Shared learning – a collaborative education and training initiative for community pharmacists and general medical practitioners

AIM – To plan, implement and evaluate a shared learning, collaborative education and training initiative for community pharmacists and general medical practitioners.

DESIGN – A series of three (2.5 hour) direct learning courses was commissioned from the Scottish Centre for Post Qualification Pharmaceutical Ediucation for GPs and community pharmacists in spring, 1998. The courses were evaluated for aspects of quality, relevance and how the education met its stated objectives. A questionnaire, looking at encouragements for shared learning and attitudes of the professions, was utilised.

SUBJECTS AND SETTING – An invited audience of community pharmacists and GPs in the Greater Glasgow health board area.

OUTCOME MEASURES – Benefit of shared education to participating community pharmacists and GPs.

RESULTS – A total of 162 community pharmacists and general medical practitioners attended over the three courses. Participants appraised the courses highly and the comments given were generally very positive. Reasons given for participation in the workshops related to collaboration with other professions, interest in the topic and relevance to practice. Encouragements for future participation in shared learning included topics of interest, professional accreditation and local involvement. The encouragements for future joint working in primary care included improvement in patient care, increased professional interaction and increased prescribing efficacy.

CONCLUSIONS – Multiprofessional education raises important issues for educational providers around funding, topic choices, learning materials, speakers and facilitators, and accreditation. Funding shared learning may be difficult from present funding sources. Topic choice is a balance between interest and relevance for each of the participating professions and to capture the interest of both of the professions the learning resources speakers and facilitators should be of the highest quality. Group dynamics is also important, in that the environment for learning should encourage collaboration and cohesion between the professional groups. Recent evidence into shared learning provision offers a three-dimensional perspective. The three dimensions are the context in which the learning is applied, the curriculum goals and stated outcomes of the education, and the shared learning continuum where professional isolation is at one end of the spectrum through to transprofessional education, where shared learning takes place in the real clinical setting. Our study has shown that the benefits of this initiative in shared learning are mainly in terms of impact on the professionals themselves. The real challenge, for both providers and professions, is to measure the effect of shared learning in terms of benefit to patient care.

Shared learning between professionals was one of the areas highlighted in the Royal Pharmaceutical Society’s Pharmacy in a New Age initiative.1 Health care and the relationships between health care professionals are changing fast. This change is driven by a number of factors, including new government priorities, questions of funding, growing public expectations, demographic change and new technologies.

Multiprofessional education is widely perceived as one way of helping professionals respond to these changes. The goal is to encourage the development of collaborative and cohesive practice in health care. Evidence suggests that multiprofessional education has the potential to:²

• Enhance personal and professional confidence
• Promote mutual understanding between health care professionals
• Facilitate intra- and interprofessional communication
• Encourage reflective practice

However, multiprofessional education is not a panacea for the health service. There has been active debate in educational circles as to the effectiveness of multiprofessional education, the careful planning required, the issue of outcomes and the context of the education and resources required.³

Even the terminology in this area is problematic. Multidisciplinary education is one of many different terms which have been used to describe such initiatives; others include interprofessional working, transprofessional education, and shared learning. The different nomenclature can reflect the differing educational concepts and approaches, and the terms may not always be synonymous. The World Health Organisation (WHO) has defined multiprofessional education as “the process by which a group of students (or workers) from health-related occupations with different educational backgrounds learn together during certain periods of their education, with interaction as an important goal, to collaborate in providing promotive, preventive, curative, rehabilitative and other health-related services”.⁴
This definition may be too restrictive for adoption in the National Health Service; however, it needs to be recognised that the use of differing terms interchangeably can lead to confusion.

Terminology aside, the question of effectiveness of multiprofessional education is perhaps more testing. There is evidence that the perceived benefits of multiprofessional education are widely appreciated in Europe5?8 and the United States.^9?11
However, these benefits are mainly evaluated in terms of the impact of multiprofessional education on attitudes than on outcomes, such as improved patient care.¹²

This paper describes one initiative in shared learning between community pharmacists and general practitioners in Scotland. It highlights issues for education providers and commissioners of multiprofessional education, and draws conclusions from the evaluation in terms of quality, awareness and attitudinal perspectives.

Method

The Scottish Centre for Post Qualification Pharmaceutical Education (SCPPE) has a remit to provide education and training for hospital and community pharmacists in the NHS in Scotland. A number of the direct learning courses provided by the SCPPE are offered on a multiprofessional basis, depending on the topic area and the underlying educational aims of the programme. In early 1998, Greater Glasgow health board (GGHB) was approached with the proposal that the SCPPE be commissioned to undertake shared learning between local community pharmacists and general medical practitioners. This proposal was discussed, refined and agreed among the primary care prescribing team in Glasgow and the relevant professional representative bodies.

A series of three direct learning courses, each of 2.5 hours’ duration, was arranged for February and March, 1998, and invitations sent to community pharmacists and GPs in the GGHB area. The overall aim of the series of courses was to provide an opportunity for local community pharmacists and GPs to develop closer professional links and to gain better understanding of their respective roles in the interest of patient care. The topics for the three events were carefully chosen to be as inclusive as possible, but without raising any contentious issues over professional boundaries.

The three topics were closely aligned to the PIANA expression of strategic intent and included:

• The costs of non-compliance in hypertension
• The management of minor ailments
• Repeat prescribing and medication review

Each of the three courses consisted of a keynote speaker to introduce the topic (40 minutes) and small group work in a problem-based learning format to discuss patient case studies, protocols and systematic approaches to pharmaceutical services in the primary care environment. The overall objectives for the sessions were to enable the participants to:

• Describe the opportunity for co-operation between GPs and community pharmacists to optimise therapy, facilitate compliance, monitor and review therapy for a given therapeutic area
• Demonstrate the important role of the community pharmacist in the areas of medicines management and repeat prescribing
• List the key factors that influence patient compliance and develop strategies whereby GPs and community pharmacists can consistently promote concordance

Each of the three sessions was evaluated by the standard SCPPE course appraisal form, which allowed course participants to score for aspects of quality, relevance and the extent to which the provision met its stated objectives, on a scale of 1 (low) to 5 (high). In addition, in the second course, “Managing minor ailments”, a questionnaire looking at the quality of the provision and attitudinal aspects of each of the professional groups was given to participants.

The questionnaires were completed anomously by the individuals, but the forms were colour-coded for the two professions to allow information to be collected separately for GPs and community pharmacists. The questions that were related to expectations about the course, encouragements for further participation in shared learning and identification of areas for joint projects, were all designed as open questions. The questions relating to the main reasons for participating in the course was from a list of four choices, with space for the participant to add other comments.

The questions relating to the attitudinal aspects of each profession around confidence, knowledge, arrogance and patient focus were presented as a Likert scale where respondents could strongly or partially agree or disagree.

Results

A total of 162 community pharmacists and GPs attended over the three courses. The attendance figures and the associated percentage values (0 [low] ? 100 per cent [high]) for quality, relevance and the extent to which the courses met their stated objectives, are shown in Table 1.

The total numbers are given and the breakdown figures for GPs and community pharmacists are given in brackets for each course.

Participants were asked to include any comments on the course appraisal form and all of these comments, separated for GPs and community pharmacists, are given in Panel 1.

In the second course, of the series of three, “Managing minor ailments”, a questionnaire was given to all of the participants. They were asked for some demographic details and to say three things they were looking forward to about the course, three main factors for participating in this course, and three main encouragements for future provision and joint projects. Table 2 gives details on professional characteristics of community pharmacists and general practitioners who completed the questionnaire.

The questionnaire responses are shown in Panels 2 to 5 and Table 3. The community pharmacists and GPs’ questionnaires were completed separately and the results are presented for each professional group. Seventeen out of a total of 20 GPs and 32 out of 39 community pharmacists completed the questionnaires (a return rate of 85 per cent and 82 per cent, respectively).

Panel 2 gives the details of the most common replies when both practitioners were asked about their expectations of the course. Panel 3 describes practitioners’ three main reasons for participating in the course, when given a list of four options.

Panels 4 and 5 give details of the most common responses when practitioners asked about future participation and projects.
When asked, “Would you participate in other shared learning events?”, all GP and community pharmacist respondents answered “yes”.

The last question on the questionnaire related to interprofessional attitudes, and both parties were asked about characteristics of their own profession and that of the other participating profession. The results are shown in Table 3. There was no prior definitions of confidence, knowledge, arrogance or patient-focus given to the delegates before completing the questionnaire.

Discussion

This paper describes one initiative in multiprofessional education, and outlines the participants’ response to the shared learning events in terms of quality, attitudes and perceptions. In interpretating the results it must be remembered that the course appraisal form was used in all three courses and that the questionnaire was used only at the second course in the series of three. However, the attendance of GPs and community pharmacists at the second course “Managing minor ailments” was representitive of the 162 attendances on all three courses.

Multiprofessional education raises a number of important issues for education providers in planning or implementing shared learning events. The source and amount of funding required for multiprofessional education may present the first barrier to potential education providers. Funding for education and training is usually compartmentalised into uniprofessional organisations and structure, so it may be difficult to source an adequate amount of funds to appropriately resource shared learning. In this instance, the Greater Glasgow health board commissioned the SCPPE as an education provider to support the underlying goal to promote better understanding between the professions and to explore methods of strengthening the primary health care team.

The context in which multiprofessional education is provided is another major dimension for educationalists and practitioners. The topic choice for direct learning is important and is a balance of attracting the appropriate practitioners’ interest, providing encouragement and motivation to attend, and, ultimately, avoiding potentially divisive topic areas. The topic areas chosen should be as inclusive and as relevant to the practice situation as allowable. The associated learning material or resources should be of as high a quality as possible and call on good educational practice in each of the professions involved. It is also important to have a quality presenter or keynote speaker and experienced facilitators for the interactive small group sessions. The group dynamics, setting and environment for learning should be amenable to encourage collaboration and cohesion between the professional groups.

Finally, any professional accreditation for education and training should be sought and advertised in the promotional material used to market the provision to the professionals. In this case, PGEA and SCPPE accreditation were achieved for GPs and community pharmacists, respectively, to encourage each of the professional groups to utilise the education provision towards their continued professional development.

A recent paper from the medical education field¹³
offers an insight into multiprofessional education by describing a three-dimensional perspective. The three dimensions are:

• The context in which the multiprofessional education is applied, including the stage of introduction to the professionals and the learning format. (The context in the SCPPE initiative includes funding, topic choices, learning resources, setting, group dynamics and accreditation)
• The curriculum goals, which are the stated outcomes of the educational provision. (In this initiative, the overall goal was to encourage collaboration and cohesion of GPs and community pharmacists in primary care)
• Multiprofessional education as a continuum with a number of clearly defined steps or stages, where isolation is at one end of the spectrum (which describes a situation where there is no contact between professionals with regard to planning or implementing teaching), through to transprofessional education (which describes a situation where the multiprofessional education takes place in the context of the clinical practice in real life and not in the classroom) at the other end

This continuum offers a framework within which multiprofessional educational initiatives can be studied and evaluated. Multiprofessional education is likely to be effective when it takes into account the differences as well as the similarities between the professions, moves from passive to interactive learning, and from little awareness to the development of an understanding from the perspective of the other profession.

Continuing medical education providers have examined multiprofessional education as a spectrum with loosely co-ordinated effects of collaboration at one end and more tightly organised work of teams at the other.¹⁴
High quality multiprofessional education requires collaboration over the shared objectives, effective participation, and mutual support and teamwork to ensure tasks are achievable, participation is balanced and responsibility is shared. The Standing Committee on Postgraduate Medical and Dental Education (SCOPME), in a working paper, concluded that “conventional continuing medical education is no longer adequate to meet all the education and career development needs of doctors in modern health care”.¹⁵
In addition, it stated that continuing medical education needs to be set in the wider context of continuing professional development and that, while updates of clinical knowledge for individual doctors remain important, other learning is needed, including strategies for multidisciplinary and multiprofessional working.

This initiative in multiprofessional education between GPs and community pharmacists in Glasgow describes the impact and issues in terms of increased awareness of each of the professional roles, the attitudes towards the professionals and the potential for collaboration. It has generated very positive responses from both community pharmacists and GPs, and has revealed some surprising issues related to interprofessional attitudes. It is interesting to note that the respondents (on this occasion the community pharmacists) felt that they were more patient-focused than their GP colleagues, and that perceptions of professional arrogance within each of the two groups did not directly coincide.

However, it is important that, to prove the effectiveness of multiprofessional education, the outcomes are measured in terms of benefit to patient care. This is a major challenge for commissioners, education providers and professionals alike. If, as one researcher suggests,¹⁶
that “education is the key to expanding and changing clinical practice methods within the health care community” and that “it is in this manner that we shall prepare health professionals for the challenges of tomorrow”, it is a challenge we ignore at our peril.

ACKNOWLEDGMENTS The authors wish to express their gratitude to the area pharmaceutical committee, the local medical committee, the Greater Glasgow health board and the prescribing team in Glasgow, and all of the community pharmacists and general medical practitioners who participated in this shared learning initiative.

The project was funded by Greater Glasgow health board as an element of its 1997-98 prescribing management scheme.