods School of Health amp Social Care HSC Bournemouth University RI 14 Royal London House Christchurch Road Bournemouth Dorset BH 3LT UK 2 MSc Programme Leader School of Health Sciences University of Southampton 3 Head of Department of Clinical and Health Sciences School of Human and Health Sciences University of Huddersfield Keywords Abstract curriculum There is increasing interest in the theoretical underpinning of interprofessional development oe as i i education IPE and writers in this field are drawing on a wide range of disciplines for evaluation E n i iteproksiond theories that have utility in IPE While this has undoubtedly enriched the research education learning theory Corresponding author Tel 44 0 1202 9 62201 fax 44 0 1202 9 62194 e mail shean bournemouth ac uk literature for the educational practitioner whose aim is to develop and deliver an IPE curriculum that has sound theoretical underpinnings this plethora of theories has become a confusing and un navigable quagmire This article aims to provide a compass for thos
12. J 1997 Transformative learning theory to practice New Directory for Adults and Continuing Education 74 5 12 Mezirow J 2004 Forum comment on Sharan Merriam s The role of cognitive development in Mezirow s trans formational learning theory Adult Education Quarterly 55 69 70 Moon J 2004 A Handbook of Reflection and Experiential Learning Theory and Practice Routledge Falmer London Newble D I 2002 Don t presume about experienced adult learners in medicine British Medical Journal 325 779 Norris E Alexander H Livingston M Woods K Fischb acher M amp MacDonald E 2005 Multidisciplinary perspectives on core networking skills A study of skills and associated training needs for professionals working in managed clinical networks Journal of Interprofes sional Care 19 156 163 O Toole L J 2004 The theory practice issue in policy implementation research Public Administration 82 309 329 Pawson R amp Tilley N 1997 Realistic Evaluation Sage London Payler J Meyer E amp Humphris D 2007 Theorizing interprofessional pedagogic evaluation framework for evaluating the impact of interprofessional continuing professional development on practice change Learning in Health and Social Care 6 156 169 Perry W G 1970 Forms of Intellectual and Ethical Development in the College Years A Scheme Holt Rinehart and Winston New York Piaget J 1973 To Understand Is To Invent Gros
13. arized in Table 1 A search of the published literature however showed no explicit reference to the use of these IPE competencies in curriculum design Although it is hard to believe that at least some of these learning outcomes are not included in the learning objectives of current IPE curriculum it is likely that the Table 1 Interprofessional competencies identified by interprofessional education IPE authors taking a behaviourist approach to learning Author Interprofessional competency After completion of an IPE unit s students should have the ability to Norris et al 2005 Managing change Resolve conflict Negotiate Work in challenging situations After completion of an IPE unit s students should have Arredondo et al 2004 Foundational knowledge e g theories of interprofessional collaboration theories of organizational behaviour An awareness of their own beliefs and values The ability to distinguish between what they know and do not know in different contexts in terms of their abilities to collaborate The ability to appreciate and act on different conflicting world views After completion of an IPE unit s students should have the ability to Barr 1998 Work with other professions to assess plan and provide care Describe their roles and responsibilities to other professions Recognize and respect the roles responsibilities and competence of other professions Cope with uncertaint
14. ation interacts or comes into conflict with existing knowledge held by the individual This interaction between existing and new knowledge is important in learning and has led to the recognition that teaching must take account of students existing knowledge Bigge amp Shermis 1999 These processes appear largely to be excluded from writing within the IPE literature Hughes Ven tura amp Dando 2004 being one exception These authors described a third year undergraduate online IPE module In the IPE curriculum described here students are given the opportunity to revisit and rework initial submissions of group work in an iter ative process Hereby successive layers of knowledge are added to existing knowledge through each cycle of the process in keeping with a constructivist approach to learning The search strategy was also less successful in uncovering the application of a cognitive constructivist approach to the evaluation of IPE The use of a Realistic method of evaluation Pawson amp Tilley 1997 in which mechanisms and processes are addressed in the evaluations of some IPE modules Clarke Lapthorn amp Miers 2005 was one of the few examples of such an approach Although the above cognitive constructivist theo ries are not commonly utilized in the IPE literature the search strategy showed adult learning theories in contrast to be widely utilized in the field Fig 2B 1 Craddock et al 2006 Adult learning theory in this
15. e educational practitioners by presenting a framework that summa rizes key learning theories used in IPE and the relationship between them The study reviews key contemporary learning theories from the wider field of education used in IPE and the explicit applications of these theories in the IPE literature to either curriculum design or programme evaluation Through presenting a broad overview and summary framework the study clarifies the way in which learning theories can aid IPE curriculum development and evaluation It also highlights areas where future theoretical development in the IPE field is required Introduction Historically curriculum design and evaluation of initiatives in interprofessional education IPE have been accused of being theory less Freeth et al 2002 EjBarr et al 2005 Clarke 2006 However the scene has changed over the past 5 years with an increasing number of published works in the field that do con sider theoretical underpinnings Within these arti cles writers turn to more established disciplines mainly sociology psychology and education for theories with utility for IPE e g contact theory 2009 The Authors social identity theory activity theory and adult edu cational theories Colyer Helme amp Jones 2006 This however has resulted in an abundance of theories of potential use in IPE research each author using a favoured approach to articulate his her own under standi
16. evaluations explicitly measuring student behavioural change a fact previ ously noted in the IPE literature Barr et al 2005 Some few exceptions include the work of McNair et al 2001 where students are asked to make self reports of their own developing interprofessional competencies and interprofessional confidence and involvement These authors suggest facilitator obser vation of student working be included in future mea surement of behavioural change Similarly Pollard et al 2006 collected students self reports of their own communication skills Generally however there is a dearth of behavioural measures beyond the level of self report This is largely because measurements of behavioural change in IPE programmes e g teamwork behaviours are hard to identify and mea sure effectively If a broader definition of competen cies is taken that includes student attitudes and knowledge then several other instances in which competences have been incorporated into evalua tions were found For example changes in students attitudes or stereotypes were measured as an IPE learning outcome in several IPE evaluations Hind et al 2003 Mandy Milton amp Mandy 2004 Hean et al 2006 A behaviourist approach to understanding IPE learning designing IPE curriculum and evaluating its outcomes is likely to appeal to those more com fortable with a positivist approach to research and curriculum development in which clear outcomes are
17. f the evolution and connect edness of theories also helps us position ourselves as both educational practitioners and researchers For example evaluators who may have focused on IPE evaluation on measurement of stereotype change through quantitative surveys Carpenter et al 2003 Hean et al 2006 would recognize from Fig 5 that their theoretical underpinnings are from more posi tivist behaviourist traditions in which comfort is MICRO CONSTRUCTIVISM B MACRO ia Cognitive Expansive learning Social conflict theory Socio cultural learning Activity theory Situated learning Been based Communities of practice Collaborative learning PONY B3 Interprofessional learning B 1 Social Developmental stage theory Self directed experiential B2 Focus on uncertainty absence of a teacher non linearity Expansive learning Complexity theory Focus on reflection Transformative learning Reflective practitioner Experiential learning B 1 2 Fig 5 Overview of key learning theories in the interprofessional education literature and the relationships between one another 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd Learning theories and interprofessional education lI taken in assessment of measurable outcomes in an evaluation The approach is also in line with a socio psychological research approach in which the
18. ial Constructivism Cognitive Activity theory Constructivism Social conflict theory Socio cultural learning Situated learning Collaborative learning Interprofessional learning Micro level of analysis Developmental stage theory Self directed experiential problem based discovery learning Fig 4 Learning theories used in interprofessional education at a macro and micro level of analysis To consider learning at the macro level the con cepts of socio cultural learning have been expanded to explain learning beyond that which occurs at the level of the individual and whereby learning is viewed as being mediated by a single cultural arte fact This evolution is seen in Fig 3 Engestr m 92001 where Vygotsky s triangle of individual activ ity develops into a macro level description of collec tive human activity and the learning that takes place within these Community is a key factor within the activity system In the arena of interprofessional working Engestr m 2001 uses the concept of activity systems to frame the learning that takes place when parents and practitioners from different professions and organizations work collaboratively to plan and monitor the care of sick children admit ted to their care In this system knowledge is often generated in these interactions in parallel and simul taneously to people and organizations learning within the system Knowledge is therefore not stable
19. ies arose Please respond to these by marking up your proofs with the neces sary changes additions Please write your answers on the query sheet if there is insufficient space on the page proofs Please write clearly and follow the conventions shown on the attached corrections sheet If returning the proof by fax do not write too close to the paper s edge Please remember that illegible mark ups may delay publication Many thanks for your assistance Query reference Query Remarks Ql AUTHOR A running head short title was not supplied please check if this one is suitable and if not please supply a short title of up to 40 characters that can be used instead AUTHOR Please provide full address for the second and third affiliations AUTHOR Clarke 2006 has not been included in the Reference List please supply full publication details AUTHOR Daghlen 2006 has been changed to Dahlgren 2006 so that this citation matches the Reference List Please confirm that this is correct AUTHOR Knowles 1984 has been changed to Knowles et al 1984 so that this citation matches the Reference List Please confirm that this is correct AUTHOR Engestr m et al 2001 has been changed to Engestr m 2001 so that this citation matches the Reference List Please confirm that this is cor rect A AUTHOR Please provide all author names in Armitage et al 2003 AUTHOR Please provide journal name volume and page span
20. indi vidual is the common unit of analysis In contrast those who have applied activity theory to underpin evaluations Payler et al 2007 would recognize more constructivist and sociological slants to their evaluations Both are equally valid and potentially complementary The overview Fig 5 also shows that the learning theories used to underpin the understanding of IPE are not mutually exclusive They only have a differ ent emphasis For example taking a behaviourist approach to curriculum design in which interprofes sional competencies are key does not preclude con structivist ideas in which the processes behind learning these competencies are considered in paral lel Furthermore both behaviourist and constructiv ist theorists would agree that interprofessional learning by doing and student centredness are key Conclusions Theory for theory sake is futile but practice that is not underpinned by a sound theoretical underpin ning is tantamount to incompetence Eraut 2003 It is essential that educationalists and researchers underpin their practice with sound theoretical frameworks first to improve the quality of their cur riculum development and evaluative practice but also as a means of explaining the curriculum and evaluation to sceptics We hope that this study through presenting a broad overview and summary framework has helped clarify the way in which learning theories can aid IPE curriculum development and e
21. ith from and about defi nition of IPE Freeth et al 2002 socio cultural learning is key to an understanding of interprofes sional learning For those in the field who wish to pinpoint how interprofessional learning is in fact different from learning that could occur uniprofes sionally an emphasis on the socio cultural approach in preference to more cognitive constructivist approaches will have an appeal As with cognitive constructivist and behaviourist approaches the search strategy sought out articles in the IPE literature in which a reference to socio cultural learning scaffolding Vygotsky and or the ZPD had been made It found that explicit use of the theory was limited but with some notable exceptions Although not situated within the con fines of IPE delivery in a HEI Zorga 2002 pub lished a developmental educational model of professional supervision in practice In this model the supervisor mediates the learner s reflection on a relevant work issue from which they wish to learn develop The process of supervision is seen as a mediating artefact that can accelerate learning across the ZPD a form of scaffolding for the learner under supervision Interdependence was actively discouraged and the supervision sessions are finite in order that scaffolding can be removed once the subject has developed sufficiently Hughes et al 2004 also referred briefly to the concept of the ZPD in a description of the interactions
22. k M Miers M et al 2008 Evolving IPE theory for practice the outcomes of discussion from a seminar Hind M Norman I Cooper S Gill E Hilton R amp Judd P 2003 Interprofessional perceptions of health care students Journal of Interprofessional Care 17 21 34 Learning theories and interprofessional education 13 Hughes M Ventura S amp Dando M 2004 On line interprofessional learning introducing constructivism through enquiry based learning and peer review Journal of Interprofessional Care 18 263 268 Jarvis P Holford J amp Griffin C 2003 The Theory and Practice of learning Kogan Page London Kaufman D M 2003 Applying educational theory in practice British Medical Journal 326 213 216 Knowles M S 1990 The Adult Learner A Neglected Species Gulf Publishing Houston TX Knowles M S et al 1984 Androgogy in Action Applying Modern Principles of Adult Learning Jossey Bass San Francisco CA Kolb D A 1983 Experiential Learning Experience as the Source of Learning and Development Prentice Hall Hillside New Jersey Mandy A Milton C amp Mandy P 2004 Professional stereotyping and interprofessional education Learning in Health and Social Care 3 154 170 McNair R Brown R Stone N amp Sims J 2001 Rural interprofessional education promoting teamwork in primary health care education and practice The Austra lian Journal of Rural Health 9 Suppl 1 19 S26 Mezirow
23. l be reported here Learning theories and their utility in IPE When attempting to use learning theories to under pin the design or evaluation of an IPE initiative it is useful to recognize two wide families of learning theory namely behaviourist and constructivist approaches Bigge amp Shermis 1999 Armitage et al 2003 Fig 1A B and to first consider the initiative in relation to them Behaviourism Behaviourists believe that 1 Learning occurs through experiencing the conse quences of one s own behaviour 2 Trial and error may be part of such learning 3 All behaviour is learned and all learning involves an observable change in behaviour A Behaviourism Focus on the outcomes of learning expressed as behaviour Interprofessional Competencies B Constructivism Focus on the process of learning Fig 1 Two key families of learning theory with application to interprofessional learning 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd 4 S Hean et al 4 Extreme behaviourists take a positivist approach through the belief that only what can be measured can be regarded as learning 5 Students own activity in obtaining these out comes is often central to learning Bigge amp Shermis 1999 Armitage et al 2003 Behaviourists are less interested in thought pro cesses and how learning has occurred but focus on learning outcomes Bigge amp Shermis 1999 Armitage et al 200
24. lied the second generation of activity theory to inform the development of a conceptual framework to guide an evaluation of the impact of pedagogy employed in continuing professional development for professionals in education health and social care Despite the lack of macro level theories in the lit erature there is an increasing interest in their appli cation In the seminar used to validate this framework it was clear from evaluations Hean et al 2008 that the theories in which the social con text of learning and working were included were seen as key In fact theories such as activity theory and socio cultural learning took precedence over the other learning theories presented in the framework It is the social component of these theories that 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd COLOUR 10 S Hean et al differentiates interprofessional from uniprofessional learning This echoes Bleakley 2006 who also criti cizes the abundance of adult learning theory stating that androgogy provides limited understanding of how learning occurs in complex dynamic systems such as teams where socio cultural learning provide a more powerful alternative Bias towards individualistic learning theory may be ideolog ical rather than evidence based p 151 However as with all theory activity theory is not without it critics Jarvis et al 2003 for example points out that although Engestr m
25. mark under matter to remain I through single character rule or underline or M through all characters to be deleted through letter or M through characters under matter to be changed under matter to be changed under matter to be changed a under matter to be changed xa under matter to be changed Encircle matter to be changed As above As above I through character or A where required As above As above As above As above As above As above cS UI linking characters so I through character or A where required between characters or words affected Marginal mark New matter followed by k or A Jo Sf new character I or new characters I h Tt Yoy under character or over character e g or 7 and or or ce or and or 9 or Y lt e n R lt lt SERLE
26. nal development and the processes of decentring in students whilst Clark 2006 has explored the application of Perry s 1970 four stages of student development in terms of students development of interprofessional knowledge and values A commit ment to relativism represents the ultimate goal on an interprofessional scale of development and when reached students are comfortable and prepared to take a stand on their own particular professional perspective but show an awareness that their per spective is governed by a system of values and beliefs and recognize that others may have committed to a different but equally valid perspective based on their own value and belief systems Clark 2006 Despite these discussions of stage theory by Daghlen and Clark no explicit reference was found to these concepts in published literature in either IPE curric ulum design or indeed the evaluation of IPE initia tives Greater application of the ideas of stages of IPE development beyond the theoretical and into the underpinnings of curriculum development and evaluation would progress the field 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd Based in the tradition of stage development Pia get 1973 also proposed two processes involved in knowledge acquisition namely assimilation and accommodation The former is the process whereby a student will take in and filter information from their environment This inform
27. ned theory tangen tially and without further discussion were excluded In future as and when theory becomes more widely applied in the IPE literature strategies to assess and distinguish between articles based upon the quality with which theory has been applied and the context in which it has been applied would be recom mended Establishing the criteria for such an assess ment will not prove an easy task however not least because of the familiarity required by the assessor of each individual theory under scrutiny The framework that resulted from the above syn thesis which summarizes key learning theories that have found application in IPE can be viewed in Fig 1 To test the validity of the framework it was presented to an audience of IPE educators practitio ners and researchers attending an Economics and Research Council funded Seminar Series Hean et al 2008 in January 2008 The objective of this series was to develop IPE theory for the future Par ticipants were asked to discuss and feedback on the framework through group work as well as in evalua tion sheets completed at the end of the seminar Members of the convening group completed written reflections on the progress of the seminar These data were synthesized to provide some preliminary pointers as to how this framework might move lean ing theories forward in their application to IPE in future Some of the conclusions that pertain to learning theories in particular wil
28. ng For the educational practitioner whose aim is to develop and deliver an IPE curriculum that has sound theoretical underpinnings this plethora of theories has become a confusing and un naviga ble quagmire This article aims to provide a compass for those educational practitioners by presenting a framework that summarizes key learning theories Journal compilation 2009 Blackwell Publishing Ltd Learning in Health and Social Care 2 S Hean et al utilized in IPE and the relationship between them The framework also represents a step towards mov ing IPE theory from a list of theories and their indi vidual application towards a heuristic critical comparison and prioritization of key theoretical tools O Toole 2004 A learning theory focus To achieve such a comparison it is tempting to try to review all theories applied to IPE however such an exercise is overambitious and unwieldy so this study focuses specifically on learning theories by which we mean those theories that describe how IPE interventions are run or organized e g complexity theory Cooper 2004 Sociological theories dealing with issues of professionalism and socialization or psycho sociological theories dealing with issues of group identity or group dynamics e g social iden tity theory the contact hypothesis Hean amp Dickin son 2005 Carpenter et al 2006 have been put aside Discussion here is confined to theories that seek to explore learni
29. ng as defined as a relatively permanent change in behaviour with behaviour incorporating both observable activities along with internal processes such as thinking attitudes and emotions Burns 1995 Hence the specific objectives of the study are to 1 present an overview of learning theories applied in IPE and their relationships with one another 2 note the relative contribution of these theories to the development of the field identifying areas for future theoretical development in IPE In so doing we briefly review 1 key contemporary learning theories from the wider field of education and used in IPE 2 explicit applications of these in IPE literature in either curriculum design or programme evaluation Readers are directed to Craddock et al 2006 for a more comprehensive review Method To achieve the above aims the authors reviewed key educational texts to identify key learning theories in the wider educational field 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd Search strategy in IPE Relevant literature was collected through a system atic search of relevant databases In order to capture literature pertaining to IPE and related terms e g inter professional multi professional education the first part of a published literature search strategy described in a critical review of the IPE literature described by Freeth et al 2002 was undertaken Hereby literature was identified in
30. on learning within an individual or a micro level analysis Some IPE edu cationalists especially those developing curricula in practice may find a macro level understanding of IPE better suited to framing their understanding and curricula They may wish to see learning as a collective exercise that takes place within or by a practice organization Fig 4B3 At this level social constructivism grows into theories such as activity theory communities of practice and expansive learning At the simplest level the social environment in which the IPE student learns can be described in terms of communities of practice These are groups of individuals engaged in a joint mutually recognized activity that binds them together where common cultural resources are shared Wenger 1998 A search of the IPE literature for the key word of communities of practice led to the con clusion that although communities of practice is becoming a popular concept to describe working in practice in health and social care it is less fre quently used to explore how learning takes place and it is student learning that we focus on in this study or how learning occurs inter professionally The concept has greater utility if subsumed in the greater complexity described by activity systems Learning theories and interprofessional education 9 Macro level of analysis Communities of practice B 3 B 2 B 1 Expansive learning g Soc
31. ped mainly through the work of Vygotsky 1978 Here student learning is per ceived to be mediated through socio cultural tools such as language see Fig 3 In the discussion of this mediated learning Vygotsky talks of a zone of proximal development ZPD This is the level of development that students can achieve via facil itated problem solving or in collaboration with more able peers In other words the ZPD is the difference between what a student can learn alone and what they can learn with the assistance of an external other This external other may be their IPE facilitator or fellow student albeit of another profession Vygotsky s belief was that individuals have vary ing potentials for ZPD in specific contexts which can be developed via teaching Jarvis et al 2003 To undertake tasks within the ZPD and allow learners to transcend this zone scaffolding systems can be employed Scaffolds may take the form of more knowledgeable people or cultural resources external to the student and which support their leaning This enables them to build on their own existing knowledge and internalize new informa tion Scaffolds by their nature are temporary support structures and will be slowly removed as 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd 8 S Hean et al students master the concepts in question and become independent learners Vygotsky 1978 Jarvis et al 2003 If one remembers the w
32. rmed practice Learning in Health and Social Care 5 220 242 D eon M 2005 A blueprint for interprofessional learning Journal of Interprofessional Care 19 S1 49 59 Dahlgren L O 2006 Developing Flexibility Through Expe riencing Variety A Potential Function of Interprofessional Learning for Improving Competence Paper Presented at The Altogether Better Health III London Dewey J 1966 Democracy and Education Collier Macmillan London Engestrom Y 1990 Learning Working and Imaging Orienta_Konsultit Oy Helsinki Engestr m Y 2001 Expansive learning at work towards an activity theoretical reconceptualisation Journal of Education and Work 14 133 156 Eraut M 2003 The many meanings of theory and practice Learning in Health and Social Care 2 61 65 Freeth D Hammick M Koppel I Reeves S amp Barr H 2002 A Critical Review of Evaluations of Interprofes sional Education LTSN Centre for Health Sciences and Practices London Hean S amp Dickinson C 2005 The contact hypothesis an exploration of its further potential in interprofessional education Journal of Interprofessional Care 19 480 491 Hean S Macleod Clark J Adams K Humphris D amp Lathlean J 2006 Being seen by others as we see our selves the congruence between the ingroup and out group perceptions of health and social care students Learning in Health and Social Care 5 10 22 Hean S Barr H Borthwick A Craddock D Hammic
33. round interprofessional stage development have potential but now need to move from the purely theoretical to an application in curriculum and evaluation design Questions such as how do we measure students stages of interprofessional development and how do we enable them to pro gress to the final stages of commitment to relativism need to be asked Finally after some neglect the IPE field is moving towards inclusion of socio cultural and more macro level theories to underpin practice Ideas of scaffold ing and ZPD have potential and should be employed further to understand and improve our educational practice utilizing scaffolds such as e learning and mediated learning through peer and tutor facilitated e learning There is also much scope for the applica tion of issues of expansive learning and activity sys tems especially to the more complicated levels described in so called third generational develop ments Despite the potential for future development the theoretical underpinnings of IPE practice has pro gressed well over the past 5 years and is no longer the atheoretical discipline it has been in the past The evidence of contemporary learning theories in education being reflected in IPE is particularly heart ening and bodes well for the future development of IPE educational theory IPE practice and research in general 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd 12 S Hean et al
34. sman New York Pollard K Miers M Dando M Evans D Hughes M Johnson R et al 2006 Evaluation of the Pre Qualifying Interprofessional Curriculum University of West of England Bristol Puliyel M M Piliyel J M amp Puliyel U 1999 Drawing on adult learning theory to teach personal and professional values Medical Teacher 21 513 515 Robinson M amp Cottrell D 2005 Health professionals in multi disciplinary and multi agency teams changing professional practice Journal of Interprofessional Care 19 547 560 Schon D A 2004 The Reflective Practitioner How Professionals Think in Action Basic Books New York Spencer J A amp Jordan R K 1999 Learner centred approaches in medical education British Medical Journal 318 1280 1283 Tennant M 1997 Psychology and Adult Learning Routledge London Vygotsky L M LS C 1978 Mind in Society Harvard University Press Cambridge Wenger E 1998 Communities of Practice Learning Meaning and Identity Cambridge University Press Cambridge Wood D F 2003 Problem based learning British Medical Journal 326 328 330 Zorga S 2002 Supervision the process of life long learning in social and educational professions Journal of Interprofessional Care 16 265 276 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd Author Query Form Journal LHS Article 227 Dear Author During the copy editing of your paper the following quer
35. valuation In some instances we raise unanswered questions and make recommendations that may appear tentative How ever this is with intent as in many instances there is no right or wrong answer no definitive recommen dation that an educator or evaluator should follow What they decide to do will largely be determined by the educational context in which they find them selves We ask at most and at the very least that edu cators and evaluators consider these questions evaluate their actions and then make an informed decision that is suitable for their own context The framework has also highlighted areas where future theoretical development is required For the behaviourists among us interprofessional compe tencies are infrequently translated into published curriculum designs and evaluation strategies and moves need to be made to redress this alongside efforts to increase and improve the measurement of interprofessional behaviours For proponents of adult learning theory in IPE the constructivist ori gins of adult learning theories need to be recog nized and the application of these theories should progress from a how we did it to a why we did it approach Those in the IPE field publishing their curricula and evaluation strategies also need to go beyond the current absence or tokenistic few sen tences describing their theoretical standpoint to a careful consideration of how the theory has informed their practice Ideas a
36. velopment A typical cognitive constructivist approach applied to the IPE field would be to use the stage or developmental the ories created by Piaget to explore learning and the acquisition of knowledge in children Piaget 1973 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd 6 S Hean et al B 1 Cognitive Constructivism Developmental stage theory Self directed experiential problem based discovery learning Constructivism B 2 Social Constructivism Social conflict theory Socio cultural learning Situated learning Collaborative learning Interprofessional learning Fig 2 Branches of constructivism that have been utilized with interprofessional education proposed that children s cognitive development pro gressed with age maturation beginning with basic sensory motor functioning and progressing to for mal operational stages of development Bigge amp Shermis 1999 Jarvis Holford amp Griffin 2003 how ever his basic premise of developmental learning has now been widely adapted from its original form to not only account for the development of knowl edge and skills in the individual but also for the development or learning of more affective traits Jar vis et al 2003 Dahlgren 2006 and Clarke 2006 appear to be the only authors who have considered these theories in their application to IPE Dahlgren 942006 considered the possible stages of interprofes sio
37. was central to the article were discarded This narrowed the focus down to those studies in which Learning theories and interprofessional education 3 the learning of a group of two or more health and social care professionals was central e Articles involved learning in higher education institution HEI and practice contexts and at an individual and organizational level were included For each study the reviewer extracted and synthe sized information from each article based on the following outcomes 1 the learning theory that was applied 2 the family of learning theory under which the individual learning theory could be subsumed i e if the theory had behaviourist or constructivist ori gins 3 whether the application of the theory had been made to underpin an IPE curriculum design or eval uation 4 whether the unit of analysis was at the micro or macro level of learning The micro level refers to learning at the level of the individual student macro level learning has a wider remit and encompasses learning that may occur within communities systems or organizations as a whole The dearth in application of learning theory in some areas e g use of activity theory made assess ment of the quality of articles reviewed a difficult exercise Because of this the only criterion for the assessment of article quality was that the theory and its application was discussed in some detail in the article Articles that only mentio
38. which the con cept of interprofessional and related terms was identified To identify IPE literature in which expli cit reference to learning theories was made the latter search was run in conjunction with searches for key words covering 1 broader terms related to learning theory in gen eral and broader families of learning theories e g Learning theor behaviour constructivis 2 specific theories that fall within these families e g interprofessional competen activity theory adult learning theory communities of practice The bibliographic databases searched were 1 Medline 1966 2008 2 Cumulative Index to Nursing and Allied Health Literature CINAHL 1982 to June 2001 3 British Education Index BEI 1964 to June 2001 Key journals in IPE Journal of Interprofessional Care Learning in Health and Social Care were searched by hand for any explicit use of a learning theory in discussion Review strategy Abstracts were reviewed and selected on the follow ing criteria e the article related particularly to IPE using the definition Members or students of two or more professions associ ated with health or social care to be engaged in learning with from and about each other Freeth et al 2002 e The articles content made explicit use of a key learning theory to articulate formalized learning that might take place in an interprofessional context This meant that articles where the learning of the patient
39. y and ambiguity Facilitate interprofessional case conferences and meetings Handle conflict with other professions 2009 The Authors Journal compilation 2009 Blackwell Publishing Ltd Learning theories and interprofessional education 5 theoretical underpinnings of these designs are not being articulated and or published more widely other than in the HEI s own course approval docu mentation Behaviourist approaches were apparent in publi cations linked to IPE evaluations particularly those that focused on measurement of learning outcomes alone and in which any process measures were excluded One clear example is the adaptation of the Kirkpatrick model of evaluation by Freeth ef al 2002 This framework has been utilized in IPE evaluations by authors such as McNair et al 2001 and Carpenter Barnes amp Dickinson 2003 In this model levels of educational learning outcomes are proposed the measurement of which should be included in an effective evaluation of an educational programme These levels include the reaction of the student to the learning experience the modification of students attitudes perceptions the acquisition of knowledge skills student behavioural change changes in organizational practice and benefits to clients The measurement of changes in student behaviour in interprofessional working would be an example of a behaviourist approach to evaluation However there is little evidence of IPE
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