http://informahealthcare.

com/jic
ISSN: 1356-1820 (print), 1469-9567 (electronic)

J Interprof Care, 2014; 28(3): 212–217

! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2014.890581

THEMED ARTICLE

Designing and evaluating an effective theory-based continuing

interprofessional education program to improve sepsis care by
enhancing healthcare team collaboration
John A. Owen1,2,3, Valentina L. Brashers2, Keith E. Littlewood3, Elisabeth Wright3, Reba Moyer Childress2 and
Shannon Thomas2
J Interprof Care Downloaded from informahealthcare.com by Nyu Medical Center on 05/11/15

1
Office of Continuing Medical Education, 2School of Nursing, and 3School of Medicine, University of Virginia, Charlottesville, VA, USA

Abstract Keywords
Continuing interprofessional education (CIPE) differs from traditional continuing education (CE) Collaboration, continuing interprofessional
in both the learning process and content, especially when it occurs in the workplace. Applying education, interprofessional learning,
theories to underpin the development, implementation, and evaluation of CIPE activities interprofessional practice, theory,
informs educational design, encourages reflection, and enhances our understanding of CIPE workplace learning
and collaborative practice. The purpose of this article is to describe a process of design,
implementation, and evaluation of CIPE through the application of explicit theories related History
to CIPE and workplace learning. A description of an effective theory-based program delivered
to faculty and clinicians to enhance healthcare team collaboration is provided. Results Received 28 January 2013
For personal use only.

demonstrated that positive changes in provider perceptions of and commitment to team- Revised 19 December 2013
based care were achieved using this theory-based approach. Following this program, Accepted 29 January 2014
participants demonstrated a greater appreciation for the roles of other team members by Published online 4 March 2014
indicating that more responsibility for implementing the Surviving Sepsis guideline should be
given to nurses and respiratory therapists and less to physicians. Furthermore, a majority (86%)
of the participants made commitments to demonstrate specific collaborative behaviors in their
own practice. The article concludes with a discussion of our enhanced understanding of CIPE
and a reinterpretation of the learning process which has implications for future CIPE workplace
learning activities.

Introduction IPE workplace scenarios to reflect the workplace environment

(AACN/AAMC Lifelong Learning, 2010). To maximize the
Traditional continuing education (CE) is primarily focused on the
effectiveness of CIPE, it is essential to underpin the development,
transfer of clinical knowledge delivered from experts to those less
delivery, and evaluation of CIPE activities with a sound
knowledgeable and often is provided in settings removed from the
theoretical framework relevant to the complexities of the work-
point of care. Continuing interprofessional education (CIPE)
place context (Hean, Craddock, & O’Halloran, 2009; Reeves &
differs both in the learning process and the content, therefore
Hean, 2013).
requiring that different theories and new approaches be used in
A University of Virginia (UVA) CIPE program for team-based
14
designing and implementing CIPE activities (Sargeant, 2009).
20
sepsis care, targeted for physicians, nurses, advanced practice
In addition, learning transfer is improved by providing a strong
nurses, and respiratory therapists who care for patients with sepsis,
relationship between what is taught and the learners’ work roles
was recently developed using a theoretical framework for CIPE in
within the workplace environment (Merriam & Leahy, 2005).
a simulated workplace setting. Recognizing that effective work-
Workplace learning, defined as ‘‘the physical location, shared
place learning occurs when the goals and interests of the
meanings, ideas, behaviors, and attitudes that determine the
workplace and those of individuals who participate in it
working environment and relationships’’ (AACN/AAMC
are shared (Eraut, 2004), this program reflected the UVA
Lifelong Learning, 2010), is a logical approach to match what
Health System priority to implement the 2004 Surviving Sepsis
is taught to the leaners’ work roles. Educators have utilized
evidence-based clinical guidelines. The guideline consists of
workplace leaning in many ways such as by creating simulated
multiple emergent steps for the resuscitation and management
of patients with severe sepsis, and teamwork is essential for
optimal implementation of these complex and time-dependent
interventions. The CIPE program was developed to enhance
healthcare team collaboration within the workplace setting where
Correspondence: John A. Owen, Office of Continuing Medical
sepsis care is delivered. The purpose of this article is to describe
Education, University of Virginia, McKim Hall, Charlottesville, VA this program and the process of its design, implementation, and
22908, USA. Tel: +14 349245318. Fax: +14 349821415. E-mail: evaluation through the application of explicit theories related
jao2b@virginia.edu to CIPE and workplace learning.
 DOI: 10.3109/13561820.2014.890581 Designing and evaluating a theory-based CIPE program 213

Background being part of a distinct ‘‘in-group’’ (Sargeant, 2009). Working

in collaborative teams can pose a threat to social identity, and
There is substantial evidence that patient outcomes improve by
can mean having to give up some of this identity (Sargeant,
enhancing professional healthcare team collaboration (Frenk
2009); by implication, CIPE must develop methods to counter
et al., 2010; Josiah Macy, Jr. Foundation, 2012). In the Institute
the influence of traditional professional group identity and to
of Medicine (IOM) report, Redesigning Continuing Education in
encourage cooperation and collaboration with professionals
the Health Professions, one of the numerous recommendations
of other groups (Clark, 2006).
focused upon the vital role of CIPE: ‘‘Continuing education
efforts should bring health professionals from various disciplines
Reflective and experiential learning
together in carefully tailored learning environments. As team-
based healthcare delivery becomes increasingly important, such Self-reflection is a learning strategy that entails learning from
interprofessional efforts will enable participants to learn both experience (Clark, 2009), and is particularly effective when
individually and as collaborative members of a team, with a professionals are faced with unique experiences not easily
common goal of improving patient outcomes’’ (IOM, 2010). understood from established practice patterns. Schön (1987)
Workplace learning, which is situated within the context of approach for educating the ‘‘reflective practitioner’’ accounts
complex systems of practice (AACN/AAMC Lifelong Learning, for health professionals’ need to be well prepared both in the
2010; Sargeant, 2009), is emerging as an important consideration science of their profession as well as in the ‘‘gray’’ areas
for CE educators and researchers (Newton, Billett, & Ockerby, where uncertainty and value conflicts are likely to occur.
2009). Its importance is underscored because workplace learning Interprofessional practice often encompasses gray and value-
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serves as a ‘‘process of reasoned learning towards desirable laden areas, and developing the ability to learn by reflecting
outcomes for the individual and the organization. These outcomes on one’s own experiences and interactions with other health
should foster the sustained development of both the individual professions is an important attribute (Clark, 2006).
and the organization, within the present and future context of The major tenant of experiential learning is that learning is a
organizational goals and individual career development’’ continuous process emanating from experience, and is not simply
(Matthews, 1999). CIPE in the workplace involves explicit a product or an outcome (Clark, 2006). Experiential learning
interactive learning (e.g. group reflection, opportunities to entails both individual and group reflection on the process, and
practice behaviors) where various health professions and others requires that health professionals learning to work as interprofes-
participating in some part of a shared care delivery effort learn sional teams have opportunities to engage collaboratively in real
‘‘about, from and with’’ each other (IOM, 2010). clinical situations, or in CIPE settings that use realist case studies
and problem-based learning experiences that reflect ‘‘real world’’
For personal use only.

situations (D’Eon, 2005; Harden, 1998).

Application of theory to CIPE
Explicit use of theories in creating effective CIPE provides Learning within communities of practice
numerous benefits: (1) Theory is integrated into educational
Learning within communities of practice is learning that occurs
practice by informing the development and delivery of inter-
through social activity within a specific context (situated
professional programs, (2) Reflection is encouraged through a
learning), such as a healthcare team (Lave & Wenger, 1991;
systematic, disciplined and critical approach to thinking about
Sargeant, 2009). The two principle elements are as follows:
these activities; and (3) Rationale is provided for making
(1) learning is strongly influenced by the context and (2) learning
decisions and testing propositions (Barr, Koppel, Reeves,
occurs through interaction or ‘‘co-participation’’. Both elements
Hammick, & Freeth, 2005; Clark, 2009). It is important to
have implications for CIPE (Sargeant, 2009).
recognize that theories applicable to CIPE are not mutually
Communities of practice are comprised of individuals who,
exclusive and that selecting a single theory is insufficient for the
as they work together on a joint goal and share their expertise,
complexities of interprofessional education (Hean et al., 2009).
create experiential knowledge and learn together; learning and
Recent publications have described many relevant theories and
work are inseparable in this context (Wenger, McDermott, &
selecting the appropriate theories relevant to the educational
Snyder, 2002). Learning is not a discrete activity separate from
context and content of CIPE workplace activities can be
work and practice, it is integral to it. Both occur at once.
confusing. Theory should be selected based on the context
Conceptually, communities of practice necessitates a reexamina-
(Hean, Craddock, & Hammick, 2012), such as an interprofes-
tion of how teaching and learning are envisioned (Sargeant,
sional team practicing in an acute care setting, and on the
2009). The content and process of IPE, and its integration into CE
understanding that interprofessional education is both product and
activities, can be improved by understanding how communities of
process-oriented (Sargeant, 2009). This selection process can be
practice work and learn together (Sargeant, Hill, & Breau, 2010).
simplified by following a recently published guide (Hean et al.,
2009). Three theories that are foundational to CIPE program
development include social identity theory, reflective and experi- Education activities
ential learning, and learning within communities of practice
At the University of Virginia, a CIPE program was developed for
(Hean et al., 2009, 2012; Reeves et al., 2007). These theories
enhancing teamwork during implementation of the Surviving
underpinned the design and implementation of the learning
Sepsis Guidelines (http://www.survivingsepsis.org). The learning
objectives, learning activities, and outcome measures.
objectives were as follows: (1) Describe the differences between
IPE and uniprofessional education based upon participants’
Social identity theory
personal experiences, (2) Identify collaborative behaviors neces-
Social identity theory is the recognition that the identities of sary for the effective implementation of the sepsis guidelines, and
people are developed through membership in social groups whose (3) Recognize which interprofessional team member(s) is(are)
members have shared knowledge and values (Ellemers, Spears, & responsible for implementing each sepsis guideline step.
Doose, 1999). These socially derived identities influence how This program, which consisted of three separate activities,
individuals perceive and relate to others, and provide individuals continued over a period of 6 months. The first activity involved
with positive feelings and self-esteem from their estimation of three days of faculty/clinician training. The second and third
 214 J. A. Owen et al. J Interprof Care, 2014; 28(3): 212–217

activities, which focused on the healthcare professionals’ roles it positively before learning could be optimized. Based on this
and responsibilities related to effective sepsis care, began theory, the Readiness for Interprofessional Learning Scale
2 months following the first activity and extended for a total of (RIPLS) Questionnaire (Parsell & Bligh, 1999) was used to
4 months. These activities were designed as work-based CIPE assess readiness related to interprofessional learning as this
through the utilization of a high-fidelity IPE sepsis simulation learning pertained to the roles of other healthcare professionals
case which linked the program content to the learners’ work roles and their scope of practice. The RIPLS consists of 19 items using
and workplace environment. a 5-point Likert scale (1 ¼ strong disagree to 5 ¼ strongly agree).
Thirty-two people (9 MDs, 19 RNs and 4 PhDs) participated RIPLS data were collected ‘‘pre and post’’ activity one.
in the first activity. Applying social identity theory to counter Reflective and experiential learning created the basis for the
the influence of traditional professional group identity and to evaluation form in which participants were asked to explore
encourage team cooperation, facilitators assigned participants to their experiences working in teams in two ways: improving their
stable 5–6 member interprofessional groups to enable participants knowledge of teamwork for implementing the sepsis guidelines
to experience and reflect on their own dynamic interprofessional and improving the CIPE learning experience itself. The evalu-
group process and apply what they were learning about these ation, which consisted of open-ended questions and 12 statements
topics throughout the course. Reflective and experiential learning measured by a 5-point Likert scale, was given at the end of each
was applied by encouraging participants to interact actively with of the 3 days of the program so that daily as well as cumulative
the facilitators and with the members of their interprofessional responses could be assessed.
group, and to engage in reflective journaling that stimulated Social identity theory was applied in the evaluation of
reflection on what was happening in the experiential learning outcomes for the second activity. Effective collaborative team
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process, and to assess the effectiveness of their collaboration behavior can threaten social identities especially if certain
skills. The overall goal of this training, entitled ‘‘Educating responsibilities comprising a health professional’s identity are
Health Professionals for Interprofessional Care’’ (ehpicÔ), was relinquished. Based on this theory, it was hypothesized that
‘‘to engage professionals in learning how to work together certain responsibilities in the implementation of the sepsis
by providing the knowledge, skills, and attitudes required to guidelines would be viewed by participants as the exclusive
effectively collaborate’’ (Oandasan & Reeves, 2005). Learning domain of certain professions prior to their CIPE training.
activities included icebreakers, didactic lectures, small group case A comparison of pre/post coding of physician (MD), nurse (RN),
study work and discussions. advanced practice nurse (APRN), and respiratory therapist
Eleven people (3 MDs, 8 RNs) participated in the second and (RT) roles was made to assess whether the identification of
third activities. Learning in communities of practice was applied responsibilities and practice behaviors necessary to implement the
in designing the second activity. Clinical simulation that demon- sepsis practice guidelines would change after viewing the
For personal use only.

strates a collaborative practice approach is a powerful educational interprofessional teamwork demonstrated in the sepsis simulation
method to prepare healthcare providers for interprofessional video recording.
practice (Morton, 1999). Participants were asked to code each Reflective and experiential learning, as well as communities
step in the Surviving Sepsis Guideline as the responsibility/role of practice learning, guided the development and evaluation of
of a physician, nurse, advanced practice nurse, and/or respiratory outcomes for the third activity. In communities of practice
therapist. They then viewed a videotape in which four participants individuals create experiential knowledge as they work together.
assumed the roles of a physician, nurse, advanced practice nurse, By identifying and committing to collaborative behaviors after
and respiratory therapist engaging in a high-fidelity simulation of having participated in the communities of practice CIPE experi-
a sepsis management case. They were asked to repeat the ence with colleagues from other professions, it was anticipated
responsibility/role coding of the guideline steps after viewing the that participants would have more incentive to implement
video recording. One, two, three, or all four of the healthcare new practice behaviors and to learn from that experience.
professionals could be assigned the responsibility for each step of The ‘‘Commitment to Change’’ strategy of asking participants
the guidelines. By having participants watch the simulation via to identify specific behaviors that they planned to promote in
the videotape and identify ways to improve care by working more their practice has been demonstrated to predict actual changes
effectively together, individual learning was shifted to situated, in practice behavior (Wakefield, 2004).
team-based learning.
Reflective and experiential learning was applied in designing
Results
the third activity. Participants were presented a list of 10
interprofessional practice behaviors and asked to respond to the For the first activity, the means of the pre/post scores in the
following question: ‘‘Drawing on your expertise in collaborative RIPLS survey did not change significantly (73.5 pre faculty
care, which of the following behaviors are most important development and 72.9 post faculty development; n ¼ 17), thus
for ensuring optimal care of patients with sepsis?’’ The six indicating that attitudes related to interprofessional learning
behaviors most frequently identified were used to create a sepsis remained basically unchanged. Program evaluation data varied
‘‘Collaborative Care Best Practice Model’’ (Owen, Brashers, over the 3 days, with a drop in positive responses on Day 2.
Peterson, Blackhall, & Erickson, 2012). Participants were then Noting these changes in quantitative data following Day 2 and
presented the same ten interprofessional practice behaviors and in response to participant suggestions to modify the material, the
asked to reflect on the question, ‘‘Which of the following originally planned content and delivery was modified for Day 3.
collaborative behaviors are you willing to make a personal Evaluations improved and participants’ increased interest and
commitment to demonstrate and promote in your practice?’’ enthusiasm on Day 3 was palpable. Averaged over the 3 days, 92%
of the participants agreed or strongly agreed that the material
was relevant to their work, 86% agreed or strongly agreed that
Methods
it encouraged them to change their practice, and 87% agreed
For the first activity, it was recognized through social identity or strongly agreed that overall the workshop had met their
theory that participants likely would encounter some internal expectations.
resistance to incorporating the views of other professions. Since only 11 participants completed the second activity,
Thus, there was a need to assess that resistance and address statistical significance could not be achieved with these limited
 DOI: 10.3109/13561820.2014.890581 Designing and evaluating a theory-based CIPE program 215
Table I. Comparison of pre- and post-test selections of the appropriate providers for 3 sepsis care guidelines steps.

Please indicate which provider(s) would be appropriate to perform each resuscitation activity described below.
MD RN RT APRN
Resuscitation activity Pre Post Pre Post Pre Post Pre Post
Obtain serum lactate and blood pressure 64% (7) 36% (4) 100% (11) 100% (11) 9% (1) 27% (3) 82% (9) 82% (9)
Obtain blood cultures 64% (7) 55% (6) 73% (8) 91% (10) 9% (1) 27% (3) 64% (7) 82% (9)
Provide stress ulcer prophylaxis using 91% (10) 82% (9) 64% (7) 82% (9) 0% (0) 0% (0) 91% (10) 91% (10)
H2 blocker or proton pump inhibitor

Table II. Importance of and commitments to demonstrate collaborative behaviors.

‘‘Drawing on your expertise ‘‘Which of the following

in collaborative care, which collaborative behaviors are
of the following behaviors are you willing to make a personal
most important for ensuring optimal commitment to demonstrate and
care of patients with sepsis?’’ promote in your practice?’’
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Behavior % Response (n ¼ 11) % Response (n ¼ 11)

Ensure that information exchanged is being heard and under- 91% 82%
stood correctly through active listening and reflection.
Display interest, trust, and mutual respect across the 91% 100%
professions.
Effectively exchange knowledge and ideas with other 82% 82%
professions.
Identify which team member will take the appropriate leader- 73% 55%
ship/facilitator role in specific contexts.
Define individual responsibility for implementing joint deci- 73% 18%
sion and follow-up.
Integrate collective knowledge to develop alternative solutions. 64% 27%
For personal use only.

Implement joint decisions taking into account all options and 64% 36%
evidence provided, discussed and evaluated for risks and
benefits.
Share discipline specific knowledge with the team. 45% 55%
Identify strategies for addressing disagreements and 27% 9%
approaching situations in which conflict is likely to occur.
Determine whom to involve depending on the needs of the 18% 18%
patient/client.

data. However, pre/post changes in the assignment of responsi- and skills, they desired to adjust the content and delivery of the
bilities for the roles of physician, nurse and respiratory therapist CIPE experience to better meet their needs while learning was
were noted, most often with less assignment of responsibility still in progress. This observation illuminated our understanding
being given to physicians and more assignment of responsibility of CIPE, and revealed that using continuous feedback from the
being given to nurses and respiratory therapists after having learners to adjust the content and delivery of instruction enhanced
viewed the video. By way of illustration, data for three of the the learning process.
guidelines steps are presented in Table I. The observation that the means of the pre/post scores in the
These same 11 people participated in the third activity and RIPLS survey differed only slightly was at first surprising.
identified behaviors needed to provide optimal sepsis care However, on further reflection, we realized that the participants
collaboratively. They then made commitments to demonstrate were likely already to be positively biased towards interprofes-
and promote specific collaborative behaviors in their practice sional learning based on their self-selection for this intensive
(Table II). workshop. This realization raises the possibility that CIPE may
not change the attitudes of participants already favorable towards
interprofessional learning. This conclusion was supported by
Discussion
a previous study which revealed that students with high self-
Foundational to the design of this CIPE workplace program reported IPE exposure had more positive attitudes towards
was the assumption that ‘‘there is nothing so practical as a good IPE than those students who reported no IPE exposure (Lie,
theory’’ (Lewin, 1951), and that underpinning the design with Fung, Trial, & Lohenry, 2013).
explicit theories would enhance our understanding of CIPE and Although interpretation of results for the second activity
collaborative practice (Reeves, 2013). The application of theories is limited by the small number of participants, the changes in
to the various aspects of this CIPE program encouraged system- the assignment of responsibilities for the physician, nurse and
atic, methodical, and analytical thinking (Barr et al., 2005), and respiratory therapist relative to the sepsis practice guidelines
supported our articulation, reflection, and potential reinterpret- suggest a change in knowledge pertaining to collaborative
ation of the learning processes linked to these theories (Hean, team practice and a better understanding of the responsibilities
2012). For example, as described in the results for activity one, and practice behaviors necessary to implement the sepsis practice
participants were encouraged to reflect on what was happening guidelines interprofessionally. Findings from a previous study
in the learning process. As participants obtained new knowledge revealed that difficulties in team collaboration occurred
 216 J. A. Owen et al. J Interprof Care, 2014; 28(3): 212–217

‘‘when team members acted towards one another as representa- Barr, H., Koppel, I., Reeves, S., Hammick, M., & Freeth, D. (2005).
tives of their professions’’ (Kvarnström, 2008). Noting these Effective interprofessional education: Argument, assumption, and
evidence. Oxford, UK: Blackwell.
changes in the assignment of responsibilities enhanced our
Clark, P. (2006). What would a theory of interprofessional education look
understanding that CIPE has the potential to minimize the like? Some suggestions for developing a theoretical framework for
threat to peoples’ professional identities that naturally occurs teamwork training. Journal of Interprofessional Care, 20, 577–589.
when healthcare professionals work together collaboratively. Clark, P. (2009). Reflecting on reflection in interprofessional education:
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number of participants who completed the second and third Josiah Macy, Jr. Foundation. (2012). Conference on Interprofessional
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Interprofessional Care, 22, 191–203.

nurses; very few professionals from other disciplines were able to Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral
attend. Future programs will explore additional ways of retaining participation. New York, NY: Cambridge University Press.
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Lie, D., Fung, C., Trial, J., & Lohenry, K. (2013). A comparison of two
Concluding comments scales for assessing health professional students’ attitude toward
Knowledge of theoretical foundations for learning enhanced our interprofessional learning. Medical Education Online, 18, 21885.
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Matthews, P. (1999). Workplace learning: Developing an holistic model.
and workplace learning, and the application of explicit theories The Learning Organization, 6, 18–29.
supported the design, implementation, and evaluation of this Merriam, S., & Leahy, B. (2005). Learning transfer: A review of the
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process linked to theory, which in turn suggested a new learning Morton, P. (1999). Using a critical care simulation laboratory to teach
strategy to employ in future CIPE workplace learning programs. students. Critical Care Nurse, 17, 66–68.
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Acknowledgements Journal of Interprofessional Care, 19, 21–38.
Owen, J., Brashers, T., Peterson, C., Blackhall, L., & Erickson, J. (2012).
The authors would like to thank Mandy Lowe, MSc, BScOT, Ivy Collaborative care best practice models: A new educational paradigm
Oandasan, MD, CCFP, MHSc, FCFP, and Belinda Vilhena, MEd, BSc for developing interprofessional educational (IPE) experiences.
who served as the University of Toronto, Centre for IPE, facilitators for Journal of Interprofessional Care, 26, 153–155.
the faculty development program entitled ‘‘Educating Health Parsell, G., & Bligh, J. (1999). The development of a questionnaire to
Professionals for Interprofessional Care’’ (ehpicÔ) and who provided assess the readiness of health care students for interprofessional
feedback on this manuscript. learning (RIPLS). Medical Education, 33, 95–100.
Reeves, S., Suter, E., Goldman, J., Martimianakis, T., Chatalalsingh, C.,
Declaration of interest & Dematteo, D. (2007). A scoping review to identify organizational
and education theories relevant for interprofessional practice and
The authors report no conflict of interest. The authors alone are education. Calgary Health Region. Retrieved from http://www.cihc.ca/
responsible for the writing and content of this paper. This Program was files/publications/ScopingReview_IP_Theories_Dec07.pdf
funded by Pfizer, Inc. Grant ID: 030608. Reeves, S., & Hean, S. (2013). Why we need theory to help us better
understand the nature of interprofessional education, practice and care.
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