Limitations and Weaknesses of Research Design

Staying focused on a wealth of data. As a research analyzing a very complex, very dynamic phenomenon of great importance for society, this research was crafted as a delicate balance between two opposites: (1) insight to just a fraction of data and (2) too much data to analyze. While, from my perspective, the balance seems to be well established, from the perspective of other stakeholders, a different balance may seem more suitable. Combining the outcomes of this research with the results of similar research, especially similar future research, is probably the best approach to address this limitation.

Bias. As a phenomenographic researcher working for the ASA, there is a risk that my personal or ASA bias might influence the research. Since per social constructivism, perceived reality is a social construct that exists on an individual and group/organizational level, my goal is to recognize how my and the ASA’s realities look and how the two realities compare with the realities of other individuals and organizations involved in this research. Ultimately, the goal is not to neutralize them but to recognize and combine them with the realities of other stakeholders.

The main steps to address bias are the following:

• Actively hold back my assumptions and theories that I would get a better insight into how the phenomenon is understood by respondents (Sandbergh, 1997) without the influence of personal perspectives, material world, and subjects (Chan, Fung, & Chien, 2013).
• Use phenomenographic research to gather insight into the realities of other stakeholders and, through follow-up interviews, ask them to evaluate how I interpreted their reality.
• Share a part of my findings with selected leaders and the public and ask them for feedback.

The data from those four clinical professions will allow me to define the main themes and interactions among different professions while remaining focused and on scope; however, insight from other professions will be very valuable. Therefore, future research should include perspectives from the following:

• Other clinical groups involved in care, such as operating room nurses, surgical technicians, pharmacists, and nonclinical professions like IT and management
• Students—future professionals and residents

References

Chan, Z. C., Fung, Y.-l., & Chien, W.-t. (2013). Bracketing in phenomenology: only undertaken in the data collection and analysis process? The Qualitative Report, 18(30).

Sandbergh, J. (1997). Are phenomenographic results reliable? Higher Education Research & Development, 16(2), 203-212.

Literature review: Theories behind IPL and QIE

There are a number of theories that can be used to define and analyze IPL (Hean, Craddock, Hammick, & Hammick, 2012) and QIE. The approach to theory in papers on QIE/IPL has evolved from not using any theory at all, to using multiple theories to explain the concept. However, that progression has been very gradual. Even today, significant numbers of CME/CPD papers do not reference theory (Curtis A. Olson, 2013). QIE/IPL papers, as a subset of that group, follow the same trend.

As described below, in most cases, a specific theory can describe just part of the process. Therefore we have to combine theories. Relevant theories can be categorized primarily as theories that explain QIE/IPL educational process, and theories that describe interprofessional QI practices. A secondary level of classification, mainly based on historical divisions, are theories related to QIE and theories related to IPL.

QI theory. The value and function of theory in healthcare quality improvement has been seriously neglected (Davidoff, Dixon-Woods, Leviton, & Michie, 2015). At the same time, factors influencing sustainability of QI interventions have been poorly understood (Hovlid, Bukve, Haug, Aslaksen, & von Plessen, 2012). That is a huge issue – very often causing QI interventions to fail. Following such QI intervention, returning to old underperforming work practices is a significant waste of resources and, in the long run, can fuel resistance to future/better QI initiatives. Therefore, more vigorous and better-informed use of theory is essential to strengthen QIE/IPL programs, ensure vaid assessment of their impact, and promote their sustainability and generalizability of outcomes (Davies, Walker, & Grimshaw, 2010).

Role of theory. Unfortunately, theory is usually perceived as something mystical and impractical; something even quality professionals do not want deal with. That contradicts practice needs. Theory or “the reasons why things are happening” is intimately integrated into almost all of our activities. Theories may be formal or informal, public and shared, or private. Yet theories drive our decisions and shape our impact (Hean et al., 2012). Whether the theory says: “This is how it has been always done – and therefore we should not change it,” whether it is an informal experience-based theory used by a small team, or it is an official, publicly developed theory, it will have an impact on our activities (Tilly, 2006). The question is not: Are we using theory? We know we are. We should ask: Are we aware of that theory, how good is it, and is it the right theory?

Practice shows that when we lose sight of the importance of theory, bad things happen. A weak hypothesis or even just a hunch, biased and limited in scope (Kahneman, 2011), can be used to drive our actions, often with negative results. Lack of a theoretical background is a common reason why QI and patient-safety interventions in healthcare often result in limited positive changes or no relevant changes at all (Shojania & Grimshaw, 2005). If the intervention proves to be successful, but lacks a sound theoretical basis, it is usually hard to make it permanent and generalize it in other contexts (Dixon-Woods, Leslie, Tarrant, & Bion, 2013).

The literature provides a variety of theories that may foster sustainable QI change. That variety ranges from a big set of learning theories and change agent theories, to organizational change and economic theories. Shojania, McDonald, Wachter, and Owens (2004) argue that it may be challenging to develop interventions based only on one of those theories. Effective QI strategy can be developed more easily when theory and implementation are tested simultaneously. As a manual to help users navigate through that process, Kaplan, Provost, Froehle, and Margolis (2012) developed Model for Understanding Success in Quality (MUSIQ). The model describes 25 contextual factors that may influence success of QI projects. It serves as a checklist of elements that should be included in a QI theoretical plan.

IPL. In the early days of IPL research, a significant number of papers were very pragmatic and didn’t describe a theoretical background. Many later papers grounded IPL research in a single theory – usually related to a specific school of thought and academic discipline (Barr, 2013). Today, a growing number of papers build a sound, flexible and inclusive IPL framework by combining multiple theories and practices. As a result, Hean, Craddock, and O’Halloran (2009) argue that a large number of theories currently used to describe IPL have created a hard-to-navigate quantifier.

Social theories (social constructivism, social capital) (Hean et al., 2012), adult learning (P. G. Clark, 2006), identity theories, situated learning (Ranmuthugala et al., 2011; Wenger, 1998, 1999) and networked learning (Dev & Heinrichs, 2008) are the main theories relevant to QIE/IPL learning processes. On the other hand, the theories most relevant to QIE/IPL context are sociology of professions, organizational theory and activity theory. They present a compelling example of how different theories complement each other. For example, Larson (1979) argues that professional guilds are actively engaged in monopolizing knowledge in specific areas, to ensure cognitive exclusivity. That may explain why, despite learning organization (Roberts & Thomson, 1994; Senge, 2006) being a very popular theory concept (Barr, 2013), it is especially hard to achieve it among different professional organizations and patients. Fortunately, activity theory allows us to analyze organizations as “distributed, decentered and emergent systems of knowledge” (Blackler, Crump, & McDonald, 2000, p. 278); it provides insight into connections between activities and context and reasoning behind complex social activities.

The connected, networked nature of modern life and work is at the heart of learning as a social activity, and knowledge as a social construct. (Hean et al., 2009) Therefore, to fully understand learning, we have to analyze curricula through a social theoretical lens. Only through that lens will we be able to comprehend how organizations, professional societies, professional regulations, education providers and communities of learners shape the knowledge development process.

Social capital theories are focused on the benefits individuals and society can achieve by being part of and nurturing a social network. They suggest the equilibrium concept (Boix & Posner, 1998). Social capital will increase through repeated cooperation and collaboration. In return, strong social capital will boost social collaboration and the happiness of individuals. Research of Leung, Kier, Fung, Fung, and Sproule (2013) showed that social capital is one of the major cornerstones of happiness. In the healthcare field, social capital is popular due to the known relationship between social capital (strong social network) and health benefits. Ultimately, social capital, happiness and collaborative behaviors can significantly improve tacit and explicit knowledge-sharing among employees – creating a basis for a productive learning organization (Hau, Kim, Lee, & Kim, 2013). Therefore social capital theory can be used to describe benefits of interprofessional, networked learning, and guide us to maximize benefits from that learning model.

Adult learning theories are often described as a cornerstone of successful QIE/IPL. They provide a toolset or learning modalities that motivate students as individuals and groups to activate existing knowledge and use it as a platform to develop new knowledge. In that context they can be viewed as an extension of constructivist learning theories.

Networked learning theory uses connections between students, students and teachers, and between student resources and tools to create a framework where students (working professionals) as individuals and groups have access to all elements needed for successful continuous professional development. It created a framework that connects CME/CPD providers and the professional learning community (Jackson & Temperley, 2007). Whether they need access to content, expertise, QI tools or peer moral support, students will be helped by networked learning principles. With that, students can combine real world context and highly integrative learning activites to address complex situated problems (G. Campbell, 2016).

Community of practice, as situated learning theory, can explain many benefits professional societies provide to their members (Webster-Wright, 2009). The society and profession acts as a community of practice; a community of professionals that jointly work together to improve practice in a specific domain (health, nursing, surgery) (Simons & Ruijters, 2004). There is potential to further support that community with social media .

Each mentioned theory deserves detailed description, which is out of scope of this literature review.

What we can notice from the aforementioned brief descriptions is that there is lot of overlapping between theories and that theories often complement each other (Hean et al., 2012).  For example, networked learning will benefit if social capital is strong, and social capital can be further enhanced with properly designed networked activities. Adult learning in the QIE/IPL context will also be enhanced if social capital is strong and the proper networked practices are in place. Ultimately, community of practice can benefit from all aforementioned theories – and create a framework where they can be better implemented.

Activity theory, being a macro theory, will be discussed last as a separate example. A macro theory can be used as a descriptive framework taking into account all elements of a complex healthcare activity system. Examples of an activity system include a perioperative surgical home team or an organization such as the ASA. Therefore, activity theory can serve as a lens to analyze human activities in such a complex and dynamic system. The third generation of activity theory is specifically interesting for this research because it is focused on how different activity systems interact (Engeström, 2001). Each profession (anesthesiologists, nurse anesthetists, surgeons, etc.) and patients or the public can be analyzed as a separate activity system. The third generation of activity theory can help us understand how those systems interact during preparation for implementation of QIE/IPL activities. A small detail that confirms the suitability of activity theory is that in the paper introducing the third generation of activity theory, (Engeström, 2001) uses interaction among healthcare activity systems (hospital, patient’s family) as the main examples.

Figure 8. Two interacting activity systems are the minimal model for the third generation of activity theory (Source: Engeström, 2001). Each profession can be analyzed as a separate activity system. Outcomes (Object₂) of each profession interact creating outcome of collaboration – Object₃.

References

• Barr, H. (2013). Toward a theoretical framework for interprofessional education. Journal of interprofessional care, 27(1), 4-9. doi:10.3109/13561820.2012.698328
• Blackler, F., Crump, N., & McDonald, S. (2000). Organizing processes in complex activity networks. Organization, 7(2), 277-300.
• Boix, C., & Posner, D. N. (1998). Social capital: Explaining its origins and effects on government performance. British journal of political science, 28(04), 686-693.
• Campbell, G. (2016). Networked learning as experiential learning. Educause Review, Vol. 51 No., 50(1, January 11), 1.
• Clark, P. G. (2006). What would a theory of interprofessional education look like? Some suggestions for developing a theoretical framework for teamwork training 1. Journal of interprofessional care, 20(6), 577-589.
• Davidoff, F., Dixon-Woods, M., Leviton, L., & Michie, S. (2015). Demystifying theory and its use in improvement. BMJ quality & safety, bmjqs-2014-003627.
• Davies, P., Walker, A. E., & Grimshaw, J. M. (2010). A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implement Sci, 5(14), 5908-5905.
• Dev, P., & Heinrichs, W. L. (2008). Learning medicine through collaboration and action: collaborative, experiential, networked learning environments. Virtual reality, 12(4), 215-234.
• Dixon-Woods, M., Leslie, M., Tarrant, C., & Bion, J. (2013). Explaining Matching Michigan: an ethnographic study of a patient safety program. Implementation Science : IS, 8, 70-70. doi:10.1186/1748-5908-8-70
• Engeström, Y. (2001). Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of education and work, 14(1), 133-156.
• Hau, Y. S., Kim, B., Lee, H., & Kim, Y.-G. (2013). The effects of individual motivations and social capital on employees’ tacit and explicit knowledge sharing intentions. International Journal of Information Management, 33(2), 356-366.
• Hean, S., Craddock, D., Hammick, M., & Hammick, M. (2012). Theoretical insights into interprofessional education: AMEE Guide No. 62. Medical teacher, 34(2), e78-e101.
• Hean, S., Craddock, D., & O’Halloran, C. (2009). Learning theories and interprofessional education: A user’s guide. Learning in Health and Social Care, 8(4), 250-262.
• Hovlid, E., Bukve, O., Haug, K., Aslaksen, A. B., & von Plessen, C. (2012). Sustainability of healthcare improvement: what can we learn from learning theory? BMC Health Services Research, 12(1), 235.
• Jackson, D., & Temperley, J. (2007). From professional learning community to networked learning community. In K. S. L. Louise Stoll (Ed.), Professional learning communities: Divergence, depth and dilemmas (pp. 45-62). UK: McGraw-Hill Education.
• Kahneman, D. (2011). Thinking, fast and slow. Farrar, Sraus and Giroux, 18 West  18th Street, New York, USA.: Macmillan.
• Kaplan, H. C., Provost, L. P., Froehle, C. M., & Margolis, P. A. (2012). The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ quality & safety, 21(1), 13-20.
• Larson, M. S. (1979). The rise of professionalism: A sociological analysis (Vol. 233). USA: Univ. of California Press.
• Leung, A., Kier, C., Fung, T., Fung, L., & Sproule, R. (2013). Searching for happiness: The importance of social capital The exploration of happiness (pp. 247-267): Springer.
• Olson, C. A. (2013). Reflections on Using Theory in Research on Continuing Education in the Health Professions. Journal of Continuing Education in the Health Professions, 33(3), 151-152. doi:10.1002/chp.21178
• Ranmuthugala, G., Plumb, J., Cunningham, F., Georgiou, A., Westbrook, J., & Braithwaite, J. (2011). How and why are communities of practice established in the healthcare sector? A systematic review of the literature. BMC Health Services Research, 11(1), 273.
• Roberts, C., & Thomson, S. B. (1994). Our Quality Program Isn’t Working. In P. M. Senge (Ed.), The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. USA: Doubleday.
• Senge, P. M. (2006). The Fifth Discipline: The Art & Practice of the Learning Organization. USA: Doubleday.
• Shojania, K. G., & Grimshaw, J. M. (2005). Evidence-based quality improvement: The state of the science. Health Affairs, 24(1), 138-150.
• Shojania, K. G., McDonald, K. M., Wachter, R. M., & Owens, D. K. (2004). Toward a Theoretic Basis for Quality Improvement Interventions. Retrieved from
• Simons, P. R.-J., & Ruijters, M. C. (2004). Learning professionals: towards an integrated model Professional learning: Gaps and transitions on the way from novice to expert (pp. 207-229): Springer.
• Tilly, C. (2006). Why?:[what happens when people give reasons… and why]. Princeton, New Jersey, US: Princeton University Press.
• Webster-Wright, A. (2009). Reframing professional development through understanding authentic professional learning. Review of Educational Research, 79(2), 702-739.
• Wenger, E. (1998). Communities of Practice: Learning, Meaning, and Identity. Cambridge: Cambridge University Press.
• Wenger, E. (1999). Learning as social participation. Knowledge Management Review, 1(6), 30-33. Retrieved from https://modules.lancs.ac.uk/pluginfile.php/210525/mod_page/content/37/W3_Wenger%281999%29.pdf

Methodology

The social constructivist worldview allows me to focus “on the participants’ views of the situation being studied” Creswell (2009). It suggests open-ended questioning to find what people think or do in their daily lives. A phenomenographic approach is a good tool for that task – providing insight into the more subjective side of the world.

On the other hand, although IPL and QIE have become quite well-known concepts, most interviewees haven’t had a chance to practice it. They haven’t experienced it as something real and objective. To better understand objective aspects of the phenomenon, case study focused on how their professions and their professional associations are tackling that issue may be needed.

Methodology is the systematic, theoretical analysis of the methods applied to a field of study.

Case study

Therefore, the methodology of choice will be a qualitative, interpretive multiple-case case study (Yin, 2003) that encompasses phenomenographic analysis. Activity theory will be used as a lens to analyze interrelations among multiple elements in this system.

QIE/IPL-related practices and learning technology that can support QIE/IPL used by each profession will be analyzed as an independent case. The four cases are:

• ASA,
• American Association of Nurse Anesthetists (AANA),
• American College of Surgeons (ACS), and
• American Academy of Physician Assistants (AAPA).

An alternative solution was to use single-case with embedded multiple units of analysis. That approach would be appropriate if we had collaboration and shared programs among two or more of the specialties in place. In that situation the case would be shared QIE/IPL-related practices and learning technology that can support QIE/IPL of all professions together. Activities specific to each profession would be embedded units of analysis.

Since at this time I’m not aware of any collaboration on QIE/IPL, QIE/IPL activities in each specialty should be analyzed as separate entities.

Case study data sources will be interviews with staff and physician members, the website of a professional association, and literature published by a professional association. Two interviews (non-phenomenographic) and one site visit/meeting will be scheduled with representatives of each profession. Phenomenographic interviews will also serve as a source of data over and above standard phenomenographic research.

Phenomenographic analysis

Phenomenographic analysis focused on how CPD professionals, clinicians (anesthesiologists, nurse anesthetists, surgeons and anesthesiologist assistants) and their respective leaders perceive QIE/IPL and technology that supports those practices will be the central part of the case study. Phenomenography appears to be the optimal method for this approach, because at this point QIE/IPL is in its early stage and human perceptions are the dominant factor. Additional reasons are:

1. Attempts to implement QIE/IPL in the U.S. healthcare system have a long but troubling history, and drivers influencing implementation of QIE/IPL create a very complex picture. The phenomenographic approach is recognized as a good tool to analyze changes in such a complex system (Bunniss & Kelly, 2010; Stenfors‐Hayes, Hult, & Dahlgren, 2013).
2. Understanding the perceptions of groups involved in the learning and teaching process can enable us to address current and emerging challenges in that dynamic environment (Richardson, 2005).
3. QIE/IPL is ultimately a social endeavor.

During the past two decades, phenomenography proved to be very useful in medical education (Stenfors‐Hayes et al., 2013). It provides insight into the different ways that people perceive phenomena in the world around them and how those perceptions relate one to another (Marton, 1981; Marton & Booth, 1997). Therefore, it can serve as a lens to analyze a specific research question and direct how research is carried out. In a medical setting, phenomenographic research is valuable for topics like clinical practice, communication and healthcare learning, and, especially, the processes and outcomes of learning (Larsson & Holmström, 2007; Richardson, 1999). According to Stenfors‐Hayes et al. (2013), phenomenography can serve as a link between three important elements this research is tackling: research, organizational change and educational development. That feature can be especially valuable in the context where, as the Macy (2013) expert team concluded, huge changes affecting the U.S. medical system are not linked effectively with changes affecting CPD of healthcare professionals in the U.S.

Phenomenography was chosen over phenomenology because QIE/IPL is in this context an emerging concept. Therefore, we can expect numerous ways in which QIE/IPL is perceived (Larsson & Holmström, 2007).

Activity theory

The third element of the research framework is activity theory: a descriptive framework taking into account all elements of a complex activity/work system. Examples of such an activity system may be teams like a perioperative surgical home team or organizations such as the ASA. Therefore, activity theory can serve as a lens to analyze human activities in such a complex and dynamic system. The third generation of activity theory is specifically interesting for this research because it is focused on how different activity systems interact (Engeström, 2001). Each profession (anesthesiologists, nurse anesthetists, surgeons, etc.) and patients or the public can be analyzed as a separate activity system. The third generation of activity theory can help us understand how those systems interact during preparation for implementation of QIE/IPL activities. A small detail that confirms the suitability of activity theory is that in the paper introducing the third generation of activity theory, (Engeström, 2001) uses interaction among healthcare activity systems (hospital, patient’s family) as the main example.

Figure 4. Two interacting activity systems are the minimal model for the third generation of activity theory (Source: Engeström, 2001). Each profession can be analyzed as a separate activity system. Outcomes (Object₂) of each profession interact creating outcome of collaboration – Object₃.

Resources

• Bunniss, S., & Kelly, D. R. (2010). Research paradigms in medical education research. Medical Education, 44(4), 358-366.
• Creswell, J. W. (2009). Research design: Qualitative, Quantitative, and mixed methods approaches. London: SAGE.
• Engeström, Y. (2001). Expansive learning at work: Toward an activity theoretical reconceptualization. Journal of education and work, 14(1), 133-156.
• Larsson, J., & Holmström, I. (2007). Phenomenographic or phenomenological analysis: Does it matter? Examples from a study on anaesthesiologists’ work. International Journal On Qualitative Studies On Health And Well-being, 2(1), 55-64. doi:10.1080/17482620601068105
• Macy, Josiah Macy Jr. Foundation. (2013). Transforming Patient Care:  Aligning Interprofessional Education with Clinical Practice Redesign. Paper presented at the Macy Conference on Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign, January 2013.
• Marton, F. (1981). Phenomenography — describing conceptions of the world around us. Instructional science, 10(2), 177-200.
• Marton, F., & Booth, S. (1997). Learning and awareness. Mahwah, NJ, US: Lawrence Erlbaum Associates, Publishers.
• Richardson, J. T. E. (1999). The concepts and methods of phenomenographic research. Review of Educational Research, 69(1), 53-82.
• Richardson, J. T. E. (2005). Students’ approaches to learning and teachers’ approaches to teaching in higher education. Educational Psychology, 25(6), 673-680.
• Stenfors‐Hayes, T., Hult, H., & Dahlgren, M. A. (2013). A phenomenographic approach to research in medical education. Medical Education, 47(3), 261-270.
• Yin, R. K. (2003). Designing case studies. In R. K. Yin (Ed.), Case study research: design and method (pp. 19-56). London: Sage.

Literature review

Evolution

Distance learning of the U.S. healthcare workforce has a long history, starting with correspondence education in the 1960s (Josseran & Chaperon, 2001). Some popular correspondence programs, such as Refresher Courses in Anesthesiology, were initiated in the early 1970s (ASA, 1973).

Online has become the dominant way of delivering CPD. Five years ago, Harris, Sklar, Amend, and Novalis‐Marine (2010) predicted that “online CPD is likely to be 50% of all CPD consumed within 7-10 years.” Four years later, in 2014, all education delivered by the American Society of Anesthesiologists (ASA) is online or enhanced by online formatting. On the other hand, it has been known for a long time that online CPD programs are as effective as traditional CPD programs (Wutoh, Boren, & Balas, 2004).  Consequently 97% of physicians expect more online CPD in the future (archemedx.com, 2013).

Historically, the focus of CPD was primarily on content transmission. More recently, strong societal forces are converging focus shift toward behavior changing learning activities with impact on patient population (Moore, Green, & Gallis, 2009; Russell, Maher, Prochaska, & Johnson, 2012). We can also notice a shift of focus from individuals towards to CPD of groups and organizations (Webster-Wright, 2009).

Five generations of distance education, as described by (Taylor, 2001) and later elaborated on by (Bates, 2008), can categorize the evolution of CPD as provided by the ASA.

1. The Correspondence Model, based on print technology, is losing its share and is enhanced with online delivery. However, it still plays a significant part. In 2014, approximately 30% of CPD credits claimed by ASA users was done through that model.
2. The Multi-media Model – delivery of multimedia content on print, digital storage devices (CD/DVD, flash memory), or through the Internet, but without any communication among humans. It is well-suited for industrial mass production. It is the dominant method of delivery, with around 68% of credit hours delivered in this format.
3. The Telelearning Model delivers synchronous communication, such as webinars, and is used quite rarely in CPD. There were no CPD credits awarded by ASA this year through this model.
4. The Flexible Learning Model is based on asynchronous online communication (Bates, 2008). In the U.S., CPD context it is very rarely used. The current LMS used by the ASA does not provide support for it.
5. The Intelligent Flexible Learning model will become possible after implementation of the new LMS. It builds on the functionality of the Flexible Learning Model. Some of the additions are: easy access to institutional guidelines and resources; computer-mediated communication; user- generated content; and peer assessment. The system will be integrated with the Anesthesia Quality Institute clinical outcomes tracking system(Dutton, 2014), allowing individuals and groups to assess and reflect on their clinical performance and create improvement and learning plans. The system will also deliver a business intelligence layer that suggests learning based on users’ clinical performance, and performance in courses and certification status.

Specific learning theories are associated with each of those generations. Generations 1 and 2 are associated primarily with behaviorism and cognitivism (Bates, 2008). A majority of CPD is delivered through the first two generations of distance education. Generation 3 is not popular anymore and instead of implementing generation 4 the ambition is to go straight to generation 5. Simultaneously, generation 5 utilizes constructivist approaches like collaborative learning, knowledge construction, communities of practice and self-directed learners (Peters, 2002). Between the first two generations and the fifth generation we have significant technological, theoretical and cultural differences. As described below, the U.S. healthcare reform and recently adopted educational technology solutions will enable those changes to happen in the form of IPL and QIE. However, the technology is just one element in that formula. This research will contribute to those efforts by providing insight into human perceptions of QIE and IPL, and technology enhanced learning solutions available to perioperative care teams.

Definitions

IPL is a situation “when two or more professions learn with, from and about each other to improve collaboration and the quality of care” (CAIPE, 2002).
QIE is a system-wide educational framework focused on three goals: better care, better health and reduced-cost patient care (Batalden & Davidoff, 2007). Its holistic system design approach tackles all potential barriers for quality improvement (QI), attempting to make permanent system-wide changes. In that context, QI is coordinated with the continuous efforts of all stakeholders – healthcare professionals, patients, researchers, educators and the public – toward better patient outcomes, better system performance and better professional development.

QIE roadmap

The Alliance for Continuing Education in the Health Professions (ACEHP) in 2015 launched the QIE roadmap (Figure 2). As Figure 2 illustrates, QIE by ACEHP is a continuation of the gradual evolution of CPD from didactic lectures to practice-based activities with real impact on clinical performance. It assumes incorporation and integration of education professionals, tools, resources and methods into system-wide QI efforts. Since successful QIE changes are usually system-wide, and involve multiple professions, the QIE roadmap presented below (Diamond, Kues, & Sulkes, 2015) predicts the currently siloed education of healthcare professionals will evolve in interprofessional education during next 10-to-15-years.

Figure 2. Alliance QIE Initiative: A Transformation Shift – toward interprofessional team-based QIE (Source: Diamond et al., 2015)

QIE and IPL

Knowing that the traditional CPD has limited impact on quality of care (Hager, Russell, Fletcher, & Macy Jr, 2008; IoM, 2010; Macy, 2013), it is fair to say that IPL and QIE have different learning formats and different goals than traditional CPD.

QIE and IPL have numerous similarities. They assume that the best way to ensure individual and system- wide professional development and QI is to have a well-integrated and coordinated system (Shortell, Bennett, & Byck, 1998), where healthcare workers from all professions are connected and focused on meeting the needs of individuals and communities (Macy, 2013). They are each individually described as great tools to address the same three goals: better care, better health and reduced cost (Batalden & Davidoff, 2007; IoM & 2013). Finally, WHO (2010) presented IPL as an important prerequisite for a high-performing collaborative practice and continuous quality improvement. Therefore, QIE and IPL can be viewed as two different entry/view points of the same system-wide QI system (learning/networked health system) – as Figure 3 illustrates. IPL will start with creation of a skilled, collaborative, practice-ready workforce that can practice quality improvement and deliver optimal health services. On the other hand, QIE will start with system changes that require the collaborative practice-ready workforce IPL can produce. Ultimately, they should be treated as two related parts of the same system. Further on, I will refer to them as QIE/IPL.

Figure 3. IPL and QIE entry point or lenses into Health and Learning Health Systems. Left lens is more focused on IPL. Right lens is more focused on QIE. Together they provide the full picture (Adopted from: WHO, 2010, p. 9).

Need

Healthcare is a team sport (Salas, DiazGranados, Weaver, & King, 2008). Healthcare professionals participate in it daily, and each one of us as patients participates in important healthcare events at least a few times in our lives. However, it is a very dangerous team sport. No other team sport has a greater potential for fatal outcomes. For example, the Institute of Medicine concluded that between 44,000 and 98,000 Americans die each year as a result of medical errors (IoM & 2001). Yet healthcare practitioners in the U.S. are rarely trained as a team and they have limited insight into QI methodology (Starr et al., 2015) .

Political-economic drivers

Strong political-economic and social factors shape CPD of healthcare professionals in the U.S. (Balmer, 2013; Cervero & Moore Jr., 2011) and have obstructed interprofessional learning for decades (Hayes, 2012). As history shows, those factors (pay-for service, siloed guilds or accreditation systems, for example) may have a stronger impact than professional and educational factors.

This research will be done in the context of the perioperative care team (surgery and anesthesia professionals). The literature suggests that due to rivalry between professionals or specialties, learning and change in networked practices may be difficult (Norman, 2013). That may be very noticeable in this context where one very relevant issue is a long, intense and passionate debate between physician anesthesiologists and nurse anesthetists over nurse scope of practice (Hayes, 2012). In addition to the main factor – patient safety – nurse scope of practice directly influences positions and payment of physician anesthesiologists and nurse anesthetists, making it a strong political-economic factor (with a huge impact on social capital). For example, in a recent article Johnstone (2015) showed that, in addition to high membership fees ($665), one of the main reasons cited by anesthesiologists for not joining the ASA was related to the ASA’s policy toward Nurse Anesthetists (NAs). It is interesting that while some non-member anesthesiologists think the ASA is working too closely with NAs, others think it is not working closely enough.

On the other hand, new political-economic and social factors started changing that power dynamic recently. Rising costs of U.S. healthcare-associated quality and patient safety issues (Berwick & Hackbarth, 2012; Davis, Stremikis, Schoen, & Squires, 2014) have triggered massive changes in the U.S. healthcare system. IPL is recognized as an important tool to improve performance of U.S. healthcare teams and address the changes that the U.S. healthcare system and the CPD system are undergoing (IoM, 2010; Macy, 2013; WHO, 2010).

Clinical microsystems

One important feature of the current healthcare reform is focus on development and performance of clinical microsystems. Clinical microsystems are small, interdependent groups of healthcare professionals who work collaboratively to deliver optimal and comprehensive healthcare for specific groups of patients (Batalden, Nelson, Edwards, Godfrey, & Mohr, 2003). Clinical microsystems are made up of groups that participate in immediate delivery of care and interact directly with patients, such as physicians, nurses or pharmacists, and groups that support the microsystem, like laboratory, IT and leadership professionals.
Communities of practice can be an important tool to improve performance of microsystems (Webster-Wright, 2009; Wenger, 2006). It is a very flexible tool and depending on purpose, communication methods an structure, they can vary significantly (Ranmuthugala et al., 2011). Results of this research may contribute toward better utilization of technology enhanced CoP methodology in this specific context.

Selected professions

Perioperative surgical home (PSH), a clinical microsystem focused on delivery of perioperative care – from the decision for surgery to complete recovery (ASAHQ.org, 2014) – is the context of this study. The four professions participating in PSH involved in this research will be: physician anesthesiologists, surgeons, nurse anesthetists and anesthesiologist assistants. Those professions were selected because:

• Clinicians are the main stakeholders in the healthcare microsystems and their interactions and professional cultures greatly shape how teams work and the quality of service they deliver (Macy, 2013)
• There is a specific political-economic dynamic between these professions mainly focused on questions of who will lead the PSH team and the role of each profession in that team (Hayes, 2012).
• For the scope of this research, it was important to limit the number of professions involved.

Maintenance of Board Certification – Another political-economic factor

Turbulent changes that affect Maintenance of Board Certification (MOC) of physicians in the U.S. may significantly influence context and implementation of QIE/IPL. Current MOC practices are mainly developed around multiple-choice questions and credit hours. Criticism toward them has been building during the past few years (Gray et al., 2014; Kempen, 2012, 2014; O’Gara & Oetgen, 2014; Strasburger, 2011). In 2014, the Association of American Physicians and Surgeons took the American Board of Medical Specialties and MOC to court, claiming that MOC “imposes enormous ‘recertification’ burdens on physicians, which are not justified by any significant improvements in patient care” (AAPS, 2014). The beginning of 2015 was marked by a nation-wide revolt against MOC. Significant amounts of criticism were supported with the current educational theory and online learning formats that QIE/IPL will promote. As a result, majority of the boards are reorganizing their MOC programs (Baron, 2015).

Organizational and technological context

Thus far, a majority of CPD providers rely on LMS (if they use LMS), which has limited functionality. Such LMS systems are built around a combination of SCORM + files + quiz + survey + certificates, and usually are completely lacking in support for collaborative education. They can address needs of content-focused education, but can’t address needs of collaborative or networked learning. The ASA’s leadership has recognized that and at this moment the ASA is in the process of implementing a new Moodle-based LMS – Totara. Totara comes with all the collaborative features of Moodle. Therefore, it will be a big change. In addition, Totara provides strong support for learning plans and organizational structure/hierarchies.[1] Through the Totara hierarchies’ framework, the ASA can assign specific competencies and courses to specific roles in a team/organization. That feature may enable the ASA to deliver programs for multiprofessional teams.

This research is located in the context of perioperative team. Associations representing the other two key players in the perioperative team – the American College of Surgeons and American Association of Nurse Anesthetists – are planning to select LMSes with the functionality similar to the LMS ASA selected by the end of August 2015. Those selections may significantly influence the context and perspectives interviewees have on QIE/IPL.  This research will help better navigate toward better and more coordinated utilization of learning technology available to members of perioperative team.

Theories

There are a number of theories that can be used to define and analyze IPL (Hean, Craddock, Hammick, & Hammick, 2012) and QIE. The approach to theory in papers on IPL has been evolving. At the beginning, a significant number of papers were very pragmatic and didn’t describe a theoretical background. Many later papers grounded IPL research in a single theory – usually related to a specific school of thought and academic discipline (Barr, 2013). Finally, at this point, a growing number of papers build a sound, flexible and inclusive IPL frame of references by combining multiple theories and practices. Following that evolution of thought, this research will reflect on a few major theories that can be used to describe IPL and possible interactions/overlaps between different theories.

Social theories (social constructivism, social capital) (Hean et al., 2012), adult learning (Clark, 2006), identity theories, situated learning (Ranmuthugala et al., 2011; Wenger, 1998, 1999) and networked learning (Dev & Heinrichs, 2008) are the main theories relevant to QIE/IPL learning processes. On the other hand, theories most relevant to QIE/IPL context are sociology of professions, organizational theory and activity theory. They may present a compelling example of how different theories complement each other. For example, Larson (1979) argues that professional guilds are actively engaged in monopolizing knowledge in specific areas, to ensure cognitive exclusivity. That may explain why, despite learning organization (Roberts & Thomson, 1994; Senge, 2006) being a very popular theory concept (Barr, 2013), it is especially hard to achieve it among different professional organizations and patients. Fortunately, activity theory allows us to analyze organizations as “distributed, decentered and emergent systems of knowledge” (Blackler, Crump, & McDonald, 2000, p. 278); it provides insight into connections between activities and context and reasoning behind complex social activities.

Resources

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• Balmer, J. T. (2013). The transformation of continuing medical education (CME) in the United States. Advances in medical education and practice, 4, 171.
• Baron, R. J. (2015, 2/3/2015). ABIM Announces Immediate Changes to MOC Program.   Retrieved from http://www.abim.org/news/abim-announces-immediate-changes-to-moc-program.aspx
• Barr, H. (2013). Toward a theoretical framework for interprofessional education. Journal of interprofessional care, 27(1), 4-9. doi:10.3109/13561820.2012.698328
• Batalden, P. B., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality and safety in health care, 16(1), 2-3.
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• Bates, A. W. T. (2008). Transforming distance education through new technologies. In T. Bates (Ed.).
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• Blackler, F., Crump, N., & McDonald, S. (2000). Organizing processes in complex activity networks. Organization, 7(2), 277-300.
• CAIPE, Centre For The Advancement Of Interprofessional Education. (2002). Interprofessional Education – The definition.   Retrieved from http://caipe.org.uk/resources/defining-ipe/
• Cervero, R. M., & Moore Jr., D. E. (2011). The Cease Smoking Today (CS2day) initiative: A guide to pursue the 2010 IOM report vision for CPD. Journal of Continuing Education in the Health Professions, 31(S1), S76-S82.
• Clark, P. G. (2006). What would a theory of interprofessional education look like? Some suggestions for developing a theoretical framework for teamwork training 1. Journal of interprofessional care, 20(6), 577-589.
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• Dev, P., & Heinrichs, W. L. (2008). Learning medicine through collaboration and action: collaborative, experiential, networked learning environments. Virtual reality, 12(4), 215-234.
• Diamond, L., Kues, J., & Sulkes, D. (2015). The Quality Improvement Education (QIE) Roadmap: A Pathway to Our Future. Retrieved from http://www.acehp.org/p/cm/ld/fid=209
• Dutton, R. P. (2014). Quality management and registries. Anesthesiology clinics, 32(2), 577-586.
• Gray, B. M., Vandergrift, J. L., Johnston, M. M., Reschovsky, J. D., Lynn, L. A., Holmboe, E. S., . . . Lipner, R. S. (2014). Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA, 312(22), 2348-2357.
• Hager, M., Russell, S., Fletcher, S. W., & Macy Jr, J. (2008). Continuing education in the health professions: improving healthcare through lifelong learning: Josiah Macy, Jr. Foundation.
• Harris, J. M., Sklar, B. M., Amend, R. W., & Novalis‐Marine, C. (2010). The growth, characteristics, and future of online CME. Journal of Continuing Education in the Health Professions, 30(1), 3-10.
• Hayes, J. C. (2012). Anesthesiologist-CRNA Teamwork Common, but Groups at Odds. Medscape Anesthesiology.
• Hean, S., Craddock, D., Hammick, M., & Hammick, M. (2012). Theoretical insights into interprofessional education: AMEE Guide No. 62. Medical teacher, 34(2), e78-e101.
• IoM. (2010). Institute of Medicine: Redesigning Continuing Education in the Health Professions (9780309140782). Retrieved from http://www.ama-assn.org/resources/doc/cme/iom-report-cme.pdf
• IoM, & , Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf
• IoM, & , Institute of Medicine. (2013). Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice: Workshop Summary: National Academies Press.
• Johnstone, R. E. (2015, 4/10/2015). ASA Membership: Some Say No. Anesthesiology News. Retrieved from http://www.anesthesiologynews.com/ViewArticle.aspx?d=Commentary&d_id=449&i=April+2015&i_id=1168&a_id=30903
• Josseran, L., & Chaperon, J. (2001). History of continuing medical education in the United States. Presse medicale (Paris, France: 1983), 30(10), 493-497.
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• Kempen, P. M. (2014). Maintenance of Certification and Licensure: regulatory capture of medicine. Anesthesia & Analgesia, 118(6), 1378-1386.
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[1] Totara: Frequently Asked Questions for Positions, Organizations and Competency Hierarchies http://help.totaralms.com/FAQs_for_Hierarchies.htm

Theoretical framework

Ontology. Social constructivism is my dominant worldview. It assumes that meanings are created in social interaction. They are constructed on individual and group/organizational/professional levels and influenced by numerous historical, cultural and technological factors.

Epistemology. The social constructivism learning theory (Curran, Fleet, & Kirby, 2010; Vygotsky, 1978) is associated with that worldview. I will use it as a lens to analyze potential challenges of QIE/IPL.

Social constructivism assumes that groups actively construct knowledge through social interaction internally among team members, and as a team interacting with the external world. In that process they create group culture, a collection of shared artifacts and shared mental models. Ultimately, according to a social constructivist view, the society exists simultaneously as subjective and objective reality (Andrews, 2012).

Research questions

As the literature review shows, education focused on quality improvement of clinical practice and IPL has been grabbing our attention for more than half a century, and there is a wealth of publications on that topic. However, very few changes were accepted. It is fair to say that QIE/IPL are still in the early stages. On the other hand, recent strong political-economic forces and technology-enhanced learning solutions have created an environment that can enable implementation of QIE and IPL on a scale that was never possible before. Therefore, the research questions are:

1. How are QIE/IPL and technologies and policies that shape QIE/IPL perceived by four groups involved in perioperative teams: anesthesiologists, surgeons, anesthesiologist assistants and nurse anesthetists?
2. How is technology-enhanced collaborative learning used and perceived in the context of QIE/IPL and perioperative teams?
3. How are professional cultures and contextual factors related to collaborative learning influencing implementation of technology-enhanced QIE/IPL?

Answers to those questions will help us better utilize technology to support QIE/IPL, to the benefit of all healthcare professions involved, and their patients; it will help us understand cultural and contextual factors so we can navigate more quickly and safely to successful QIE/IPL programs.