The consequences of the COVID-19 pandemic have impacted particularly acutely for practice-based learning and placement provision in health and social care programmes worldwide, necessitating reconfigurations in programme delivery and more flexible approaches for practice-based learning and work placements. Higher education institutions, together with their practice partners in the UK, were mandated to work with guidance and emergency standards issued by the professional, statutory and regulatory bodies to support students in securing progression and transitioning into the workplace without compromising quality, standards or public safety (Nursing and Midwifery Council (NMC), 2021; Quality Assurance Agency, 2021).
As identified in the first article in this series (Power et al, 2021), opportunities for interprofessional education, where different professions can learn with, from and about each other, are key to fostering collaborative practice and improving the quality of care (Centre for the Advancement of Interprofessional Education (CAIPE), 2002). The possibilities of incorporating interprofessional practice-based learning (Anderson and Lennox, 2009; Anderson et al, 2016; Brewer and Barr, 2016; Barr et al, 2017) adds a further dimension where curricular, logistical and resource implications influence how much of an individual student's learning experience is facilitated in intradisciplinary, profession-specific rather than interdisciplinary, interprofessional groups (Thistlethwaite, 2013; Langlois et al, 2020; Yamashita et al, 2021).
This article, the fifth in the series on interprofessional education, will focus on the experiences and adaptations used in relation to practice-based learning and placement provision during the COVID-19 pandemic. Changes in provision and approaches to practice-based learning and student placements will be explored, drawing on theory and findings from existing literature. This analysis will be illustrated with case study reports and reflections from academics working with a range of professional groups. Consideration will be given to opportunities for innovation and evidence-informed guidance for future and alternative approaches to practice-based learning and placements that seek to incorporate remote and online learning opportunities while continuing to meet the required quality and standards.
Practice-based learning: territory and constituents
Practice-based learning is an integral part of many health and social care professional programmes, providing situated and experiential learning opportunities that contribute to meeting the learning outcomes and competencies required for safe and effective professional practice. For midwifery pre-registration education, the programme must ‘provide an equal balance of 50 percent theory and 50 percent practice learning’ (NMC, 2019). Practice-based learning is conceptualised as distinct from ‘classroom’ and ‘theory-based’ learning in that it enables students to gain real world experiences where they can apply the knowledge and skills learned during their programmes and develop their capabilities through observation and participation in a variety of work-based settings (Thistlethwaite, 2013). While practice-based learning is normally associated with situated workplace learning undertaken in placements, it can also include simulations, roleplays and case-based learning, which may take place outside the workplace (Hutchings and Loftus, 2012). However, what can be counted as ‘practice hours’ varies in different professional programmes. For example, nursing programmes can use simulation hours in lieu of practice hours, whereas midwifery programmes cannot. This means that midwifery students must complete 2300 clinical/service user facing hours in addition to 2300 hours of theory (some of which may include simulation).
Such practice-based learning strategies offer a wide spectrum of learning opportunities, from developing core clinical skills, such as taking a blood pressure measurement or performing a vaginal examination, to developing interprofessional skills, such as shared decision making, communication, teamworking and leadership, facilitated in, for example, ward scenarios or intensive care simulations (Alinier et al, 2004; Pearson and McLafferty 2011; Gorantla et al, 2019; Anderson and Bennett, 2020). The resources deployed can encompass real patients, actors, online simulations, and fully-interactive patient simulators; hence, the territory and constituents of practice-based learning strategies can be very diverse.
As highlighted by Thistlethwaite (2013), practice-based learning is not solely about preparation for practice after qualification; it is also about situated and relational learning in and about practice through authentic experience of doing and becoming part of a community of practice. Higgs (2012) offers a critical frame of reference for understanding the aims, strategies and contexts for achieving practice-based learning or ‘doing it for real’, drawing on key theoretical foundations to suggest, as an education strategy, practice-based education:
- Is situated within practice-relevant contexts
- Involves reflexivity, participation and dialogue
- Occurs in many communities of practice (including workplace, academic and multidisciplinary communities)
- Involves a process of socialisation into professional/occupational worlds, roles, identities and career paths
- Involves engagement, through industry partnerships, in practice-based teaching and learning activities
- Develops capabilities and behaviours that will enable graduates to contribute to local communities and society as responsible citizens and professionals who display ethical conduct and duty of care.
The value of the informal, hidden curriculum of situated learning for legitimate peripheral participation in relevant practice contexts cannot be underestimated, whether within clinical or community settings, or comprising multiple encounters between students, service users and their families, clinical teachers, practice supervisors and other health and social care staff (Lave and Wenger, 1991; Roberts and Kumar, 2015). The potential for experiential learning through participation, dialogue and reflexivity over time not only introduces students to the workplace and gives them a sense of preparedness for practice, but also involves a process of socialisation and engagement with different communities of practice, influencing the direction and development of professional identities, capabilities and behaviours (Dewey, 1933; Vygotsky, 1978; Kolb, 1984; Wenger, 1998). The interplay of situated and relational opportunities provides a rich social space for learning, founded on social-constructivist and situated learning theories, all of which endorse the pre-eminence of the ‘gold standard’ for practice-based learning and reinforce the argument that healthcare is innately relational (Hutchings et al, 2013; Roberts and Kumar, 2015; Langlois et al, 2020).
Practice-based learning and interprofessional education
Interprofessional education is designed primarily to enhance students' knowledge and understanding of the professional roles and responsibilities within the health and social care team. This has the aim of enhancing communication and teamworking skills and, ultimately, ensuring students are suitably prepared for interprofessional or collaborative practice on graduation (Morphet et al, 2014; Thistlethwaite, 2015). Interprofessional education is primarily delivered through campus-based, simulation, online or practice-based learning activities. Case-based scenario learning and simulations have developed as an important part of clinical education and interprofessional education curricula, providing opportunities for practice in structured, safe and supportive learning environments (Lindqvist et al, 2005; Bligh and Bleakley, 2006; Ricketts, 2011; Nasir et al, 2017). Simulation-based education offers opportunities to develop interprofessional interactions, bridging ‘theory to practice’, as theoretical knowledge learned in the classroom can be applied through hands-on practice on simulators prior to real patients (Gorantla et al, 2019). However, evidence suggests that maximum impact is achieved where this can be delivered within authentic interprofessional practice-based learning settings, constituting students from two or more professional groups (Barr and Low, 2013; Anderson et al, 2016; Brewer and Barr, 2016; Naumann et al, 2021).
Such experiences are considered an essential component in facilitating the integration of the theory of interprofessional education into interprofessional or collaborative practice (Gilbert, 2014; Fraher and Brandt, 2019; O'Leary et al, 2020; 2021; Naumann et al, 2021). These experiences provide a place for students to learn and collaborate together as they perform their own professional activities, before assuming their professional roles on successful completion of their studies (Lapkin et al, 2012; Morphet et al, 2014; Brewer and Barr, 2016). CAIPE guidelines (Barr et al, 2017) advocate each healthcare student be exposed to at least one interprofessional practice experience during the course of their training and the NMC (2019) standards require student midwives to become proficient in ‘interdisciplinary and multiagency team working’ by the end of their programme of study. A number of successful interprofessional practice-based learning experiences are cited within the literature, including the Leicester Model (Anderson and Lennox, 2009; Anderson et al, 2016) and initiatives within satellite clinics, emergency departments, operating theatres, labour wards and nursing homes (Reeves et al, 2013, Naumann et al, 2021).
The global reach and provision of interprofessional education for collaborative practice has been strongly endorsed by the World Health Organization (2010) as a key evidence-informed strategy for improving the quality of care for service users, patients, families, carers and communities through enabling effective teamworking. It is also promoted by international networks of educators and researchers worldwide, as exemplified in current guidance from CAIPE (Barr et al, 2017) and Interprofessional. Global (Khalili et al, 2019). Yet while the benefits of such experiences in developing a competent workforce are recognised and even considered by some to constitute ‘essential learning experiences’ (Morphet et al, 2014), these opportunities can be nonetheless challenging to embed in health and social care curricula and even more so to implement in the practice setting (Reeves et al, 2006; Reeves, 2008; Piterman et al, 2010; Morphet et al, 2014; O'Leary et al, 2020). The challenges and complexities involved in developing and sustaining team-based interprofessional practice placements have led many universities to rely on interprofessional learning in the classroom, online, and/or simulated contexts (Brewer and Barr, 2016). However, with the advent of the pandemic, it is increasingly apparent that both interprofessional education and collaborative practice are needed now more than ever (Singh and Matthees, 2021).
Practice-based learning and achieving competencies
The territory and constituents of practice-based learning and interprofessional education are diverse. The question of what constitutes ‘doing it for real’ is made all the more challenging during times of uncertainty and the rapid change wrought by the pandemic. Guidance and emergency standards issued by relevant professional, statutory and regulatory bodies, including the General Medical Council (2021), the Health and Care Professions Council (2020) and the NMC (2021), continue to emphasise the upholding of quality and public safety, while encouraging opportunities for creativity and innovation in practice-based learning within the constraints of meeting required learning outcomes. The NMC (2021) emergency and recovery standards stated that ‘practice learning in direct contact with healthy or ill people and communities in audited practice learning placements is considered optimal’. This confirms the ‘gold standard’ of practice-based learning; however, they specify that, where this optimal experience of practice-based learning is constrained or not possible, alternative learning opportunities using simulation, virtual and digital learning and other contemporary approaches may be deployed. Such learning opportunities include ‘peer learning; actors; high and low fidelity including manikins/environments; and virtual and online practice learning training programmes involving authentic case studies, reflection and interaction with people’ (NMC, 2021) with the proviso that appropriate student supervision and assessment are in place, up to a maximum of 300 hours (8 weeks). The NMC (2021) also recommend that implementation of alternative methods give due consideration to involving and learning with other health care professionals. Implementation should also align with the interprofessional education competencies for midwifery, outlined in the third article in this series (Sy et al, 2022).
COVID-19 adaptations and innovations
The COVID-19 pandemic presented many new challenges for health and social care educators, particularly in relation to practice-based learning experiences. COVID-19 restrictions and social distancing requirements affected traditional and established methods for delivery of practice-based learning in face-to-face and real-time simulation experiences, whether scheduled to take place in the higher education institution or in the clinical or community setting. Many practice-based learning opportunities, whether uniprofessional or interprofessional, have experienced significant disruption, being postponed as programmes were mandated to rephase their delivery or requiring the adoption of innovative, alternative approaches to existing provision, with rapid transitions to remote and online learning. The impacts for educators and students worldwide have proved considerable (Hickland et al, 2020; Winship et al, 2020; Bartlett et al, 2021; Lawton et al, 2021; Marchant, 2021).
It is from this theoretical and evidence-informed position that consideration will be given to the COVID-19 adaptations and opportunities for innovation in practice-based learning and interprofessional practice-based learning, drawing on the literature and illustrated by case study reports and reflections from academics working with a range of professional groups. The case studies were acquired from members of CAIPE and their affiliated institutions, who were invited to outline how they had responded to the provision of practice-based learning and student placements during the pandemic, identifying changes in provision and approaches in the pivot to alternative forms of practice-based learning and placement provision and the resultant impact for students and staff.
Partnership working and barriers for interprofessional practice-based learning
Case study 1 (Box 1) reflects the impact of COVID-19 on established provision of interprofessional practice-based learning, describing a well-evaluated approach involving an interprofessional simulation session between medical and nursing students from two different universities delivered in the hospital setting and facilitated by hospital clinical staff. The case study describes how this was halted as a result of the pandemic.
Box 1.Case study 1: University of BradfordFrom established interprofessional practice-based learning provision to stasisPrior to lockdown, all pre-registration nursing students had the opportunity to attend an interprofessional simulation session, in practice, with medical students from another university. These were delivered in the hospital setting and facilitated by clinical staff from the hospital alongside a representative from the university. Up to 10 nursing and 10 medical students would attend, with the opportunity to participate in one simulation and observe and feedback on two others, which could be observed by video link. The first- and second-year nursing students would attend with fourth-year medical students and third-year nursing students attended with fifth-year medical students. These needed careful co-ordination to ensure the students were in practice at the same time.The simulation activities remained similar for all years, with slight adaptations to reflect the level and experiences of the students. For example, one simulation activity involved an actor simulating a patient with delirium. The third-year nursing/fifth-year medical students included a healthcare assistant that was unhelpful and did not offer further information. However, for the first- and second-year nursing students/fourth-year medical students, more advice was offered, such as signposting them to the patient's medical notes.Students generally enjoyed working together and came away with a better appreciation of what each did and how they could work better together in practice.While other interprofessional education activities, including those with patients, were quickly moved to online delivery, these simulations stopped during lockdown and have not yet been restarted. Although the use of virtual simulation was explored, there was no appetite for this in the Trust at the time.
Long before the advent of the COVID-19 pandemic, online approaches to interprofessional learning have been documented as a means of resolving some of the inherent challenges to interprofessional education delivery, including barriers of capacity, logistics and scalability to achieve high-quality interactions in interprofessional groups (Clouder, 2008). The increased reliance on technology during the pandemic is thus not surprising and has enabled some institutions, particularly those where interprofessional education is already strongly embedded, to move large-scale immersive learning experiences to a virtual platform, developing online simulations and revising practice-based learning experiences and reflections to accommodate simulated environments in a virtual context (Langlois et al, 2020; Power et al, 2022). While the feasibility of developing a virtual interprofessional simulation was explored as a means of continuing interprofessional practice-based learning while maintaining social distancing, case study 1 demonstrates the tenuous and fragile nature of interprofessional practice-based learning provision. It reveals barriers that can emerge in times of crisis and change management and where novel technology enabled solutions may themselves act as a barrier.
Some barriers may prove more difficult to overcome, for example, differences in professional requirements and regulations and resistance to taking ownership and commitment to interprofessional learning (Clouder, 2008; Lawlis et al, 2014). This case study highlights the significance of ongoing partnership working strategies between higher education institutions and their practice partners to help minimise risk factors and negotiate complexity, supported by robust team approaches and staff development to secure a shared vision and interprofessional culture that can maintain and sustain interprofessional learning (Hutchings and Quinney, 2015).
Embracing opportunities for adaptation and innovation
A number of successful and innovative transitions and approaches to practice-based learning and interprofessional practice-based learning during the COVID-19 pandemic have been cited within recent literature and are further illustrated in the subsequent case studies. Case study 2 (Box 2) identifies challenges in the provision of practice-based learning faced by staff and students as the impacts of the pandemic emerged and the commitment and resilience of the healthcare programme teams in developing alternative provision, encompassing face-to-face and online provision via online resources, simulations and blended placements. The adaptations were mainly uniprofessional but with some learning between professional groups and plans to further capitalise upon the effective framework for simulated practice that has evolved.
Box 2.Case study 2: Bournemouth UniversityFrom negotiating challenges to a springboard for innovationThe pandemic created extensive challenges for healthcare programmes, requiring specific practice experiences to be achieved to effectively prepare students for registered practice. Challenges included reduced placement provision as services were reconfigured, limited staff to support learners in practice and initial concerns around provision of personal protective equipment and the safety of letting students be in practice because of the risks associated with COVID-19 (especially for students who were considered clinically vulnerable).While the university supported the initiative for senior students from some programmes to return to placement under the paid placement framework, this was not available or appropriate for all students. Therefore, representatives from healthcare programme teams designed and delivered a range of alternative experiences to replace the traditional placement, ensuring that they were reflecting regulatory body requirements while also providing effective learning against the backdrop of COVID-19 restrictions around education provision.The physiotherapy programme designed and delivered an online placement where second-year undergraduates were provided with real life cases depicting key conditions that they analysed in small groups to provide treatment plans for an individual, while considering professional approaches to care.Further innovation evolved as the pandemic continued and some services reverted to more usual ways of working, albeit with continued reduction in placement availability. In some areas, students undertook a blended placement, split between a clinical service and a research project; the latter overseen by university personnel or other professions such as a medic, providing an additional opportunity for insights into other professions.The need to facilitate alternatives to practice placement provided opportunities to innovate and provide learning between professional groups. Students from the physiotherapy and operating department practice programmes worked together in the clinical simulation setting to develop knowledge and skills around airway management and associated respiratory care.Enhanced use of simulation was provided for paramedic science students who undertook a simulated event depicting a major incident that required intervention from paramedics. Additional simulation experiences were designed for all years of nursing students using a blend of virtual learning resources augmented with face-to-face experiences in the simulation suite at the university.These initiatives were evaluated as an acceptable alternative to traditional placement provision. However, concerns around confidence and gaining sufficient experience in the clinical setting were cited regularly and will need to feature in further placement planning for students.The restrictions provided a springboard for considering innovations to replace elements of the usual placement pattern. During the pandemic, this has been implemented to ensure student progression was subject to minimal disruption and was done at pace. Going forward, consideration of staffing resources and provision of sufficient simulation facilities is needed. Clear protocols for a virtual clinical activity need formalising if this facet is to be developed further. The requirements of the regulatory body and programme approval arrangements are key to informing the breadth of alternative activities; the parameters for embracing new ways of interprofessional practice learning in an alternative setting would benefit from further mapping of programmes.With an effective framework of simulated practice in place, this university is well positioned to capitalise upon the excellent practices that evolved as a result of the COVID-19 pandemic.
Adopting novel solutions
Case study 3 (Box 3) focuses on the development of a novel solution, introducing a ‘pop-up hospital’, Waterside General, a simulated inpatient and community setting, providing authentic scenario-based learning as an alternative to clinical placements. Developing into a 6-week virtual placement, it included ‘real people’ drawn from the university's service user group, adopting the roles of patients and opportunities to learn from other professions.
Box 3.Case study 3: University of NorthamptonWaterside General: from a pop-up hospital to virtual placementsProviding opportunities for nursing students to practise hands-on patient care has been challenging during the pandemic. A novel solution with a ‘pop-up hospital’ was devised to allow ‘alternative’ clinical placements for first-year nursing students to continue. ‘Waterside General’ created a simulated inpatient and community setting, with third-year nursing students playing the different patient roles in scenarios encompassing all four nursing fields. University staff from a bank of associate lecturers and permanent staff adopted the roles of practice assessors.Initially, 150 students undertook an 8-hour shift over weekends in small cross-field teams working their way around acute and community settings, depicting nursing experiences they may encounter in practice. Some dramatic events were added to the learning opportunities, including a patient who collapses with a cardiac arrest, a heated argument and a fire necessitating evacuation.Waterside General was well evaluated by students and staff as a safe space for students to learn. Feedback included ‘experiencing all four fields of nursing was memorable: it helps with understanding about the multidisciplinary team. We had a flavour of what each of us does and how we can all work together, which is so important when you're delivering person-centred care.’This feedback informed the ongoing development of learning opportunities and as the pandemic continued to affect practice learning opportunities in the clinical setting, the nursing team developed a 6-week ‘virtual’ placement at Waterside General for 160 students to complement time in clinical practice. The virtual placement was made as authentic as possible, with each week having a different topic, starting with getting to know the area and team, followed by a week where each field of nursing taught field-specific skills to all students. Each week ended with students undertaking shifts with members of the university's service user group, ‘real people’ adopting the roles of patients (including children). The virtual placement culminated in a final week of skills and scenarios with service users acting as patients.Scenarios were developed around current issues, for example a long covid patient was presented. Students watched videos recorded by the service user and then in teams discussed and agreed on a care plan and completed appropriate referrals to physiotherapy and occupational therapy. This led to further learning opportunities, with the introduction of a session delivered by a senior lecturer in physiotherapy to discuss their role within the interprofessional team.Other interprofessional scenarios included a session facilitated by the university's campus police force around their involvement in mental health support when called to incidents on campus. These scenarios provided students with real-world case studies to reflect on and triggered valuable discussions and learning around the role of the police officer in the wider public health agenda.Future plans for Waterside General include developing more scenarios with an interprofessional focus to provide students from a wider range of professions to learn with from and about each other in a ‘safe space’.
Case studies 2 and 3 demonstrate how the challenges resulting from the pandemic have paradoxically presented educators with the opportunity to ‘reimagine, reinvigorate, and innovate’ their delivery (Takizawa et al, 2021). Simulations and scenarios focused on real-life cases and people continue to provide a vital dimension for creating authentic practice-relevant spaces and virtual placements during the pandemic and are reflected in the literature worldwide. For example, Prasad et al (2020) at Monash University, Melbourne, describe an online, synchronous interprofessional simulation experience, previously conducted as a face-to-face learning activity. The obstetric and neonatal simulation workshop is run remotely for medical and midwifery students to experience perinatal emergency management. Langlois et al (2020) identify further examples of simulations widely used in exposure and immersion level interprofessional learning that have been adapted for the virtual platform. This includes the Teamworks! Program, delivered virtually at the University of Toronto where student groups engage in shared decision making. Similarly, interprofessional simulations at Dalhousie University have students participate in a variety of practice-based simulations and Indiana University has teams of learners collaborate to provide interprofessional care to individuals living in the community, focusing on a person with complex chronic conditions, and health coaching for a person living with long-term mental and physical disabilities and his/her caregiver.
Pottle (2019) (pre-pandemic) and Mateen and Kan (2021) further highlight the possibilities of the world of virtual reality. They offer a new method of simulation with the benefits of an ‘anytime, anywhere’ educational delivery, enabling multi-participant, immersive and realistic delivery of practice-based interprofessional education at scale. Taylor et al (2021) discuss virtual placements as an alternative to traditional clinical placements, drawing on the example of a simulated clinical placement developed for dietetic students at Coventry University, where students immerse themselves in a virtual placement experience. While this innovation is profession-specific, there are plans to develop and adapt the use of a virtual placement framework in a range of professions.
From adapting for sustainability to realigning and reconceptualising interprofessional practice-based learning
Continuing the themes of adaptation for sustaining practice-based learning, the final two case studies, case study 4 and case study 5 (Boxes 4 and 5), demonstrate how opportunities to reinvent the curriculum can reinvigorate and lead to reconceptualising interprofessional practice-based learning. Case studies 4 and 5 offer the opportunity to compare and contrast two well-established interprofessional education programmes to review the question of what constitutes doing practice-based learning and interprofessional practice-based learning ‘for real’. Each of the programmes describe how they adapted to fully online delivery as a result of COVID-19 while holding to established practice-based models and approaches.
Box 4.Case study 4: University of Leicester and De Montfort UniversityAdapting and sustaining interprofessional practice-based learning by shifting from face-to-face to technology enhanced remote learningInitial reflections were that so much of practice-based interprofessional education in the city focused on the central role of patients and access to patients to visit their homes in the community; this was lost. A pedagogical model is used, the Leicester Model of practice-based learning which uses the steps of the Kolb learning cycle, in which actual patients were the trigger for interprofessional student work. Access to patients in hospital settings was also lost.However, use of the experiential learning model continued, for example, in medicines optimisation. A call was sent to patients (>100 in the patient and carer group) to come forward if they had complex prescriptions and the ability to use IT, asking for help. There was a high response rate, and 10 people were identified whose stories were recorded. GP colleagues and clinical pharmacists worked with university staff to give students access to summary care records, patient observations and biochemical markers and prescriptions, so they could work together to reconcile prescriptions; students found ways to work together online. Teaching was adapted with a blended approach and workbooks reworked to offer pre-course work, and online class and time for students to work together using different e-platforms.Patient stories were well received, and the GPs and clinical pharmacists came to the student presentation feedback sessions online to hear the students present their medication review and debate and discuss the choices they made and changes, if any, that should be followed up with the patient prescription.As a result, practices in geographical areas were used where before it was difficult to gain access because students could not travel to them easily. In this way, capacity for more students has grown. All 330 medical and 220 pharmacy students complete this learning online and immersed in-practice. The course will continue using a blended approach. Student evaluations of this course remained positive and interprofessional student groups continue to contribute to everyday clinical work.
Box 5.Case study 5: Glasgow Caledonian UniversityTeam observed structured professional encounter (TOSPE): from demonstrating collaborative competence to recognising practice-based learningPractice-based learning was disrupted by the pandemic, affecting the immediate availability and timing of workplace learning opportunities for students in allied health, nursing and social work pre-registration/pre-qualifying programmes. This sparked a range of innovative plans as well as a general reconsideration of the nature, structure and form of what constitutes practice-based learning. One example was a third-year undergraduate module that changed to fully online delivery as a result of the pandemic, providing essential opportunities for students to develop and maintain practice skills specifically related to collaborative competence.The method of TOSPE was developed as part of the School of Health and Life Sciences interprofessional education framework in 2014. The method was developed as a core means of interprofessional learning, teaching and assessment (both formative and summative). It involved interprofessional groups of students developing and demonstrating collaborative competence through a range of classroom-based and desk-top simulations focused on case scenarios, with the interprofessional care planning team meeting as the main vehicle. The simulation scenarios were carefully developed to ensure constructive, horizontal and vertical alignment across different programmes. This ensured that while the scenarios were relevant to the Scottish/UK context of practice, they were also appropriately challenging, contextually relevant and appropriate for the stage of each student on their respective programme of study. Over the course of the 12-week module, each student had the opportunity to engage in four encounters as part of their learning. This provided valuable opportunities for peer and formative feedback from their facilitator (an academic member of staff). Students were assessed on their ability to demonstrate effective interprofessional communication and collaboration, management of conflict, interprofessional team functioning and awareness of human factors.During the pandemic, delivery of the module and TOSPEs successfully transitioned to a fully online experience and has proved to be highly successful in terms of student achievement, progression and satisfaction. Facilitators have been positive about the online delivery experience. It is anticipated that the online TOSPEs will continue to have a central place in the module after the pandemic, given the new and emerging methods of video consultation and team collaboration in the workplace (eg Near Me/Attend Anywhere) and its contribution to the facilitation of digital capabilities in students.Prior to the pandemic, the module was clearly focused on the development of collaborative competence in the classroom using primarily low-tech simulations, based on case scenarios and artefacts (referral letters, extracts from case records/charts) that formed the basis of the TOSPEs. They had not been considered a ‘formal’ practice-based learning module and therefore did not accrue any placement hours. The pandemic has highlighted the need to reconsider this configuration and explore how each professional discipline involved in the module might capitalise on both the learning and the potential for hours to be formally recognised as part of the programme structures. This also reflects the shift in many professional bodies where simulation can be considered towards placement hours.
Case study 4 (Box 4) builds on a long-established and strongly embedded model and approach to the provision of interprofessional practice-based learning, the Leicester Model. This is an experiential learning approach using steps adapted from Kolb's (1984) learning cycle to develop critical analysis and problem-solving (Anderson and Lennox, 2009; Anderson et al, 2016).
This case study is juxtaposed with case study 5 (Box 5) which uses another well-established method for interprofessional learning, the team observed structured professional encounter (TOSPE), informed by the McMaster-Ottawa team observed structured clinical encounter (TOSCE) (Solomon et al, 2011). This method is used to develop practice skills specifically related to building collaborative competence.
Table 1 identifies the educational strategies at work in a comparative analysis of case studies 4 and 5 and what constitutes doing practice-based learning and interprofessional practice-based learning ‘for real’, adapted from Higgs's (2012) critical frame of reference for practice education.
Table 1. Comparative analysis of educational strategies
| Education strategy | Case study 4 | Case study 5 |
|---|---|---|
| Situated learning in relevant practice contexts | Students immersed in practice to analyse pre-recorded stories of ‘live’ clients supplemented by summary case records and prescriptions | Students immersed in practice to review authentic person-centred client and family/carer case scenarios and supporting artefacts (referral letters, extracts from case records, charts) |
| Experiential learning though participation, dialogue and reflexivity over time | Medical and pharmacy students work together, engaging in critical analysis and problem-solving to reconcile prescriptions over 2 days | Students work together in small interprofessional groups to review client case scenarios and develop care plans, engaging in interprofessional communication and collaboration, undertaking four formative team observed structured professional encounters (TOSPEs) over a 12-week module |
| Development of professional identities, capabilities and behaviours | Students deliver online presentation before engaging in debate and discussion with clinical experts (GP and clinical pharmacist) and teaching staff to agree changes, if any, that should be made to prescription | Regularised interprofessional working practice observed and reviewed by peers and academic facilitator |
| Preparedness for practice | Observed behaviour not graded but interprofessional practice-learning recorded in professional portfolio reflective account or short essay | Summative TOSPE assessment to demonstrate effective interprofessional communication and collaboration, management of conflict, interprofessional team functioning and awareness of human factors |
| Socialisation and engagement with communities of practice | Opportunity for online debate and discussion with clinical experts | Developing awareness of different professions' contributions to care and influencing development of professional identity |
| Partnership working | Clinical staff join teachers for students' online presentations. While clients are no longer directly available to meet students in their homes, some contributed by volunteering recorded stories | Case scenarios created in partnership with professional and clinical practice representatives |
The question of being situated in practice relevant contexts is addressed in each of these case studies by immersion in case scenarios where the stories of clients, families and carers provide the essential ingredient and trigger for facilitating authentic, relevant, person-centred practice-based learning (Pulman et al, 2012). Team working and collaboration is transposed into ‘interprofessional working practice’ by students actively working together to achieve optimum outcomes. These outcomes are task-oriented, whether to reconcile a prescription for a real client or create an interprofessional care plan, but also relationally oriented, focused on people learning together. Students from different professional groups develop an increasing awareness of each other's contributions to care and, in doing so, further develop their own professional identities. The students also work with and learn from professional and clinical experts and clients, through receipt of advice and feedback, either directly or indirectly. In case study 4, while clients were no longer directly available to meet with students in their homes, some clients were prepared to do so in the online environment. Looking to the future, while many more volunteers would be required to manage student capacity, this approach in direct relationship with clients lends itself to opportunities for telehealth and video consultation.
The two case studies demonstrate alternative blends of task-oriented product outcomes and relationally oriented process outcomes, positioned at different points on a continuum of interprofessional practice-based learning design according to student composition and orientation, constructive alignment between learning activities and intended learning outcomes (Biggs and Tang, 2011), and the time period devoted to interprofessional practice-based learning provision. While experiential learning with active participation and dialogue are at the heart of these two case studies, the period of time devoted to student immersion in authentic practice experiences varies between a short, intensive 2-day problem-solving task oriented approach (case study 4) and regularised practice (case study 5) over a 12-week period.
For students to be able to work effectively within the complexities of health and social care systems, Langlois et al (2020) refer to the four essential Cs of communication, collaboration, critical thinking and creativity required. The comparative analysis of the two case studies demonstrates that opportunities for reinventing the curriculum can lead to reconceptualisation of practice-based learning and interprofessional practice-based learning. They illustrate that it is feasible to redesign time-limited people-focused, relationally-oriented learning activities with task-focused outcomes of improving client care in unison with embedding interprofessional communication, collaboration and critical thinking skills in action for the development of professional identities, capabilities and behaviours. Ultimately, these approaches can help students prepare for professional practice by ‘doing’ in association with reflective practice, peer support and supervision, thus informing and influencing their embodied understanding of ‘becoming’ and ‘being’ a professional practitioner (Todres, 2008).
Conclusions and considerations for future provision of practice-based learning and placements
Going forward, the pandemic has led to the realisation that traditional conceptualisations of what is and what is not ‘practice-based’ learning need to be critically re-examined. The gold standard for practice-based learning was defined as ‘learning in direct contact with healthy or ill people and communities in audited practice learning placements’ (NMC, 2021). While this standard prevails, increasing pressures to provide, sustain and expand placements in partnership with practice providers remain, despite and beyond the impacts of the pandemic (Health Education England, 2018; NHS Employers, 2020).
While acknowledging that the practice-based learning and interprofessional practice-based learning experiences described in the case studies presented here can only be proxies for the complexities of the clinical workplace (Thistlethwaite, 2013), this paper argues that opportunities for experiential learning in situated practice contexts contributes to the development of behaviours and capabilities, supporting preparedness for practice and initiating processes of socialisation into professional roles and identities. Further research may be needed to identify the most appropriate blends of task-oriented and relationally-oriented learning activities to achieve optimum outcomes for interprofessional practice-based learning, which can align interprofessional communication and collaboration with critical thinking and reflective practice.
As technological advances go hand-in-hand with human commitment to adaptation and innovation, a greater shift to further innovative opportunities for practice-based learning and interprofessional practice-based learning using simulation and virtual platforms is envisaged, for example, where health and social care programmes choose to build in experiential learning with telehealth to prepare students for future practice. The case studies demonstrate a culture of commitment to practice-based learning that has been harnessed to facilitate transitions to alternative practice-based learning and interprofessional practice-based learning strategies and address the challenges of COVID-19. The necessary realignment of practice-based learning and interprofessional practice-based learning provision, facilitated by greater use of technology enabled solutions, builds on earlier innovations, where inherent challenges to interprofessional education delivery (including the barriers of capacity, logistics and scalability) were addressed through deployment of technology enhanced learning to achieve high-quality interactions in interprofessional groups (Clouder, 2008).
Regrettably, new approaches to interprofessional practice-based learning may be put aside as curricular, logistical and resource implications exert influence and steer curriculum design towards prioritising profession-specific teaching and learning over interprofessional provision beyond COVID-19 (Langlois, 2020; Power et al, 2021). Such challenges highlight the tenuous and fragile nature of interprofessional practice-based learning provision and the continuing importance of partnership working for promoting and sustaining an interprofessional culture within and between academic and practice settings including primary, secondary and tertiary healthcare, and community and voluntary sectors.
The question of what is and what is not ‘practice-based’ learning will have continuing relevance beyond COVID-19 and its continuing development may form the springboard for furthering interprofessional practice-based learning provision.
Upcoming article
The sixth article in this series will focus on the considerations and adaptions aligned to the assessment of interprofessional education, including examples of the alternative assessment strategies used by faculty, the modality of assessment and the tools used, the student and faculty experience of remote/online assessment and the challenges faced by both during the rapid pivot to remote learning and assessment.
CPD reflective questions
- How did the COVID-19 pandemic influence the provision of practice-based learning and student placements?
- How can the situated and relational space associated with the gold standard of placement provision be delivered outside the workplace?
- What are the key aspects that can be transferred to post-pandemic practice-based learning and interprofessional placement provision?