Online learning for interprofessional education is not a new phenomenon (Beck and Owens, 2007; Power et al, 2021). According to Aldriwesh et al (2022), e-learning is one of the most popular approaches used in interprofessional education delivery. However, social distancing restrictions in response to the COVID-19 pandemic saw all face-to-face learning both in the UK and worldwide suspended, with an immediate, wholescale move to online learning (emergency remote teaching). Previous articles in this series have discussed interprofessional education and its impact on delivery (Wetzlmair et al, 2021) and student experiences (Sy et al, 2022) particularly in a remote arrangement. This article aims to further explore academics' experiences in the UK who developed and delivered interprofessional education during the pandemic. They reflect on all aspects of interprofessional education provision, from programme development to student evaluation, to make recommendations for future delivery.
The importance of interprofessional education is well recognised and is no less important for midwives than for other health and social care professions. While its logistical challenges have been well documented (Barr et al, 2014), it is a core element of pre-registration education for student midwives, nurses and nursing associates (Nursing and Midwifery Council (NMC), 2018a; 2019) and so any barriers, either historical or logistical (such as timetable clashes, room bookings), or unforeseen (such as the COVID-19 pandemic), must be overcome to ensure interprofessional education is embedded in the curriculum and the quality of provision is maintained. Core learning outcomes in professionally validated and regulated educational programmes must be maintained to ensure health professionals, such as midwives, are fit for practice.
While academics must ensure that the quality of midwifery education delivered online is on par with pre-pandemic educational arrangements, the practice of quality assurance has become more challenging. To improve the practice of teaching, one has to make time to solicit feedback, design lesson plans, self assess, and reflect on what has been done. Given the high expectations placed upon academics to deliver their teaching online with the same quality as before, not to mention adhering to national standards outlined by professional regulatory bodies, academics may have become exhausted. The increased workload, teaching preparations, navigating technology, dealing with health issues and facing the pandemic among other challenges (Rabe et al, 2020; Rodham et al, 2020) can negatively affect academics' ability to reflect, especially those in health professions. Rolfe (2002) argued that reflecting in the midst of healthcare practice has been ‘reduced from a radical alternative to technical rationality into merely an adjunct to it, a tool to be applied in order to meet’ requirements in education and practice. In other words, because of the hegemony of positivism in the health sciences, reflection and its practice has been situated at the bottom of the hierarchy of evidence-based practice. Without reflecting, healthcare will continually be faced with a culture of problematic communication between doctors, midwives, nurses and health and social care professionals (Owens, 2015). It is the authors' aim to demonstrate intentional reflection of their experiences as academics who facilitate online interprofessional education. Specifically, the authors framed this practice by first elucidating what reflective practice and learning are and then providing reflective accounts of the authors, who are academics, based on Rolfe et al's (2001) reflective model.
Reflective practice and learning
The NMC (2018b) code sets out expected standards of conduct and behaviour for midwives, nurses and nursing associates. Irrespective of the context of practice or levels of responsibility, all registrants are accountable for their actions and should take part in ‘appropriate and regular learning and professional development activities’ (NMC, 2018b) to remain on the professional register. Reflection is identified as a core element of the revalidation process (NMC, 2019) and is therefore recognised as an authentic means of continually developing practice knowledge and skills.
Reflection is acknowledged in a joint statement by nine UK health and care professional bodies as benefitting service users by (General Chiropractic Council et al, 2019):
- Supporting individual professionals in multi-disciplinary teamwork
- Fostering improvements in practice and services
- Assuring the public that health and care professionals are continuously learning and seeking to improve.
A number of theories and models to facilitate practitioner reflection have been developed and these offer useful frameworks to structure, enhance and ground reflective accounts with current evidence (Kolb, 1984; Johns, 1995; Driscoll, 2007). Gibbs’ (1988) reflective cycle is a well-known approach used in pre-registration education to consider students' experiences with respect to literature, identifying learning and influencing future practice. Rolfe et al's (2001) reflective model is popular with healthcare professions when reflecting on practice. This reflective model asks: ‘what?’ ‘So what?’ ‘Now what?’ The first question (what?) allows the writer to reflect on the issue at hand. The second question (so what?) allows the writer to reflect on how evidence or personal experience can help in addressing the issue or not. The third question (now what?) allows the writer to think of what to amend or consider next time the issue arises.
The following reflective accounts adopted the Rolfe et al (2001) reflective model to illustrate the experiences of academics at three UK universities who developed and delivered interprofessional education programmes during the COVID-19 pandemic. The authors propose a further stage, the ‘then what?’, which they use to consider further directions for interprofessional education delivery.
Reflective account 1: Vikki Park (adult nursing)
What?
The first UK lockdown in March 2020 happened during the second semester. Mid-teaching, university campuses closed, but health and social care programmes, which included interprofessional education, had to continue. At Northumbria University, over 800 students and 20 staff and practitioners were immediately impacted, which created pressure to move 90 hours of face-to-face teaching to an online virtual learning environment within 2 weeks. This had never been done before and had to be converted quickly. This was a stressful time as all healthcare education had to be converted for online delivery across all programmes.
The Northumbria University model meant that half of the interprofessional education provision was already online in the Blackboard Ultra virtual learning environment and students were in 30 interprofessional groups, so discussion boards were used to create virtual spaces for interprofessional conversations. The online platform enabled the addition of weblinks, videos and documents and, based on the learning outcomes and interprofessional education strategy, an interprofessional education workbook was created by the interprofessional education leads. which students followed throughout the week.
Of concern was how to communicate changes to the interprofessional education week to students and these were shared using the Blackboard Ultra announcement function. Academics and students were in unfamiliar territory and had never engaged with emergency remote teaching. Guides were produced to introduce academics and students to the additional functions in the virtual platform they had not used before.
Staff were paired to facilitate multiple student groups and to engage in interprofessional conversations within the virtual learning environment discussion board. Academic peer support to facilitate interprofessional education was needed to adapt to new delivery formats and to support academics through the rapid change in teaching.
So what?
Academics had to urgently redesign teaching materials to minimise disruption to student education. Continuation was essential for health and social care students who were needed to contribute to the pandemic crisis. Decisions about emergency remote teaching had to be made quickly, pragmatically, and realistically while still meeting the core learning outcomes of validated professional programmes. With respect to learning culture, the NMC (2018a) only approves educational programmes where team working and interprofessional learning are embedded. Therefore, it was essential for interprofessional education to continue throughout the pandemic.
Behind the scenes, academics were under additional hidden pressures, including:
- Providing increased levels of student support
- Learning how to use digital learning technologies
- Challenges of homeworking
- Academics with children had the extra role of childcare and homeschooling while working under pressured circumstances
- Health professional academics were also contacted by external organisations seeking help, such as hospitals asking them to join nursing banks, regional teams developing Florence Nightingale hospitals and requests for vaccination volunteers.
These additional pressures while planning ongoing interprofessional education facilitation are becoming increasingly apparent within literature. For example, Wray and Kinman (2022) note that these pressures have added to academics' already deteriorating mental health and existing increasing work-related stress.
Now what?
During the initial crisis phase of the pandemic, health and social care academics prioritised emergency remote teaching but this urgency excluded the input of wider team members such as fellow academics, students, practitioners and patients. Moving forward, there is opportunity to evaluate and redevelop online interprofessional education provision and collaborative design is needed.
The pandemic highlighted the need for increased digital literacy and during emergency remote teaching, academics often taught each other how to navigate different platforms that they had never used before. There was a sense of a community of practice for staff working together to learn about different online technologies.
Over time, as the urgency has abated and academics have increased their digital skills, teaching has moved to online blended learning rather than emergency remote teaching. Academics have had more time to begin working with colleagues to develop new resources. Examples of resources designed by Vikki Park include guides for using closed captioning to promote student inclusion with online sessions and an online virtual simulation ward to meet interprofessional module learning outcomes.
Reflective account 2: Alison Power (midwifery)
What?
The University of Northampton's approach to learning and teaching is defined as ‘active blended learning’, which is a flexible, student-centred approach, combining face-to-face teaching with synchronous and asynchronous online learning opportunities (Institute of Learning and Teaching in Higher Education, 2020). Active blended learning allowed the university to quickly adapt to the impact of the pandemic on teaching and learning opportunities, including its interprofessional education provision.
The interprofessional education ‘collaborative curriculum’ was first introduced in 2019, with interprofessional education being embedded in a module at every level for students enrolled on 16 health and social care programmes in the faculty of health and society. A subsequent faculty restructure welcomed education programmes to the provision, meaning there are currently 17 health, education and social care programmes engaging with interprofessional education across the faculty.
Since September 2020, students have attended a cross-faculty synchronous online session in a virtual classroom hosted by the university's virtual learning environment: Blackboard Ultra. The sessions begin with an introductory keynote speech, which is followed by interprofessional group work in virtual breakout rooms using the educational technology Padlet (a cloud-based, real-time collaborative platform that allows users to upload, organise and share content such as images, videos, documents and hyperlinks to virtual ‘bulletin boards’) as a collaborative learning tool.
So what?
As interprofessional education provision at the University of Northampton was delivered synchronously online prior to COVID-19, sessions were pre-planned and e-resources were developed to deliver the session in a synchronous online environment, unlike some institutions who were forced to move sessions planned to be delivered face to face to an online environment with minimal time to prepare (Bozkurt and Sharma, 2020). That said, sessions were not without their challenges and on reflection, lessons have been learnt that will influence future provision. It has been suggested that the success of synchronous online learning from the education provider's perspective lies in a robust technical infrastructure and competent and confident e-facilitators (LeBlanc, 2020), with well-planned and structured sessions (Moor, 2020). From the student perspective, Moor (2020) suggests they need to take responsibility for their learning and be active participants. In order to do this, they should be proactive in preparing for online sessions, having ensured their devices and internet access are set up in advance. Since March 2020, there have been seven interprofessional education synchronous online sessions delivered to students across all 3 years of their pre-registration programmes. This has provided an opportunity for ongoing review and development in response to student feedback.
Students are emailed in advance of timetabled sessions, giving comprehensive instructions (video and Padlet) on how to find the virtual classroom and how to ensure their audio and video and wifi are set up appropriately in order to fully engage with learning. On the day, e-facilitators move between virtual breakout rooms to ensure all students have at least microphone access so that they can participate in interprofessional group work.
Feedback suggests these interventions have made a positive impact; however, there remain students who are hesitant to engage because they perceive interprofessional education as an additional learning burden beyond the expectations of their programme of study. This requires more focused attention at programme level to ensure students are aware that interprofessional education is embedded in their programme and that cross-faculty sessions are an important aspect of their learning, providing a real-time opportunity to collaborate and learn with, from and about students from other health, education and social care programmes.
Now what?
The COVID-19 pandemic continues to be a trigger for reflection as academics navigate their way through a new educational landscape to ensure students continue to receive a high-quality learning experience. As an educator, Alison tries to inspire and motivate students to learn, and feels she achieves this within the midwifery curriculum as she works with cohorts of students she has built a relationship with. The challenges with interprofessional education mirror the challenges of interprofessional working, motivating ‘strangers’ to see the benefit of collaboration to achieve a shared goal. Add to this a second perceived barrier to learning in an online environment and the challenge becomes more complex and multifaceted. The misconception that interprofessional education is an ‘optional extra’, rather than the cornerstone of safe, effective, high-quality care and a fundamental component of pre-registration education also needs to be challenged and replaced with a more receptive attitude to interprofessional education.
Reflective account 3: Melissa Owens (learning disability nursing)
What?
At the University of Bradford, the main interprofessional education activity is a half-day event that is offered four times a year, with two of these including midwifery students. The event focuses on the impact of collaborative working on service users and carers, who are a central part of the event (Owens and Cook, 2019) (which will be discussed further in the seventh article in this series). It starts with a keynote lecture where Melissa Owens discusses what the event will involve and is followed by two service users/carers telling their stories, emphasising positive and negative experiences of collaborative working. Students then move into breakout rooms and watch a short video, based on a practice scenario, which they then discuss in interprofessional groups.
Initially, Melissa found the prospect of moving to emergency remote teaching to be fairly stressful. Although she had previously delivered interprofessional education online, this had been planned and involved mainly asynchronous interactions via a virtual learning environment and it had been a long time ago (Beck and Owens, 2007). Melissa is a tactile learner (Kratzig and Arbuthnott, 2006) and consequently felt it important to virtually walk herself (and the team) through the event in advance to ensure it would run smoothly.
First, a mitigation list of each element of the event was created, identifying what could go wrong and what the team could do to prevent or minimise the effect of this. For example, a troubleshooter was identified who was responsible for managing the technology on the day; the team shared mobile numbers on a WhatsApp group so the troubleshooter could be alerted quickly if there were any problems and did a final ‘walkthrough’ the day before delivery of the first emergency remote teaching interprofessional education event to identify any final snags that had not been previously considered.
A ‘netiquette’ was created for students that provided etiquette for engaging in the event. Netiquette, from the terms internet and etiquette, provides students with a set of rules that enable them to come together online, with a shared understanding of what is expected (Buelens et al, 2007). Melissa was unable to find a university-wide netiquette, but took copies of individual netiquettes that colleagues shared in order to create one specific to the event's needs. The netiquette included asking students to keep their cameras on during the event, considering what they were wearing (being dressed and not in pyjamas), being aware of any images in their background (for example, inappropriate pictures on the wall) and not smoking. It also told students how to include their profession with their name on Zoom, so they could easily be identified by profession and quickly moved into mixed-professional groups in breakout rooms at the end of the 1-hour launch.
As the interprofessional education event focused on service users and carers, they were also taught to use the technology, which the academics were only just getting to grips with.
So what?
As academics, the start of the pandemic was a time of incredible pressure. All programmes continued to be delivered but had to quickly move to emergency remote teaching without the usual time for planning and preparation. Preparation of interprofessional education added to this pressure as it involved students from across a number of different programmes and would be the biggest online event that any of the team had been involved in up until that time. The team also ‘did not know what they did not know’, which added extra anxiety to the team.
However, planning for the event and considering what might go wrong was helpful in relieving anxieties about delivering the event on the day. As a lecturer, Melissa was aware of the principles of workload management and used these to help plan for the day. She also used Eisenhower's urgent/important principles to promote planning in a structured way without getting distracted by other people's agendas (Covey, 2017). Colleagues felt prepared and knew what to expect, as well as what to do if something went wrong on the day.
Planning in advance also meant it was possible to identify potential vulnerabilities that could impact on the delivery on the day. Working from home, for example, meant that broadband speeds could affect connectivity, (Khalini et al, 2021), while homeschooling, for some facilitators and students, could affect engagement.
The creation of the netiquette ensured the students knew what to expect and turned up prepared.
Now what?
Delivery of interprofessional education continues to be a challenge. Organising large numbers of students to be together in the same place (either virtually or face to face) requires planning and coordination. A firm belief in its value helped Melissa ensure it remained a priority and ensure interprofessional education could continue to be delivered throughout the period of emergency remote teaching.
Not everything went as planned; facilitators dropped out at the last minute because of sickness and despite careful planning, not all information technology worked as planned. Nevertheless, having a mitigation plan ensured that it was still possible to deliver events and evaluations from students suggest that it was well received. Equally, the crisis seemed to bring everyone together. Students were perhaps more forgiving when technology failed and colleagues more supportive towards each other, bringing a collegial determination to ensure interprofessional education events would continue to run.
Then what? Shared learning and future directions
The move to emergency remote teaching required speedy adaptation from previous modes of interprofessional education delivery without the luxury of time and preparation enjoyed previously. However, looking forward, it is possible to reflect on what was learnt during this unprecedented period, considering what went well as well as what might be done differently: ‘then what?’ One lesson learnt was that interprofessional education can be delivered and facilitated effectively on virtual platforms, despite limited time to prepare. The full functionality of platforms should be used to enhance student learning experiences, and students and interprofessional colleagues need to be involved in developing online resources. Ensuring adequate preparation, working collaboratively, and preparing guidelines for using technology and for engagement online (netiquette) were all important in achieving this. Conversely, responding quickly to online learning meant there was less time for co-creation of e-tivities, while home working (and for some, home schooling) meant that working environments were not always ideal. Nevertheless, there have been some positive elements of emergency remote teaching that can be built on for future learning. For example, an increase in digital literacy and technology skills ensures confidence in e-facilitators that will help prepare them in the future.
It is now 2 years since the world was first thrown into the crisis of rapid change that COVID-19 brought. However, there is now an increasing body of knowledge and experience that is beginning to grow around emergency remote teaching and interprofessional education (Tobie et al, 2020; McKinlay et al, 2021; Power et al, 2021; Wetzlmair et al, 2021; Sy et al, 2022). This allows consideration of others' experiences, as well as one's own, in order to continue to improve interprofessional education delivery. For example, Khalini et al (2021), call for recognition of the importance of team resilience in delivering interprofessional education, as well as giving consideration to the practicalities. Langlois et al (2020) discuss the importance of ensuring interprofessional education is underpinned by theory and this continues to be important, irrespective of mode of delivery.
Conclusions
Overall, and in the spirit of interprofessional education, the pandemic has provided academics with an opportunity to learn with, from and about colleagues who have developed and delivered interprofessional education over the past 2 years. However, this learning has been retrospective with the move to emergency remote teaching reducing the time ideally wanted for planning, to enable reflection in learning as well as on learning, in order to enhance interprofessional education provision. Looking forward (then what?), there is now time to consider how to build on what has been learnt to ensure the continued ability to deliver high-quality interprofessional education that is of value to students.
Upcoming article
The fifth article in the series will explore changes in provision and approaches to practice-based learning and student placements, drawing on case studies and examples, to identify challenges for incorporating interprofessional practice learning (Barr et al, 2017), opportunities for innovation and guidance for future practice.