Reflecting back to look forward: the gifts of continuity and change for interprofessional education and collaborative practice during Covid-19

 

Maggie Hutchings, CAIPE Vice-Chair, Member of the Board and CAIPE Executive

 

We are experiencing unprecedented challenges and disruption to our day-to-day lives as a result of the pandemic. Yet all around us, we see the benefits from the humanising and caring impacts of health and social care key workers, including medical, nursing and allied health professionals, community pharmacists, essential support staff working in care homes and outreach, and not forgetting the emergency call handlers, food suppliers and shopkeepers, postal and door-to-door delivery services, police and military personnel, all going about their daily duties and responsibilities in difficult circumstances to bring safety, support, and caring to people in the community.

Within this milieu, the interprofessional education and collaborative practice (IPECP) community continues to play its part, demonstrating agility, tenacity and resilience, in rising to the challenges and adapting and changing practices as necessitated by the exigencies of the pandemic to maintain continuity and purpose in promoting, practising, enhancing, and sustaining IPECP.

As my term of office as CAIPE Vice Chair is nearing its conclusion, this guest editorial provides an opportune moment to review and reflect, drawing on recent events in the CAIPE 2020 calendar, to offer some thoughts and possible directions as we look forward in 2021 and beyond.

While offering a personal perspective, these reflections are nourished by the creativity, enthusiasm and commitment of CAIPE members and colleagues and the wider IPECP global community providing influential and mutual support networks for sharing and advancing the art, science and scholarship of IPECP through education, practice and research (Barr 2020; Xyrichis and Williams 2020).

The choice of events is based on the joint responsibility shared with my dear friend and colleague Sundari Joseph. As Vice Chairs, we are responsible for organising key events in the CAIPE calendar, CAIPE Regional Forums (previously Corporate Forums), which are normally scheduled twice a year and the CAIPE Symposium (previously Chair’s Event) which takes place annually.

Stepping back to move forward

My starting point is 13^th March 2020 at the University of East Anglia in Norwich where Professor Susanne Lindqvist and her team welcomed participants to a CAIPE Regional Forum. CAIPE recognises the important contribution corporate members make to the promotion and development of IPECP. The Regional Forums provide opportunities for the host to share developments within their institution and with other partners, academic, service providers and users within their local networks.

Contextualising IPL
The theme was 'Leading and Championing IPL: the art of stepping back to move forward' and we were treated to a range of excellent presentations and guided discussion throughout the day. The opening presentation from the Director of Workforce highlighted the significance of contextualising interprofessional learning (IPL) within the realities of a health and social care system faced with workforce shortages and lack of investment with a social care sector reliant on significant numbers of volunteers and unpaid carers (Health Foundation 2018; Naylor et al. 2013, Read 2020; Shembavnekar 2020).

Working and learning together for more collaborative and holistic person-centred care
Yet what stood out for me as a counterbalance to these workforce challenges was the sense of IPL as a people-centred journey founded on creativity achieved through people actively working and learning together, exemplified in the #WeCareTogether People Plan initiative for Norfolk and Waveney and the exciting engagement events so enthusiastically shared by student representatives from the student-initiated UEA IPE Society. This focus on collaborative working was further reinforced by presenters sharing their experiences of facilitating and developing IPL, founded on the strengths of melding education and practice underpinned with continuing research and evaluation.

The gifts of continuity and change for IPECP during Covid-19

While concerns were growing worldwide from January 2020, with evidence of the spread of COVID-19 steadily accumulating, few could have anticipated the subsequent escalation of the crisis and its impacts on people’s daily lives. The World Health Organization (WHO) declared the virus a pandemic on the 11^th March and the UK government announced a series of measures from 16^th to 23^rd March ‘urging everybody to work from home and avoid pubs and restaurants to give the NHS (National Health Service) time to cope with the pandemic’ (BBC 2020), culminating in the first ‘lockdown’ when people were advised to ‘stay at home’, only going outside to buy food, exercise once a day, or go to work if they absolutely could not work from home (British Foreign Policy Group 2021).

These announcements quickly followed the success of the CAIPE Regional Forum in Norwich and heralded a period of disruption which is continuing here in the UK with a second ‘lockdown’, following rapid increases in transmission as new strains of the virus have appeared in England, Wales, Scotland and Northern Ireland.

The idea of Covid as 'a gift' is purposely controversial. The concept and understanding of 'gift' is deeply significant in anthropology (Mauss 1950) and bound up with what it means to be human. While people in Western society tend to see 'gifts' as something given freely, the 'gift' can also be seen as creating a system of exchange where obligations and services are reciprocated. The paradox of Covid-19 is that it creates opportunities and challenges for changing social practices, a 'gift' that has the power to bind us into new patterns of exchange and obligation despite and because of its challenges. While some social practices in IPECP will continue during and following the pandemic, the current disruption generates challenges and opportunities for changing practices, adapting and innovating, within higher education institutions (HEIs) and health and social care systems with corresponding opportunities for advancing research and evaluation.

What then are the opportunities and challenges for IPECP during this period of disruption?
The special edition of the Journal of Interprofessional Care 34 (5) 2020 devoted to Covid-19: Interprofessional Considerations and the CAIPE Symposium with the apt yet contentious title, Covid-19, a Gift or Challenge for IPE Educators and Practitioners? held online on 27^th November 2020 offer testament to the ways that the IPECP community is rising to the challenges, demonstrating creativity, agility tenacity, and resilience, maintaining continuity of its mission and purpose while adapting and changing to adopt innovative approaches in education, practice, and research.

Continuity and change in education

The pandemic has provided the impetus for change in education provision, creating opportunities for cross-faculty and inter-institutional development of digital IPE. As higher education institutions (HEIs) closed their campuses, the workforce was mobilised to shift learning and teaching activities online, offering new blends of technology-mediated strategies for the design and management of sessions previously facilitated face-to-face in classrooms.

Opportunities for Digital Interprofessional Education
The CAIPE Symposium theme of Opportunities for Digital Interprofessional Education offered two thought-provoking examples of some of the digital approaches being adopted. Vincent Geukers representing collaborators from the Faculty of Medicine, University of Amsterdam and the Faculty of Health, University of Applied Sciences, Amsterdam highlighted how Covid-19 catalysed plans for digitalisation of the interprofessional collaborative (IPC) phase of their inter-institutional IPE programme, concluding it was both feasible and meaningful, enabling team collaboration and co-creation in the same space by using digital facilitation, not just a shared drive for documents. Hester Smeets and Aimee van Loo from Zuyd University of Applied Sciences in the Netherlands shared lessons learned by trial and error, clearly identifying how they had to transform the curriculum from ‘regular’ to ‘digital IPE’ “really quickly” and outlining some of the logistical problems of collaborating with three educational institutes.

But while Covid-19 has acted as a catalyst for change it raises questions concerning the efficacy and sustainability of replacing direct face-to-face interactions, considered so integral for student learning in health and social care programmes, with technology-mediated approaches (Gurbutt 2020; Essen 2020; Lackie et al. 2020). Further, it is not only a question of how technology mediated strategies will have an impact on the quality of human-to-human relationships and interactions but also how the contingencies of managing rapid change are impacted by prioritisation of limited resources. Lackie et al (2020) identify the challenges of delivering uniprofessional education programs to online/virtual platforms, suggesting a consequence of the rapidity and intensity of development could mean that IPL/IPC, ‘teaching learners how to collaborate as future healthcare workers’, may not receive the same level of attention due to the logistical complexity of bringing multiple professions and programmes together virtually, similarly reported in pre-Covid digital IPE initiatives, for example Hutchings and Quinney (2015).

Yet the IPECP community has a history of engagement with digital initiatives in IPE (see for example, Bromage et al. 2010) and these current experiences suggest digital approaches and innovation are alive and well and will continue beyond Covid-19 in a variety of blends within IPE programmes (see for example, Bluteau 2020). Geuker et al. (2020) concluded their presentation with the compelling argument: “At an institutional level, if we truly are committed to interprofessional collaboration and education, we really need to facilitate this in a digital world too.”

Continuity and change in practice

Covid-19 arrived within the realities of policy makers and practitioners coping with the challenges of workforce shortages and fragmented provision of care. The scale of these challenges and the threat posed to the delivery and quality of care by fragmentation and siloed working between hospitals, primary care and social care had been highlighted by a Health Foundation briefing for England published in 2018. Recognising concerns about staffing and funding together with inequalities and pressures from a growing and ageing population, the NHS Long Term Plan (2019) set out a service model based on the development of integrated care systems (ICSs) with the aim of offering patients ‘more options, better support, and properly joined-up care at the right time in the optimal care setting’.

Opportunities for Collaborative Practice
The pandemic has crystallised these workforce challenges yet demonstrated the agility and creativity of practitioners, responding and adapting in innovative ways that underline the strengths of a continuing ethos of caring, IP team-based approaches and shared learning. The CAIPE Symposium theme of Opportunities for Collaborative Practice offered two exciting examples of such initiatives.

Jascha de Nooijer, Matthijs Bosveld and Dan van Doorn, representing colleagues from Maastricht in the Netherlands, described the development of a student-initiated scheme to co-ordinate the provision of placements for students who volunteered to work in hospitals, undertaking a variety of tasks including, screening, ICU support and Covid-19 after care, following the suspension of clinical rotations when the Dutch national policy on social distancing was introduced on 16^th March 2020. The impacts of this unexpected learning opportunity for IPE were captured in evaluation and poignantly summarised in one of the student’s comments about what they learned: “Being there for each other”.

Collaborative practice for Integrated Care in the Primary Care sector
Working in primary care, Nasrin Razzaq, a general practitioner (GP) and Education Lead, and Deepa Solanki, Project Manager and Training Co-ordinator, for Integrated Care Education in the London Borough of Harrow, highlighted the value of multidisciplinary teams (MDTs) as enablers to achieving more holistic and person-centred care in ICSs. Education was recognised by stakeholders as fundamental to improving service delivery and the value of training together to work together. But the impact of Covid-19 and the need to prioritise clinical duties meant that face-to-face sessions were not feasible, so the training programme introduced a variety of technology-mediated strategies to engage participants in shared learning and team building. Key to this was the creation of learning forums where participants could ask questions and share ideas via WhatsApp©. Programme outcomes have included building of trust and mutual respect between team members with ‘hierarchies disappearing’ and supporting much needed resilience during the pandemic as participants identified a sense of ‘sharing the burden’ and ‘not being alone and now being able to reach out to a colleague’.

The impacts of Covid-19 in the primary care sector are cogently analysed by Gray and Sanders (2020) in the special edition of the Journal of Interprofessional Care devoted to Covid-19: Interprofessional Considerations. Gray and Sanders (2020) describe how the crisis has driven changes in current professional roles and specialisms and development of new professional roles, for specialist nurses, community consultants, and independent prescribing roles, together with greater use of technology-mediated provision in offering remote consultation and communication and in so doing make an important contribution to our understanding of the context and position of primary care within a health and social care sector coping with the pandemic.

In the current climate of the pandemic, while it is understandable that the focus of headline news and social media is on reporting pressures in secondary and acute care as a result of rising numbers of Covid cases and hospitalisation, Gray and Sanders (2020: 672) point out that ‘there has been less communication and understanding about the situation within community and social care and the access point offered through general practice or family medicine’. Their analysis reinforces the issues of workforce challenges together with recognition and prioritisation of services within a health and social care system seeking to achieve integrated care pathways for holistic person-centred care (Read 2020; Shembavnekar 2020). They identify human costs for the workforce experiencing ‘increased fear, stress, uncertainty and risk’ (Gray and Sanders 2020: 673) and for the population being served, explaining how Covid-19 is ‘amplifying gaps’ in the provision of care for marginalised and vulnerable groups including people living in care homes, those with dementia and other long-term conditions, homeless people, victims of domestic abuse and those with substance misuse problems (2020: 676), revealing long-standing inequities in the system associated with the “inverse care law” put forward by Tudor Hart (1971) where the need for care is inversely related to its accessibility and utilisation (Gray and Sanders 2020: 674).

Ways forward for developing ICSs to work effectively, will require greater emphasis on IPECP approaches to build interprofessional relationships and enable a mix of formal structured and informal serendipitous opportunities for shared learning and team-based reflection grounded in the principles and values of IPE (CAIPE 2011). Such approaches, generated through teamwork, collaboration, coordination or networking (Reeves et al. 2018) and represented here by the learning forums described by Razzaq and Solanki (2020) and the regular team meetings, Balint groups, and Schwartz rounds, identified by Gray and Sanders (2020), can underpin and support effective collaborative working, bringing mutual benefits for improving holistic, person-centred care and for building and maintaining workforce resilience. By helping to enhance the emotional wellbeing of staff these communicative spaces for non-hierarchal MDT-based approaches can offer mechanisms for coping with the current challenges and uncertainties, but also a continuing source for nurturing integrated collaborative working and resilience in the future.

Continuity and change in research

Research, as with education and practice, has been impacted by the pandemic. Research projects have been paused, or suspended, due to restrictions on research activities involving physical contact. Nevertheless, the IPECP community is responding positively. Lackie et al. (2020) draw our attention to a pathway mapped out for IPECP research outlined in the IPR.Global’s proposed research priorities. They include (1) building the science and scholarship of IPECP through  discovery and integration of innovative evidence-informed strategies, (2) identifying and applying innovative approaches that embrace and address the inherent complexity of interprofessional endeavours, and (3) developing evidence of impact along the continuum from IPE to CP in person- and community-centred service delivery (Khalili et al., 2019).

Opportunities for Research
CAIPE is committed to supporting the IPECP research community during these uncertain times, promoting collaborative research opportunities, and developing guidance for research approaches and methodologies. A Covid-19 IPE Research Registry was set up for CAIPE members to raise awareness of planned, in progress, and completed IPE research related to COVID-19; and to facilitate collaboration among research teams with common interests. CAIPE’s Research Group have been active in developing guidance and facilitating networks for undertaking collaborative research during Covid-19.

The CAIPE Symposium theme of Opportunities for Research offered three insightful contributions on research. Michael Sy and Noreen O’Leary presented a paper on doing interprofessional research in the COVID-19 era, on behalf of members of CAIPE’s Research Group, following their collaborative writing for the special edition of the Journal of Interprofessional Care 34 (5) 2020. The presentation provided practical advice on adapting conventional methods and adopting alternative research approaches and online methodologies to assure the continuation of existing and new research projects (Sy et al. 2020).

Alla El-Awaisi et al. (2020) presented novel research exploring public perceptions of who is in the health care team, using a social listening technique and undertaking content analysis of social media posts during the COVID-19 pandemic. While findings identified gratitude for staff risking their lives around the clock, they also revealed stereotypical perceptions fuelled by the media’s focus on doctors and nurses. Frustration was identified for other members of the health care team who felt excluded, invisible, and not valued because many roles, including health care assistants, porters, laboratory staff and cleaning staff, were overlooked.

The third research presentation was delivered by Lesley Diack*(2020) in the form of a poster presentation, outlining the impact of COVID 19 on healthcare teaching and learning based on a Delphi study which forms part of a major EU Erasmus+ funded project entitled Humanizing Healthcare Education through the use of Storytelling (StoryAidEU), coordinated by the International Network for Health Workforce Education. The Delphi study, organised by research partners at Robert Gordon University in Aberdeen, Scotland was conducted to gain consensus on the project definitions for IPE, Humanism and Storytelling, to complete a needs analysis for training and assess what were the preferred methods for teaching and learning (Diack and Falconer 2020). Questions on the Covid pandemic and its effect on teaching and learning were included in preparation for the development of resources for teaching Humanism, IPE, and Storytelling.

Conclusions: Looking forward

Covid-19 has ‘gifted’ the IPECP community with challenges and opportunities and in so doing crystallised some reflections for the future. Considerations at the heart of continuing to build and nurture IPECP include:

• Appreciating the challenging contexts for IPECP

The territory of IPECP is complex, demonstrating hierarchies, barriers and fluidity in systems and professional boundaries, influenced by the different contexts and circumstances of practice. Understanding the context of IPECP frames important considerations for identifying, reviewing, and refining the constituents of its contribution towards achieving viable integrated care systems and pathways to person-centred care for all at the point of need.

 

The question of what the constituencies (or boundaries) for practice are, is reflected in debates about fractures and boundaries in the structural components and operational networks of health and social care systems (Health Foundation 2018; Naylor et al. 2013, Read 2020; Shembavnekar 2020). Gray and Sanders’s (2020) analysis of primary care during Covid-19, illuminate gaps, firstly, in the differential recognition and prioritisation of systems of secondary and acute care compared with primary care; secondly, in social care funding and the need for an adequately funded voluntary sector; and thirdly, in the provision of care for marginalised and vulnerable groups. The question of who is in the health care team considered by El-Awaisi et al. (2020) is also significant here.

 

• Celebrating and sustaining IPECP developments

The Covid-19 pandemic has demonstrated the strengths of learning in and through adversity. The examples presented here celebrate the power of agency to adapt and make changes necessitated by unprecedented circumstances. Individuals and teams have responded by working together creatively to develop alternative enabling pedagogical and practical strategies for nurturing and sustaining practice interactions.

 

However, the agency and will of individuals to transform practices and develop their professional roles needs to be sustained by regularising opportunities for IPECP through shared learning and team-based reflection grounded in the principles and values of IPE. The question of sustainability of collaborative working across professional boundaries is highlighted by Xyrichis and Williams (2020), describing how boundaries ‘can be reinforced and diluted in everyday practice’, and warning that any changes in the current crisis may revert back to ‘earlier stages of normality’ (2020: 577). Collaborative team-based approaches can bring benefits for supporting workforce adaptability and resilience by nurturing relationship development and sustaining connectedness.

 

• Evaluating the role of technology in IPECP for humanising care

Technology has played a pivotal role in enabling a degree of continuity in provision and services through adopting digital IPE and using remote communications technology for hosting meetings and consultations. While the future of technology’s contribution to IPECP is assured, the IPECP community will need to continue evaluating digital and remote approaches to address the question of how they are being designed and deployed to support humanising education and practice (Diack and Falconer 2020).

 

• Evidencing and evaluating practice in IPECP for improving service user outcomes

While the values and principles of IPECP (CAIPE 2011) are inextricably bound up with its purpose in focusing on the needs of individuals, families, and communities to improve the quality of care, health outcomes and wellbeing, evidence of the link between IPE and CP for achieving the ultimate outcome of improving the quality of health and wellbeing of the population have remained elusive (institute of Medicine 2015). Goldman and Xyrichis (2020)reinforce the difficulties of researching IPECP within the complexities of interprofessional learning and working, recognising the translation and implementation of research evidence into daily practice has proved the Achilles’ heel of health services research and interprofessional research (2020: 581).

 

A continuing research agenda is essential for gaining and maintaining the support of policy makers in HEIs, professional and regulatory bodies and health and social care systems to assure the prioritisation of IPL in promoting collaborative team-based approaches in IPE and CP (Lackie et al. 2020) and to ensure that the ultimate outcomes of improving the quality of health and wellbeing of patients, families, and communities can be achieved.

 

• Collaborating with professions, service users and carers by respecting diversity and inclusivity

Respecting individuality, difference, and diversity within and between the professions and all those with whom they learn, and work is central to the values and principles of IPECP (CAIPE 2011) and IPR.Global’s research priorities (Khalili et al. 2019). It is vitally important for the IPECP community to continue to build the scholarship of interprofessional sciences (Xyrichis (2020), grounded in an appreciation and valuing of lifeworld-led service user perspectives and experiences for humanising education and caring. The significance of working across boundaries to include social care and voluntary sectors draws on the strengths of diversity, inclusivity and theoretical relevancy (Khalili et al. 2019) and is essential, not only for a population living in such unprecedented times, but also for the future of IPECP and its vital contribution to the health and wellbeing of every individual no matter their age, gender, socio-economic background, ethnicity, condition and prognosis.

 

Living with the pandemic has revealed the future for IPECP is looking bright with a vibrant and flourishing community of academics, practitioners, service users, carers and students committed to pursuing and enriching the impacts of IPECP with health and social care.

We are now looking forward to our next Regional Forum which will be hosted online at Aston University on Friday 19^th March 2021 and we have provisionally identified Staffordshire University to host the subsequent Regional Forum.

*Dedication*

This editorial is dedicated to the memory of Honorary Professor Lesley Diack who sadly died peacefully in her sleep in the early hours of the morning of 22^nd December 2020. Lesley was a warm and caring person and a consummate professional, whose work epitomised the synergies in interprofessional education and research for collaborative practice.

Also remembering all those individuals who have lost their lives and the continuing impacts on their families and friends as a result of this pandemic.

References

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The Journal of Interprofessional Care- the official Journal of CAIPE, is planning a specific online open access publications in relation to COVID19.  JIC are making all COVID-19 research free-to-access at the point of publication and all research related to COVID-19 is expedited through the production process as soon as it has been peer reviewed.  They have launched a microsite at www.taylorandfrancis.com/coronavirus which is currently being updated based on daily keyword scans of articles in production to ensure that they are making all COVID-19 research free.

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PAHO 29.12.20

CAIPE INTERNATIONAL WORKING GROUP

by Sundari Joseph, CAIPE Vice-Chair and lead for the International Working Group

The Corona Virus Pandemic has brought together people from many different disciplines and they are working together collaboratively in ways that we cannot have imagined. I’ve been thrilled to see cross boundary working and interdisciplinary and transdisciplinary working on an incredible scale. It’s what we have all been waiting for. How can we learn from this and encourage its sustainability for collaborations such as these going forward after the pandemic?

This is a question many of us in the interprofessional community are thinking about. Here at CAIPE’s international group we would like to invite you to make us aware of what is going on in your areas.

What are your examples of interprofessional and cross boundary working? Please share them with us by sending us a 2min film clip using a smartphone and saved on MP4 if possible. Write some text as well so we can gain a better understanding of what your film clip is trying to portray and any photos you wish to send us. Send them to: [email protected].

 

Here is my example.  We were also recognised in our local newspaper too.

 

Sundari.

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COVID-19 - SRI LANKAN APPROACH

By Dr Chulani Herath, Department of Psychology & Counselling, Faculty of Health Sciences, The Open University of Sri Lanka

 

Here are two examples

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COVID-19 IN THE PHILLIPINES

By Michael P. Sy, OTRP, MHPEd, PhD | Associate Professor (Health Professions Education), National Teacher Training Center for the Health Professions, University of the Philippines Manila

Listen to Mike's audio file about COVID-19 in the Phillipines.

Leadership Newsletter - November 2020

King's Fund News - November 2020

NHS England and NHS Improvement want to hear from you to understand how you are feeling, what more needs to be done, and how they could adjust their communications as part of the COVID-19 response.

Click here for more information.

Nursing & Midwifery Council

NMC News - May 2020

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Lancet - State of Nursing & Midwifery

Lancet State of Nursing and Midwifery

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Resource for Children

Coronavirus-ABookForChildren

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Resource for Autism

Autism Parenting Magazine

We currently have compiled a list of resources regarding COVID19 and how families on the autism spectrum can cope up with it.

Here's our link: https://www.autismparentingmagazine.com/coronavirus-and-autism/

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Adapting to COVID-19

We have heard from many of you about the challenges of using experiential
learning tools during quarantine, and commend those of you who have adapted our
tool and others for the digital realm. Your students, clients, and colleagues all
benefit from your innovation and commitment to meet their learning needs in an
entirely new way.  Read more ...

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The Clinical Teacher

Jill Thistlewaite has sent out a general call for papers on clinical education and Covid-19 for The Clinical Teacher - would love thoughts on how faculty/educators/clinicians are coping with/adapting to this new era, particularly from an interprofessional perspective.

Format is similar to our usual Insights articles (and should be submitted as insights) - personal reflection of up to 800 words and 5 references.

For further information email [email protected]

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If you have anything you would like to share on this page, please email [email protected] .