Emergency remote teaching for interprofessional education during COVID-19: student experiences

There is a growing interest in the use of online learning in interprofessional education in part because of the emergency remote teaching implemented during the COVID-19 pandemic. This article explores student experiences of online interprofessional education considering midwifery competencies and ways to promote effective online approaches. Specifically, the paper will identify intersecting competencies in midwifery and interprofessional education, describe online teaching and learning activities that target interprofessional education competencies in midwifery education and discuss the nuanced student experiences of online interprofessional education and emergency remote teaching using case studies. The article concludes with advice on ensuring the interactivity, effectiveness, and relevance of online interprofessional education in the midst of the changing landscapes of health professions and midwifery education.

Online interprofessional education and emergency remote teaching

Recently, the impact of the COVID-19 pandemic has led many educational providers to adapt to an online delivery mode. The first article in this series (Power et al, 2021) explored definitions of online learning and emergency remote teaching, identified the different ways that technology can enhance interprofessional learning, and discussed the impact of the COVID-19 pandemic on midwifery pre-registration education, including interprofessional education. This article extends this discussion by focusing on student experiences. The key terms discussed in this article are defined in Box 1.

Box 1.Definitions of key termsOnline interprofessional educationTwo or more professions learning with, from, about each other using a virtual learning environment as the medium for delivery. This can be synchronous (in real time) or asynchronous (flexible timing).Emergency remote teachingAn unexpected, unplanned move from face-to-face education to online provision, where learning activities designed to be delivered face to face are quickly adapted to be delivered in an online environment.

Online interprofessional education and midwifery competencies

Despite the pandemic, the need for interprofessional education has continued for midwifery students. Learning with, from and about others within interprofessional teams is recognised globally as a strategy for health and social care professionals to improve health outcomes amid the increasing complexity of the global health crisis (World Health Organization (WHO), 2010). This is further indicated by international networks such as the Centre for the Advancement of Interprofessional Education (CAIPE), Interprofessional Global (IPG), Interprofessional Research Global (IPRG) and the International Network for Health Workforce Education (INHWE). In the UK, the Nursing and Midwifery Council (NMC, 2018; 2019) stipulates the competencies and standards required for pre-registration midwifery education and ongoing midwifery practice. During the COVID-19 pandemic, the NMC (2020) introduced emergency standards for nursing and midwifery education. All NMC standards include competencies to promote interprofessional collaboration, which are necessary for midwifery practice through interprofessional education (Box 2).

Box 2.Examples of midwifery interprofessional collaboration competencies (Nursing and Midwifery Council, 2019)

• Development and articulation of professional identity
• Effective collaboration with other professions
• Provision of safe care
• Effective communication
• Experience of providing interprofessional care

The NMC (2018) emphasises that midwives recognise the limits of their knowledge and practice within the boundaries of their professional role. Developing professional identity as midwives is a pivotal competence for effective interprofessional collaboration. Healthcare professionals are integrated into their fields through a process of socialisation with others (Clark, 2006; Wilhelmsson et al, 2012, Khalili et al, 2019). Through this socialisation, professionals become accustomed to the world views of their profession (Hall, 2005). Development of professional identity entails understanding the remit, jurisdiction and boundaries of their professional roles within given situations (D'Amour and Oandasan, 2005). Gaining a strong professional identity prior to qualification as a midwife is an essential interprofessional competency. Early experience of interprofessional education helps to prepare students for their future professional practice (van Diggele et al, 2020) and is one forum through which midwifery students may convey understanding of their professional identity to other healthcare professionals.

Midwives, as part of the interprofessional team, must demonstrate competence to work collaboratively and effectively with others (NMC, 2018). As fully accountable professionals, midwives are autonomous practitioners when providing midwifery-led care, and are the coordinators of care for more complex cases requiring a multi-disciplinary approach. It is vital for midwives to appropriately refer to other healthcare professionals to ensure the holistic needs of women, their babies and families are met (NMC, 2019). Through interprofessional education, competence can be demonstrated by working with other professions to learn with, from, and about each other's roles and responsibilities. Interprofessional competencies are developed, such as learning how to communicate with other health or social care professionals, assessing service users from a team-based arrangement and planning care in partnership with midwives, health professional colleagues and service users/mothers and families.

Safe practice is a shared goal for all healthcare professionals. The NMC (2018; 2019) outlines expectations for midwives to recognise signs of deterioration, to identify safeguarding issues and to implement appropriate, safe, and timely interventions. Interprofessional education strategies such as case reviews, interprofessional team meetings, and simulation-based and reflective learning provide opportunities to refine these competencies. Research has shown that health and social care professionals view their care competencies through the prism of their specific professions, which allows for the creation of different goals and competing demands when delivering care (Park, 2019). The way that different professions perceive care management priorities based on their professional worldview can become apparent during interprofessional education sessions. By intentionally using interprofessional education strategies, students can have a better understanding of not only the ‘what’ of collaboration, but more so the ‘why’ of collaboration, leading them to learn, plan and work together with the aim of providing safe, intentional and family-centred care.

Effective interprofessional communication with colleagues is a core competence when working within healthcare teams (van Diggele et al, 2020). This includes listening, making decisions in partnership with patients and families and providing sufficient clear information to facilitate informed decision-making (NMC, 2018; 2019). During interprofessional education, midwifery students have opportunities to hear others' experiences and perspectives, respond and communicate with their peers, and utilise enquiry-based learning towards achieving the shared goal of providing high-quality care.

Online interprofessional education is particularly challenging for students in health and social care programmes where the demonstration of clinical and interprofessional competencies with direct service user care is pivotal (Williams and Lakhani, 2010). Given that interprofessional education must prepare students for collaborative practice in the workplace, quality care and safe practice would be difficult to achieve with a decrease in overall physical contact with service users (Rabe et al, 2020). This situation has occurred for many students during the pandemic as placement opportunities were affected. Although telehealth and shadowing virtual consultations have become feasible alternatives, group dynamics can still be facilitated in interprofessional education through early planning, contingency plans, advanced readings and by balancing roles between teaching and facilitating (Khalili, 2020; Rabe et al, 2020). Despite the restrictions brought about by the pandemic, these interprofessional learning and working practices have continued to be actuated within online and emergency remote teaching arrangements.

Student experiences of emergency remote teaching

Across the world, the use of online learning has grown exponentially as a primary method of teaching and learning in higher education in response to the COVID-19 pandemic. In many health fields, educational programmes fully moved to emergency remote teaching to accommodate the learning needs of students while staying at home. Although the challenges of adapting theoretical and clinical content to an online setup are apparent, interprofessional education remains at the frontier of health professions' education through online interprofessional education arrangements. Globally, students' interprofessional education experiences have varied during the pandemic, and the case studies outlined in this article, gathered from members of CAIPE, provide insight into the nuances of online interprofessional education and emergency remote teaching.

Technological considerations

This article presents two international case studies that consider students' experiences of using technology during emergency remote teaching (case study 1, Box 3) and online interprofessional education (case study 2, Box 4). Enablers and barriers to using technology for interprofessional education are reviewed.

Box 3.Case study 1: emergency remote teaching in response to the UK national lockdown during the COVID-19 pandemicIn March 2020, the UK declared the first national lockdown and when higher educational institutions closed, learning was moved to online formats. At Northumbria University in the northeast of England, where interprofessional education had previously used a blended approach of both face-to-face and online activities, the university campus closure resulted in rapid conversion to emergency remote teaching and a fully online asynchronous interprofessional education programme was developed within 2 weeks.Enablers:

• Students were already enrolled into the virtual learning environment (Blackboard Ultra). This aided the transition to emergency remote teaching
• Emails could be generated from the virtual learning environment providing students with information and instructions
• Asynchronous emergency remote teaching during the interprofessional education week enabled access earlier or later in the day for those experiencing internet bandwidth constraints
• The teaching also facilitated access during off peak times of the day for those with shortages of IT equipment at home, such as homeschooled children competing for devices to complete online learning activities
• Activities could be accessed by mobile phone for those without PCs, laptops or tablets.

Barriers:

• The full functionality of Blackboard Ultra had not previously been utilised
• Some students did not engage in the interprofessional education activity and disconnected from the online platform.

Lessons learned:

• It is beneficial to explore the full functionality of virtual learning environments to ensure learning is rich and interactive
• User guides were developed for students and interprofessional education facilitators, such as guides to using the discussion forums.

Box 4.Case study 2: an online interprofessional education course for graduate students in the PhilippinesIn 2021, an online interprofessional education course for graduate students in the University of the Philippines, Manila was piloted. These graduate students were enrolled in master's and doctorate level courses in health professions education, including this interprofessional education elective course delivered online. This graduate-level course aims to develop health professions educators who are cognisant of the value of interprofessional education and collaboration within various dimensions of instruction in the context of health professions education. Through online teaching–learning activities, competencies in instructional design were honed within the context of interprofessional education. The final course outputs were a satisfactorily designed lesson plan for pre-registration health science students in their teaching practice and participation in organising an interprofessional education symposium.While interprofessional education has always been delivered in a face-to-face arrangement, the course at the university had been delivered online during its pilot implementation. Although interprofessional education, and consequently the training of interprofessional collaboration competencies, may have been hampered by the pandemic in terms of planning, implementation and evaluation, the use of technology was instrumental in ensuring that interprofessional education continues amidst the pandemic.Enablers:

• Graduate students were working as health professionals in different fields with a certain extent of teaching experience. They were acquainted with and trained in using educational technologies for their work
• Generally, the students taking interprofessional education as an elective course implied that most of them had experience in interprofessional education and collaboration and were highly motivated to learn
• Teaching–learning activities online included receiving feedback from local and international experts on students' project proposals (interprofessional education instructional design) using online collaborative applications and inviting interprofessional education experts from the UK and Australia for an interprofessional education colloquium via Zoom.

Barriers:

• More than the issues on internet connectivity, more mature students may have needed to learn additional competencies, such as basic digital literacies, alongside interprofessional education competencies.

Lessons learned:

• Interprofessional education, as an educational strategy, can be delivered both through face-to-face and online arrangements. This arrangement can ease the logistical, technological and theoretical issues that previously hindered interprofessional education implementation in pre-pandemic times.
• For graduate students and professionals, interprofessional education and collaboration capacity building activities can be implemented fully online, especially when the learning outcomes are intended to generate programs, products, processes and publications within the context of higher and lifelong learning.

Historically, interprofessional education delivered in an online environment has posed challenges for both facilitators and learners. Barriers include the lack of digital literacies and skills as well as the lack of technological equipment at home, as illustrated in case study 1 (Box 3). Since interprofessional education is traditionally employed through team and collaborative learning, the online arrangement reduces the ‘human touch’ and interactivity that naturally occur in interprofessional education (Khalili, 2020). Having interprofessional education experiences only online may deprive students and facilitators of the positive support, team learning and dynamic interactions that naturally occur in an interprofessional education programme as outlined in case study 2 (Box 4).

Prior to campus closure because of the pandemic, most students had already been enrolled in virtual learning environments to maximise the use of technology for learning. This enabled many students to continue their interprofessional education courses amidst the lockdowns (case study 1, Box 3). For some facilitators and students, attending a pilot interprofessional education course in an online arrangement may also be advantageous because of the use of collaborative applications that allow for synchronous and asynchronous group working. In case study 2 (Box 4), the use of technology also enabled harnessing global knowledge resources for consumption in the local interprofessional education context with very minimal cost and logistical efforts.

The application of online learning to interprofessional education is still in its infancy. Online interprofessional education can potentially provide positive learning experiences by using innovative online strategies that promote collaboration and are supportive, flexible and accessible for students working across all aspects of healthcare (Reeves et al, 2017). The use of technology for interprofessional education during the COVID-19 pandemic has highlighted opportunities for interprofessional collaboration and engagement (Sharpe et al, 2021). However, the transition to online interprofessional learning is not without its barriers and limitations. In particular, online interprofessional education raises concerns relating to equity and access, particularly in low-resource settings and areas where there may be low levels of digital literacy (Nedungadi et al, 2018; Early and Hernandez, 2021; World Economic Forum, 2021). Advancements of information and mobile technology have made it possible for online education to occur in most of the world (Khalili, 2020); however, the reality of engaging with synchronous online activities is not always feasible. The technological problems included log-on issues, being disconnected during the sessions and malfunctioning headsets/microphones during the sessions (Evans et al, 2014). Providing opportunities for asynchronous and on-demand online interprofessional education are potential ways of ensuring widening participation and engagement.

In addition, it is important to ensure that alongside providing such opportunities, the necessary infrastructure, equipment and skills training to undertake online interprofessional education are provided by educational providers, employers and the government, and that these resources reach the most marginalised and reduce inequality related to internet connectivity and access. Case study 1 (Box 3) illustrates how equity of access to technology was problematic for some students and the organisation responded by offering the opportunity to apply for funding to purchase laptops.

Theoretical considerations

Online interprofessional education is an emerging educational practice accelerated by emergency remote teaching and during the pandemic, students experienced asynchronous and synchronous interprofessional education, which are compared in Box 5.

Box 5.Comparison of asynchronous and synchronous interprofessional education delivered through emergency remote teaching
It fits around competing demands such as placement attendance, part-time working and homeschooling responsibilities for learners with children or caring responsibilities

It is likely that future interprofessional education programmes will retain online learning arrangements, adopting a blended learning format that uses both synchronous learning that is scheduled and asynchronous learning that is undertaken independently. Synchronous education can include student reporting, breakout sessions and use of telehealth, while asynchronous education can include listening to video recorded lectures, case-based or project-based assignments and reflective video analysis with clear and structured guidelines (Khalili, 2020).

A comparison of the two case studies, shown in Box 5, illustrates how students were provided with asynchronous interprofessional education activities to complete in one week during emergency remote teaching. This example aligns with a scoping review by Evans et al (2019), who reported that online interprofessional education facilitation is delivered more in asynchronous arrangements where the educator provides instructional materials that students work on in their own time and at their own pace. Similarly, interprofessional education facilitators encouraged interprofessional conversations between students about the instructional materials within an online discussion forum to embed theory and to consolidate learning. To enable interprofessional learning, Khalili (2020) considers the facilitator role a prerequisite for social and cognitive presence during online interprofessional education to promote professional socialisation and to enable students to construct meaning from their experiences.

Asynchronous interprofessional education enables flexibility for students to participate in activities at convenient times, which can be based around placement, work, studies or childcare. The main theoretical concerns regarding asynchronous interprofessional education relate to the challenges of forming distinctive professional and group identities whilst working virtually, as well as the risks of experiencing isolation and feeling excluded from or unsupported in independent learning activities when they are virtual and learner led.

The comparison of the two case studies additionally illustrates synchronous interprofessional education activity, where students and facilitators participated in scheduled online events. Evans et al (2014) found the synchronous facilitating experience to be positive because of ‘perceiving the students were learning’ and ‘the flexibility of the role’. However, there are many challenges related to synchronous facilitation, particularly managing technological challenges (Hanna et al, 2013; Evans et al, 2014).

Synchronous and asynchronous learning are underpinned by distinct educational theories. Regardless of the online arrangements employed to facilitate interprofessional education among students, it is important to apply theoretical principles. Asynchronous approaches must be clearly explained and they embody the theory of andragogy (adult learning), where education is autonomous and learner-centred. Andragogy, with broad constructivist views, occurs when new knowledge is constructed on the foundation of existing knowledge (Mukhalalati and Taylor, 2019). Synchronous activity tends to be pedagogically directed by facilitators as learners are guided through educational activities. As health professional learners, autonomy and continual professional development are essential health professional competence stipulated by the NMC (2018; 2019). Professional autonomy and the capacity for independent learning, critical thinking and reflection can be demonstrated through the completion of online interprofessional education activities.

Several theoretical frameworks can underpin online interprofessional education. Community of inquiry is a social constructivist framework that has three educational domains: ‘social presence’ to authenticate collaborative learning experiences, ‘cognitive presence’ to promote critical thinking, reflection and construction of meaning, and ‘teaching presence’ where the facilitator promotes the integration of social and cognitive aspects for learners, which can guide online and blended interprofessional education (Hayward et al, 2021). Gilbert and Dabbagh (2005) researched ways to structure online discussions to promote meaningful discourse between students. They defined meaningful discourse as demonstration of students' critical thinking skills by linking their experience and knowledge to course content, by being able to interpret course content by analysing, synthesising and evaluating others' understanding and thereafter, by making inferences. According to Khalili (2020), the application and evaluation of the impact of meaningful discourse and community of inquiry principles in online interprofessional education have the potential to assist facilitators and students to maintain the ‘human touch’, to co-construct knowledge and to cultivate a sense of community and supportive accountability through online learning environments.

Hayward et al (2021) conclude that interprofessional education and collaborative practice offer the opportunity to integrate theories and practices from specific professional fields to mutually inform and influence interprofessional teams within differing healthcare contexts. Therefore, online interprofessional education needs to integrate educational theories to promote interprofessional learning between students and to enhance best practice.

Logistical considerations

Historically, interprofessional education has been delivered in a face-to-face environment. While this has provided students with a physical opportunity to learn with, from and about each other, it does have logistical challenges in relation to securing large enough teaching spaces, training faculty members in interprofessional education and coordinating multiple timetables. As a result of government social distancing measures (Gov.uk, 2020) all provision in the academic year 2020-2021 had to be moved online (Power, 2020). Case study 3 (Box 6) considers the logistical issues raised by this wholescale move in mode of delivery and provides suggestions for future provision.

Box 6.Case study 3: a UK example of logistical considerations with emergency remote teaching for interprofessional educationAn ‘interprofessional education collaborative curriculum’ was introduced in 2019 in the Faculty of Health, Education and Society at the University of Northampton for 16 health and social care undergraduate programmes. The ‘Introduction to interprofessional education at the University of Northampton’ session was facilitated face-to-face for the first cohort of students; however, the session was delivered synchronously online using a virtual learning environment for the September 2020 cohort, in line with government social distancing measures.Enablers:

• Comprehensive pre-session communication is key to give context to the content and relevance of interprofessional education synchronous online sessions and to support students with setting up their devices for the virtual classroom
• By splitting a large group into additional rooms, the virtual learning environment's functionality was restored, allowing students to interact using functions such as chat, audio, video, screen and document sharing
• Padlets can be a valuable learning resource for large groups and a ‘truth or myth quiz’ was a fun and engaging way to explore common misconceptions around professional roles and responsibilities.

Barriers:

• The virtual learning environment, Blackboard, has limitations in relation to synchronous sessions for large groups with a reduction in interactivity and functionality for sessions with over 250 participants
• Unfamiliarity with the virtual learning environment can cause some students anxiety when trying to join the virtual classroom and engage with synchronous online group work
• Not all students see the relevance of interprofessional education, which negatively impacts attitudes towards online synchronous group work.

Lessons learned:

• Introduction sessions should be timetabled later in the first semester, to give students the time to become more digitally competent and confident with the virtual learning environment
• To improve the student experience, it is important to continue to work collaboratively with academics across the faculty to ensure interprofessional education is seen as valuable and relevant to all programmes in the collaborative curriculum.

Online learning can overcome some of the logistical difficulties of interprofessional education, such as bringing together learners from different institutions, regions and professional programmes (Skorga, 2002; Juntunen and Heikkinen, 2004). An online format enables the creation of accessible, organised and structured learning environments that learners can access at a convenient time and location, as evidenced by Wetzlmair et al (2021). Therefore, online learning has great potential to solve many logistical problems relating to implementing and delivering interprofessional education. However, the application of online learning to interprofessional education is still relatively new, since interprofessional education has traditionally been facilitated face to face. While some have found online environments easier than engaging with interprofessional education in a face-to-face arrangement (Connor, 2003), it is important to consider that interprofessional education is meant to prepare students for interprofessional collaboration in the real world of health and social care practices (WHO, 2010). Therefore, the effects of logistical barriers in interprofessional education require evaluation.

The challenges of the online teaching experience included the inability to conduct relevant practical and hands-on sessions, as well as the difficulty in maintaining equal opportunities for contribution and active participation between students of different backgrounds. Similar challenges were identified by both Wang (2007) and Mishra and Bartram (2002). Conducting relevant practical sessions as well as the sustainability of this interprofessional education e-learning experience remain key challenges (Abdelaziz et al, 2021).

A key consideration when ensuring digital equity involves designing online interprofessional education activities that put the users at the heart of the process, for example through human-centred approaches (Norman, 2019). Engaging students and in particular, involving more marginalised or excluded groups in the design of online interprofessional education has the potential to improve interaction and sustainability of online interprofessional education initiatives by meeting the needs of both learners and facilitators. Such approaches also have the potential to improve student engagement and motivation through embedding educational theory within the human-centred design and implementation phases of online interprofessional education (Hayward et al, 2021). For example, constructivist approaches build upon existing knowledge of students and can be used to create opportunities for online collaboration through developing virtual interprofessional communities of practice (Johnson, 2001). As illustrated by the comparison of case studies 1 and 3 (Box 5), a practical application of this might include engagement with asynchronous interprofessional discussion boards or adopting a process of defining an interprofessional education problem, encouraging effective online participation of all students through online facilitation that scaffolds and builds upon the existing knowledge and resources of the virtual community, encouraging collaborative online working and negotiating next steps within the online community of practice (Johnson, 2001; Wetzlmair et al, 2021). Integral to achieving an effective online community of practice is creating a psychologically safe online educational environment, which recognises the importance of mutual trust, participation and continued engagement with peers (Hayward et al, 2021).

Logistical barriers in interprofessional education have always been concerning for educators and curriculum designers, and this spectrum of issues has evolved, especially during the pandemic. For instance, before the pandemic, interprofessional education programmes encountered concerns about the availability of space to facilitate sessions, student-teacher ratios, schedule conflicts, resource scarcity and availability of faculty members who can facilitate learning in the interprofessional education curriculum (Breitbach et al, 2013). During the pandemic, organisational restrictions and the students' limited mobility led to many interprofessional education programmes being moved to online platforms. Although this new learning arrangement resolves the lack of classroom spaces, students have minimal to no relevant practical and hands-on experiences, which introduces difficulty in equalising students' active participation in online environments (Abdelaziz et al, 2021). Therefore, online interprofessional education introduces different challenges to face-to-face learning.

Online delivery has the potential to solve many of the logistical barriers associated with implementing and delivering interprofessional education. The online format enables the creation of an accessible, organised and structured learning environment that learners can access at a convenient time and location (Evans et al, 2013). As evidenced by students' perception and performance in the case studies of interprofessional education, the experience of distance learning was perceived to be valuable (Abdelaziz et al, 2021). Online interprofessional education could provide all students with a more equal opportunity to meaningfully contribute to the discourse. Students in online interprofessional education could have more time to construct and edit their input before sharing it with the learning community, identify challenges, explore solutions, integrate them and resolve issues. As a result of some facilitators' lack of knowledge and expertise in online education delivery, along with the high level of stress among students, there are concerns that poor execution of online education delivery may cause long-term negative impacts on online education as a teaching methodology (Moor, 2020).

The flexibility provided by asynchronous and synchronous online learning, when combined with human-centred and pedagogically embedded approaches to the design, delivery, instruction and supervision provided by digital platforms may overcome some of the barriers to achieving digital equity.

Conclusions

For midwifery students, experiences of interprofessional education during the pandemic have varied, yet the need to promote interprofessional collaboration within pre-registration education remains a constant to prepare the future health and social care workforce to effectively work and learn together to provide safe and holistic care. The following advice shows how online interprofessional education can become more interactive, effective and relevant, especially in the midst of the changing landscapes of health professions and midwifery education.

• Engage students in the design of online interprofessional education
• Ensure equity of access for those with limited digital literacy and availability of online access by ensuring options for asynchronous and synchronous learning
• Provide guidance and support for students and facilitators participating in online interprofessional education programmes
• Provide clear instructions for engagement, interaction and supervision of online interprofessional education learning activities
• Utilise the full functionality of virtual learning environment platforms to enhance students' interprofessional education experiences.

The potential of online interprofessional education is yet to be fully explored and evaluated; however, the pandemic offered an opportunity to embrace and employ this unexpected surge of online education to promote best practice in interprofessional education.

Upcoming article

The fourth article in this series will explore the move to emergency remote teaching for interprofessional education programmes from the perspective of academics through the use of personal reflections. The role of reflective practice in healthcare is well documented and this article will explore the experience of learning alongside students that came as a consequence of emergency remote teaching in the interprofessional education arena.