Twelve tips for structuring student placements to achieve interprofessional learning outcomes

Background: Increasingly, universities are being asked to provide evidence of interprofessional learning within their health and human services programs. Given the authentic nature of the placement setting, this component of curricula is well suited to provide students with these interprofessional learning experiences. Aims: To describe twelve tips for structuring student placements to achieve interprofessional learning outcomes. Methods: Development of these 12 tips was based on knowledge and experience drawn from the literature, focus groups and workshop with experts within the field, together with the authors’ own experiences over many years of teaching in multidisciplinary and interprofessional contexts. Results and conclusions: The tips provide direction and clarity for universities and placement sites to facilitate authentic learning in practice based settings. In particular, they describe the ways in which placements can be structured to maximise opportunities for students to achieve specific interprofessional competencies. They are underpinned by the principle that interprofessional learning should be a core component of all healthcare placements and that student learning occurs through participation in routine work activity in addition to structured learning activities.


Introduction
The provision of high quality, safe, effective and efficient contemporary health care requires health professionals to work together (Frenk et al. 2010, Kohn et al. 2000. To better prepare our students for this collaborative work environment, interprofessional learning is now more clearly recognised as an important element of health profession curriculum (World Health Organization 2010). Reflecting this trend, many education accreditation bodies associated Nisbet G, O'Keefe M, Henderson A MedEdPublish https://doi.org/10.15694/mep.2016.000109 Page | 2 with health and human services professional degree programs now require evidence of interprofessional learning within curricula. Examples within Australia include the most recent education curriculum standards for Nursing and Midwifery, Medicine and Physiotherapy (Australian Nursing and Midwifery Accreditation Council 2012, Medical School Accreditation Committee 2012, Physiotherapy Board of Australia and Physiotherapy Board of New Zealand 2015). In addition, a recent position statement published by the Health Professions Accreditation Councils' Forum in Australia articulates a set of interprofessional competencies applicable to all professional competencies/standards/accreditation (Table 1) (Health Professions Accreditation Councils' Forum 2015. The placement component of health curricula is a key element of many health profession education programs and an expectation of professional accreditation bodies. In the placement setting students have opportunities to gain practical experience in working with practitioners from other professions. These opportunities occur not only through formal structured interprofessional education programs where interprofessional learning is the focus of the placement, but also through routine work practice (Zhao et al. 2015). In these latter instances, it can be particularly challenging for universities to ensure student learning is adequately supported and scaffolded, and to gather evidence demonstrating interprofessional learning has occurred.
The 12 tips presented in this paper have been developed in the form of a 'road map' to provide universities and placement sites with advice on how to prepare, plan and coordinate placements to support student achievement of the interprofessional learning outcomes. These tips are based on knowledge and experience drawn from the literature, focus groups and workshop with experts within the field, together with the authors' own experiences over many years of teaching in multidisciplinary and interprofessional contexts. The strategies suggested are suitable for health and human services professional programs. They are structured around achievement of a set of core interprofesisonal competencies that are relevant to all professional entry level health profession graduates (Table 1). Moreover they are applicable to a range of placement settings including hospitals, community settings, nongovernment organisations, and the public and private sector. The strategies underpinning these tips have as their foundation, a principle that interprofessional learning during healthcare placements is a core activity, and that learning occurs through student participation in routine activities . On completion of their program of study, graduates of any professional entry level healthcare degree will be able to: • Explain interprofessional practice to patients, clients, families and other professionals • Express professional opinions competently, confidently, and respectfully avoiding discipline specific language • Describe the areas of practice of other health professions • Plan patient/client care goals and priorities with involvement of other health professionals • Identify opportunities to enhance the care of patients/clients through the involvement of other health professionals • Recognise and resolve disagreements in relation to patient care that arise from different disciplinary perspectives • Critically evaluate protocols and practices in relation to interprofessional practice • Give timely, sensitive, instructive feedback to colleagues from other professions, and respond respectfully to feedback from these colleagues

Outline of Tips
The first six tips pertain to the planning and preparation of the placement. The following six tips specifically reference the eight interprofessional learning competencies listed in Table 1 with strategies and actions that can assist leaders and educators who supervise student placements in linking student learning opportunities with interprofessional learning outcomes.

Incorporate interprofessional learning outcomes into standard course documentation
Students can be strategic in their learning and influenced by the relevance of the placement to their own learning and future practice. So that students view interprofessional learning as core to the curriculum and not a curriculum 'addon' placement documentation should include interprofessional learning outcomes alongside discipline specific learning outcomes. Explicitly identifying interprofessional learning outcomes that are associated with placements (and therefore also assessment activities) will clarify university expectations for both students and placement site staff.

Develop a single placement student induction
Best practice recommends that sites orientate students to their particular placement (Rose and Best 2005). Such orientation would include, for example, placement site expectations of students, the role of the supervisor, and structure of the placement. We suggest this orientation also includes an expectation that students participate in the interprofessional practices occurring within the placement. An interprofessional message is re-enforced when there is a common induction package for all students at the site. Students from all disciplines receive the same messages regarding their learning experience, including interprofessional learning provisions. When common inductions can be arranged, students from different disciplines can meet each other and receive the same names and contact details of key staff from the various professions and information on the particular professions at the site.

'Sign-post' interprofessional learning opportunities
There is sometimes a mis-conception that students can only develop interprofessional competencies through structured formal interprofessional education programs. However, in reality, students are often engaged in interprofessional practice as part of their profession specific placements (O'Keefe 2015). For example, students might make a referral to or discuss the care of a patient/ client with a practitioner or student from another profession. However, students (and supervisors) don't necessarily recognise these experiences as interprofessional learning opportunities (Zhao et al. 2015) and hence do not reflect adequately on these experiences through an interprofessional learning lens. Universities and sites play an important role in assisting students identify placement interprofessional learning opportunities that occur through routine practice. Prior to placements universities could provide examples of interprofessional learning opportunities in the placement setting and encourage students to seek out these opportunities. At the beginning of a placement it is important that sites orientate students to the work routines that students can engage with to develop interprofessional competencies. Throughout the placement, these opportunities can be reviewed and re-enforced to ensure students are participating in ways that are appropriate to the service and are taking full advantage of the interprofessional learning potential of the placement.

Tip 4.
Tell students what we do in our work practice From our experience of talking with students about interprofessional learning, students clearly want to know more about what other professions do and what students in other professions are learning. As educators we should expect and foster this interest from students and openly discuss our own workplace experiences with patients and their families. Modeling interprofessional practice amongst teachers within classroom activities and discussions can assist in the preparation of students for actual interprofessional placement activities (Selle et al. 2008). In addition, conversations with our practicing health profession colleagues suggest that for many the benefits and importance of interprofessional practices is often only truly realised after graduation once an individual commences practice. We should be sharing these stories with our students.

Embrace a broad concept of interprofessional practice and learning
Interprofessional learning is not owned by any one discipline or cluster of disciplines. With every current or potential future placement site, placement organisers should consider the full range of people who work together, and the services they provide in contributing to patient/ client care. Consideration should extend beyond the more traditional view of 'professional' to also include support staff and vocationally trained team members (e.g. allied health assistants, case workers) with recognition that interprofessional practice occurs within a wide range of health settings. Moreover, interprofessional learning can occur between health and non-health sectors, for example, between school-based programs and primary health centres. Existing resources should be sought and used. Central registries of placement sites may exist in some organisations and could be expanded to include more detailed information on interprofessional practice. For example, in New South Wales, Australia, the Mental Health Coordinating Council (MHCC) manages a placement listing resource of community managed/ non-government organisations offering student placements, including a description of the services each provides (Mental Health Coordinating Council 2013).

Explain what the work of interprofessional practice entails at each placement site
Interprofessional practice presents itself in many ways (Reeves et al. 2011). In some placement settings there may be a recognised interprofessional team and interprofessional approach to patient/ client care, for example in a stroke unit or mental health community organisation. In other settings collaboration may be less obvious, for example a sole practitioner may liaise with other practitioners only when this is warranted. This interaction may occur asynchronously with written correspondence. Universities and placement sites should communicate to students the extent of interprofessional exposure students can anticipate at particular sites. For example, include in a 'site descriptor' a brief description of the interprofessional nature of the placement, the range of professions a student might interact with, and the interprofessional forums available to students (e.g. attending case conferences).

Provide suggestions to students for interprofessional learning opportunities
There are numerous web sites with examples of interprofessional learning placement activities suitable for students and educators (see Nisbet et al. 2015 for a literature scan on available resources). Activities are wide ranging, for example guides to shadowing another professional, interprofessional case study presentations, team meeting participation, and following a patient/ client's journey through the health system. These interprofessional learning opportunities might involve students from different professions completing a specific activity or working together to provide patient/ client care. The development of students' professional identity and socialisation is an important aspect of the preparatory process for working interprofessionally (Arndt et al. 2009).. Interactions with health professional and students from other disciplines provide a rich source of experiences to enrich these processes. In addition, information can be shared on what different roles entail with the client groups at that site, along with the reasons that these professions need to come together, for example, in regular meetings such as case conferences or more atypical situations when difficult decisions regarding client's plan of care in unusual circumstances need to be made. When students can engage with, and explore, the breadth of personnel in their work sphere, and their contribution, they are better prepared to explain interprofessional practice to patients, clients, families and other professionals (Interprofessional learning competency 1), and to describe the areas of practice of other health professions (Interprofessional learning competency 2).

Involve students in appropriate work activities
Student placements are diverse and accordingly each offers different opportunities for interprofessional learning. Examples of routine work practices that can facilitate interprofessional learning include participating in care review and interprofessional team meetings, attending ward rounds, making a referral, or conducting a home visit with another profession. Support from the placement site and acknowledgement from the university for active student participation is important. As these discussions ideally invite diverse views and perspectives, students should be guided and supported to develop and present a well considered perspective. This challenge can encourage the student to reflect on their own priorities, thereby highlighting the need for the student to be cognizant of their discipline's perspective when interacting with other professions and personnel. Students should be encouraged and facilitated to engage in these interactions thereby gaining experience in expressing professional opinions competently, confidently, and respectfully avoiding discipline specific language (Interprofessional learning competency 3).

Scaffold interprofessional learning opportunities to student capabilities
As with all student placement activity, the potential scope and risks of student participation in workplace interprofessional learning practices need to be agreed with the student, university and workplace. Junior year students usually require more support and guidance than senior students so extent of interprofessional involvement needs to be carefully matched with student capability to minimize risk to patients and/ or themselves. Supervisors have an important role to play in guiding students as they move from peripheral 'observers' to more engaged and legitimate contributors to collaborative patient care (Conte et al. 2015). Identifying a specific work setting or activity where students can meet requisite interprofessional learning outcomes is important and university staff should check with the leaders and educators at placement sites that experiences that assist students reach their goals will be available during the placement (Henderson et al. 2007 scope of practice during placements, they are well positioned to explore their possible contribution to patient/client care in an interprofessional setting to plan patient/client care goals and priorities with involvement of other health professionals (Interprofessional learning competency 4) and to identify opportunities to enhance the care of patients/clients through the involvement of other health professionals (Interprofessional learning competency 5).

Tip 10.
Assign a dedicated staff member or team to oversee student interprofessional supervision At any one time, there can be students from multiple professions on placement at any one site. Logistics, such as timetabling, mix of professions, different year levels of students, and the priority of discipline specific learning are often cited as barriers to interprofessional learning (Forte and Fowler 2009, Ho et al. 2008, Kezar and Elrod 2012, McKimm et al. 2010, Nisbet et al. 2011, Olson and Bialocerkowski 2014, Pecukonis et al. 2008. Whilst overlap in placements may not have been intentionally planned, with collaboration between educators of different discipline groups within the site, or alternatively a designated interprofessional facilitator, learning with, from and between professional groups can occur. Leaders and educators in organisations sharing a vested interest in bringing together different groups in collaboration has been cited as a key to achieving outcome oriented team based care (Mitchell et al. 2012). A commitment can be created through appointing a designated staff member from the site to ensure students have someone to whom they can discuss controversial and or sensitive issues that they have experienced with other disciplines during the placement. A co-ordinator appointed to this role is ideally placed to facilitate development in students of the skills they need to recognise and resolve disagreements in relation to patient care that arise from different disciplinary perspectives (Interprofessional learning competency 6).

Tip 11.
Encourage students to locate and critically evaluate the interprofessional practice they observe As student learning may have predominantly focused on disciplinary perspectives prior to their first placement, students may have a limited understanding of interprofessional practice. Upon reaching the 'real world' of practice students have the chance to broaden the lens with which they evaluate practice. The placement experience provides an ideal opportunity for students to explore and test the rationale for interprofessional practice as they can see the immediate relevance to their own practice. Students should be encouraged to bring their skills in critical analysis and evidence based practice so they can display an ability to critically evaluate protocols and practices in relation to interprofessional practice (Interprofessional learning competency 7).

Tip 12.
Create open 'safe' spaces for students across professional groups to freely converse Students can lack confidence in approaching and interacting with other professions. Our experiences also suggest students are quite siloed and tribal in that they stick together within their own professional grouping when on placements. This may in part also be because they don't know any alternative ways of learning in work settings. Supervisors should facilitate the introduction of students to other professional staff as well as to other students on placement at the same time. Students may assume others know about their profession or even that they would not have anything to add to the other profession's knowledge or skill base. Educators/ academics from both the university and placement site can assist in breaking down these assumptions by incorporating tasks into student placements that require students to exchange knowledge. For example a simple 'meet and greet' ice-breaker activity could incorporate a short verbal quiz on each other's roles. Students openly discussing their beliefs and prejudices with other professions can prepare them in the future to give timely, sensitive, instructive feedback to colleagues from other professions, and respond respectfully to feedback from these colleagues (Interprofessional learning competency 8).

Conclusion
Interprofessional learning can no longer be viewed as an add-on to curricula; healthcare now and in the future demands that our graduates have the necessary competencies to work interprofessionally. The twelve tips presented in this article focus on facilitating interprofessional learning within the placement setting and on student achievement of specific interprofessional learning competencies. They are underpinned by the principle that IPL should be a core component of all healthcare placements and that student learning occurs through participation in routine work activity.