Transcript Complexity: A model for interprofessional education with medical and social work students Dr Julia Stroud Principal Lecturer, School of Applied Social Science, Faculty of.

Complexity: A model for
interprofessional education with medical
and social work students
Dr Julia Stroud
Principal Lecturer, School of Applied Social Science, Faculty of Health and
Social Science, University of Brighton
Dr Jim Price
Senior Lecturer, Institute of Post Graduate Medicine, Brighton Sussex
Medical School
Outline
 The practice environment for social workers
and doctors
 Example ...
 Interprofessional education: definition, drivers
and theory
 Complexity theory. Key concepts: relevance
for IPE
 Case study example
The Practice Environment
‘Many of the problems professionals face are neither
predictable nor simple. They are unique and complex.
Arising from environments characterised by turbulence
and uncertainty, complex problems are typically value
laden, open ended and multi-dimensional, ambiguous
and unstable ... Complex problems are not in the book
but in the ‘indeterminate zones of practice’ ...
Furthermore they are not solved once and forever.
They must be continuously managed’.
Klein J.T (2004)
Example …
Climbié Inquiry
 3 Housing authorities
 4 Social Services Departments
 2 Metropolitan Police Child Protection Teams
 1 Specialist NSPCC centre
 2 different hospital admissions with a range of
doctors, nurses and hospital social workers
Example …
 The ward round on the morning of 3rd August was carried out by Dr
A. He noted that Victoria was ‘better’ and ‘medically fit for discharge’.
However, Victoria had yet to provide a satisfactory account of what
had happened to her and he considered that a proper history was still
required.
 Dr A did not take the history himself, apparently because he
thought Nurse T would do so. However, Nurse T said that nobody ever
asked her to take a history from Victoria.
 Dr A considered it was necessary to ensure that it was safe for her
(Victoria) to return home. This would have required some formal
investigation or case conference at which the ‘specific details of further
care were discussed’.
Example …
 Later that morning Ms A the social worker responsible for
Victoria’s care telephoned the hospital and spoke to Nurse Q.
 Their…accounts of the conversation differ in a number of
critical respects.
 Nurse Q said that her conversation with Ms A lasted about 10
minutes, during the course of which she told her all the concerns
of the medical staff felt regarding Victoria.
Example …
 Ms A made a detailed note at the time which said: ‘Hospital
are satisfied with the explanation given by Anna’s mother re.
her burns. Explanation was that Anna, who had been suffering
from scabies had poured hot water from a kettle over her
head. She did this to relieve the itching’.
 Despite considerable contact between the hospital & social
services during the course of the day, little in the way of clear
information demonstrating that Victoria was the victim of
serious physical abuse was provided
Laming (2003) The Victoria Climbié Inquiry. London. HMSO
Interprofessional education: definition used
‘Interprofessional education occurs when two or more
professions learn with, from and about each other to
improve collaboration and the quality of care’
Centre for the Advancement of Inter Professional Education 2002
http://www.caipe.org.uk/
Interprofessional education: purpose
Interprofessional Education is –
‘A patient/ service user centred, team-based
approach that maximises the strengths and
skills of each contributing health and social care
worker, thus increasing the quality of the
patient/ service user’s care’ (CAIPE)
The importance of students developing an
‘interprofessionally informed’ professional identity
 The paradoxical need in training for students to develop
a strong professional identity – with collaborative
attributes
 An ‘interprofessionally informed’ professional discourse
(Whittington 2005)
 Importance of overcoming established and durable
stereotypes of other health and social care professionals
(Hean et al 2006)
 Significance of modelling good collaborative practice in
ipl (Hill, Gray, Stroud et al 2009)
Interprofessional Education and Theory
It is suggested that interprofessional education is undertheorised ...
 That IPE is not undertaken because of, or informed by, theory
in relation to either collaborative practice or learning
 Rather, that IPE is driven by the reality of integrated service
delivery in all arenas in health, social care and education
policy,
AND
 By professional training requirements ...
Interprofessional education: Training
requirements as drivers ...
Social Work
 GSCC Code of Practice (2002) ‘Recognising and respecting the roles
and expertise of workers from other agencies and working in
partnership with them’ (6.7)
 QAA Benchmark for Social Work (2008) ‘act co-operatively with
others, liaising and negotiating across differences such as
organisational and professional boundaries and differences of
identity and language’
 National Occupational Standards for Social Work (2003)
‘Work within multi-disciplinary and multi-organisational teams,
networks and systems’ (Key Role 5: Unit 17)
 DH Requirements for SW Training (2002): Requirement L – Specific
Learning and assessment on ‘Partnership working and information
sharing across professional disciplines and agencies’
Interprofessional education: Training
requirements as drivers ...
Medicine
Currently: GMC (2006) Good Medical Practice
‘Most doctors work in teams with other colleagues’
Doctors must –
(a) respect the skills and contributions of colleagues
and
(b) Communicate effectively with colleagues within
and outside the team
GMC 2006 Para 41
Interprofessional education: Training
requirements as drivers ...
GMC. Tomorrow’s Doctors 2009. A Draft for
Consultation
Outcomes 3 The Doctor as Professional
‘Learn and work effectively within a multi-professional
team’
‘Understand the roles and expertise of health and
social care professionals, in including doctors, in the
contexts of working and learning as a team, as well as
in policy and practice development....’
Recent Key Policy drivers
 Kennedy Report (2001) re. Bristol Royal Infirmary
 Laming Report (2003)re. Victoria Climbié
 2nd Laming Report The Protection of Children in England: A
Progress Report (March 2009)
‘co-operative working is increasingly becoming the normal way of
working. However, good examples of joint working too often rely on
the goodwill of individuals’ (Laming 2009: 36)
 Voices of patients/ service users and their input into health and
social care policies
 Darzi Report (2008) partnerships between NHS and other agencies
– e.g. PCT’s and LA’s re. Preventative strategies for obesity, alcohol,
drug addiction, smoking sexual health, mental health.
Complexity Theory: A Model for
Interprofessional Education
Complexity Theory
Concerns the behaviour of complex systems and
processes. Complex systems contain many discrete
elements which may be similar to each other and which
interact with other elements of the system. From this,
interactions arise, or patterns of order or behaviour
emerge which are not seen in, nor can be understood
from, the individual elements.
Complexity theory: an evolution from
chaos theory
 Chaos is often thought to represent disorder, but new order can be
emerging. ‘Chaos and order are always interconnected’ in any
system (Urry 2003:14)
 Evolution of chaos (or disorder) into a new form of order (self
organisation) is better thought of as complexity
 ‘Complexity theory is the study of complex systems and is
concerned with transformations – positive and negative...it
understands that links between the whole system and its
constituent parts is not easily made’ (Warren Adamson 2009)
 Distinguish complex systems which are irreducible (e.g. weather,
the brain) from complicated ones (e.g. motor car, computer) –
which can be disaggregated and reassembled to the same state
A Complex Adaptive System …
“a collection of individual agents
with freedom to act in ways that
are not always totally predictable,
and whose actions are
interconnected so that the action
of one part changes the context for
other agents”
Zimmerman et al 1998
Complexity theory: some key concepts
‘Complex systems place more importance on the individual
actor and the constant ...feedback between the system and the
individual’ (Haynes 2003: 26)
Emergence
Concept used to describe evolving new and complex
forms of order in systems – as a result of dynamic
feedback between individual actor and organisation
(leads to new form of order)
Attractors (Urry
2003; Byrne 1998)
Rules and logics that create some order and
replication in a system - an ‘attraction’ to order that
give a system elements of stability, despite diversity
and complexity in any one system
Simple rules
Avoid over specification – have simple ‘rules of
engagement’
Close to agreement of
Process
Zone of Complexity
Chaos
Simple
Close to Certainty of Outcome
Far from Certainty
A working definition of
complexity thinking:
‘the study of
learning systems’
Davis et al 2008
Concepts from complexity theory applied to
interprofessional education
Self organisation
Allow students as much space as possible to organise ,
discussions, learning sessions. Facilitators role seen as
creating a space and general rules for engagement for
meaningful interprofessional interaction. Barriers may
emerge in groups and be part of the IPE process
Simple rules
Avoid over specification of learning outcomes: have
simple guidelines . Relevance of PBL. Overt
acknowledgment of stereotypes, power differentials
Non linear and
transformative
learning
Allow for and encourage ‘teachable’ moments,
significant events
Emergence
IPE is evolving and ever changing. Small inputs may
have significant effects. If things do not go well it offers
learning
IPE Case study: Year 1, Term 1 Medical and Social Work Students
Case Study
Lisa is 22 years old. She has never known her father and her mother died in a car crash, which she
survived, when she was 6 years of age. She was then cared for by her aunt, who supported her
when she was diagnosed with diabetes aged 9 years: Lisa is insulin dependent.
From age of 13 years Lisa was in the care of a Local Authority, as her aunt, to whom she was
deeply attached, died of a heart attack. Lisa had many different placements with foster parents
and in Children’s Homes while in care. She presented then, and continues to present, as deeply
troubled, frequently cutting her arms to the extent that suturing is necessary. Lisa neglects her
diabetes and often doesn’t take her insulin. She has been treated in A&E for alcohol poisoning
and drug overdoses. Lisa left school at 16 years; she had some short-lived temporary jobs, but
says she sells sex for money.
Lisa in now 30 weeks pregnant: her pregnancy wasn’t planned and she does not know who the
father is. Lisa has a changing and ambivalent attitude to her pregnancy. She has continued to cut
her arms and has been treated for one overdose since becoming pregnant. In the last few weeks
she has engaged more with services. Since the overdose she has seen a psychiatrist and
described how she has wanted to die since her aunt died and how she doesn’t take insulin to
punish herself for being so unlovable. She has attended the diabetic clinic because of trouble with
her vision, linked to the neglect of her diabetes.
Over the last month she has, for the first time, kept her appointments at the ante-natal clinic, but
the midwife is concerned about whether Lisa will provide consistent, stable care for, and
safeguard, her baby – and indeed herself, and has referred her to Social Services.
IPL Case study: Year 1, Term 1 Medical and Social Work Students
SMALL GROUP TASKS
In small mixed professional groups please consider your responses to the following questions:
Having read the case study carefully, please discuss and identify:
1.
What factors in the case do you think DOCTORS should be concerned with?
What factors should SOCIAL WORKERS be concerned with?
2.
What BENEFITS are there in professions working together support Lisa?
What DIFFICULTIES might there be?
3.
What SKILLS will be necessary for successful work for other professions?
FINALLY…
How do you think Lisa might FEEL meeting the professionals involved?
Please identify THREE things you have learnt from this morning and doing this exercise together
PLEASE NOMINATE ONE MEMBER OF YOUR SMALL GROUP TO FEED BACK TO THE WHOLE
GROUP
And some comments on the learning ...
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Learnt more about the role of a social worker
Importance of negotiating
Respecting difference of opinion
Good communication
Holistic approach to care and support
Bio-psychosocial concerns – but with different emphasis
Factors that doctors and social workers look at overlap
Team work important to meet needs
Diverse range of responsibilities social workers have
All professionals and specialities are important
Respect for others roles
Being clear about each other’s roles and responsibilities
For social workers to be concerned about the doctor’s concerns and vice versa
Being alert to potential for duplication and omissions in interprofessional
teams
 Working together and appreciate each other’s views and priorities
 Each professional may have different parts of the story
 All essentially have the same concern
References
Byrne D. (1998) Complexity Theory and the Social Sciences. An Introduction. London: Routledge.
Davis B., Sumara D. and Luce-Kapler R. (2008) Engaging Minds: Changing Teaching in Complex Times. New York:
Routledge.
Hean S. et al (2006) ‘Will opposites attract? Similarities and difference in students perceptions of the stereotype
profiles of other health and social care professional groups’. Journal of Interprofessional Care. 20(2) pp162-182
Hill L., Gray R., Stroud J. and Chiripanyanga S. (2009) ‘Interprofessional learning to prepare medical and social work
students for practice with refugees and asylum seekers’. Social Work Education. 28 (3) pp.298-308
Klein J.T (2004) ‘Interdisciplinarity and complexity: An evolving relationship’. Complexity, Emergence and
Organization. 6:1-2, pp.2-10
Laming (2003) The Victoria Climbié Inquiry. London. HMSO
Urry J. (2003) Global Complexity. Cambridge: Polity Press
Warren Adamson C. (2009) ‘Collaborative practice and its complexity’. In , Ruch G. (Ed.) Post qualifying Child Care
Social Work. Developing Refelcive Practice. London: Sage.
Whittington C (2005) ‘Interprofessional education and Identity ‘. In, Colyer H. et al (Eds). The Theory-Practice
Relationship in Interprofessional Education. Health Academy Occasional Paper No.7. November 2005.
http://www.health.heacademy.ac.uk/publications/occasionalpaper/occp7.pdf
Zimmerman B., Lindberg C. and Plsek P. (1998) Edgware. VHA Inc. Irving,Texas