Received date: 9 January 2012; Accepted date: 26 February 2012
Background The context of primary care in the UK is changing rapidly, underpinned by continuing policy drivers to ensure person-centred safe and effective practice. Undergraduate and postgraduate programmes for healthcare practitioners are increasingly using inter-professional education (IPE) as one route to engender greater understanding of others’ roles and contributions to health care, with the suggestion that IPE leads to better integration and teamwork, and thus stronger collaborative practice. Access to education and professional development for those working in primary care is difficult, and individuals need the focus of learning to be clearly relevant to their practice. Aims To review and debate the evidence on the role of work-based learning and IPE in enhancing collaborative practice in primary care. MethodLiterature search and critique of key papers relevant to primary care practice. ResultsThe three themes emerged of IPE, work based learning (WBL) and collaborative practice. There is a growing body of literature to support the positive outcomes of IPE and the utilisation of WBL in developing practice. A range of practitioners in a variety of work settings have used WBL approaches in the implementation of innovations and the development of communities of practice. However, little evidence exists to support these approaches in primary care. ConclusionThe application of WBL across primary care teams can support a positive and collaborative learning culture, resulting in changes to professional practice.
collaborative practice, communities of practice, interprofessional education, learning culture, primary care, work-based learning
The complexity of the context of primary care in the UK is one that is very familiar to those working within it: it embraces an ever-changing environment of an increasing number of patients with complex needs, a shift in the balance of care from hospital services to the community, and thus a greater need for health and social services to work together closely and effectively to offer an integrated and evidence-based service. Teamwork and interprofessional collaboration are essential in meeting these multiple needs and demands, emphasised throughout the National Health Service (NHS) by watchwords such as consumer participation, choice, effectiveness and professional accountability.[1–3]
Accompanying these imperatives there are increasing pressures on those working in primary care to demonstrate the evidence for their proposed actions, the evidence of the currency of their learning, and the evidence of outcomes of these activities. These demands are posed by professional bodies, NHS employers, patients/clients and the professionals themselves.
The workforce itself is ageing, which, it may be speculated, results in greater experience, but also increases the need for continuing professional development to ensure current and safe evidence-based practice.
Busy and effective primary care practitioners have already developed strategies to balance and address competing demands, and one strategy to inform and develop innovations in practice is the use of workbased learning (WBL). This paper debates what is already known about WBL and the use of interprofessional education (IPE) in taking forward primary care practice, and advocates the concept of communities of practice as one route to implement these approaches.
IPE is seen as one way to enhance teamwork, and facilitate the collaboration needed to offer an integrated service.
One widely adopted definition is that IPE occurs ‘when two or more professions learn with, from and about each other to improve collaboration and the quality of care’. A more complex exploration of the components of IPE, was presented by Barr as ‘the application of principles of adult learning to interactive, group-based learning, which relates collaborative learning to collaborative practice within a coherent rationale which is informed by understanding of interpersonal,group, organisational and inter-organisational relations and processes of professionalization’ (p. 233). Thus, it is more than professionals sitting in the same room learning together, which is usually termed multiprofessional education. This particular definition suggests that the ultimate aim is collaborative practice. The same author earlier had identified a range of different forms of IPE, which can be implicit or explicit, work- or university related, and therefore include informal or formal learning.
Examples of IPE initiatives were identified in the 1960s, but were perhaps given greater impetus going forward into the 21st century,[9,10] with the aim of modernising health care to offer a seamless service, and addressing barriers between professions and health and social care. Professional bodies in the UK, such as the Health Professions Council, the Nursing and Midwifery Council, the Royal Colleges, and the General Social Care Council, have all supported IPE through guidelines and policies.
Partnership working and IPE have a wide range of potential benefits ascribed to them, but the evidence for the outcomes of both has some limitations. An initial Cochrane Review found no studies that met their strict inclusion criteria, while the updated review  identified six studies that met their criteria. Other work was excluded because of the heterogeneity of the IPE interventions and methodological limitations of the studies. Broader IPE reviews include Barr et al, Cooper et al, Freeth et al, Hammick et al and Reeves. Evaluation of IPE has also been reviewed.[5,14,19]
These reviews have highlighted that there is a large volume of descriptive literature about the effectiveness of IPE, but much of this evidence lacks rigour in terms of measurable outcomes.
For example, a survey inNewZealand by Pullon and Fry identified perceived benefits in greater understanding of roles, and reported collaboration in the workplace, and in the UK, Pearson and Pandya reported from their evaluation of primary care participants’ views of the positive effects on understanding of roles and enhanced clinical learning.
The same could be said about the evidence for effectiveness of team working, although this is widely accepted as essential to quality care. A wide range of literature has reported the many factors that can influence team effectiveness, which can include structure, team roles and responsibilities, leadership, communication strategies, professional boundaries and values, as well as education, encompassing broad aspects of collaboration.[22,23]
Headrick and Khaleel assert that three strategies are key to educating future health professionals: integrate theory and practice, assess learning and create interprofessional experiences.WBL,wewould suggest, is a formof learning that incorporates all these elements. As Barr et al point out ‘If education is part of the problem, it must also be part of the solution’ (p. 8).
WBL is not a new concept. It is learning that is flexible, relevant to practice and practitioner centred, thus helping the practitioner relate new knowledge directly to the work environment and enabling the focus to be on the realities of practice within a theoretical and reflective framework. However, WBL is viewed by some to be little more than task-related onthe- job training. There are many different definitions of WBL, but one common theme is that learning is derived from the work itself.
A key underpinning principle is adult learning. In adult learning there is recognition that the process of critically reflecting on and evaluating experiences is needed at an individual level through critical discourse and supportive relationships with fellow practitioners to support learning and development.[28,29]
WBL approaches have been identified as addressing the needs of practitioners in matching the requirements of a rapidly changing health service and developing practice by promoting learning that is practice driven. It has been recognised that learning in the workplace has a crucial role in professionals’ practice development, withWBLhaving a positive impact on enabling practitioners to recognise and value their ability to lead change. Furthermore, WBL has the potential to advance knowledge development, critical understanding, practical skills and professional attitudes and values, and so ensure fitness for practice and fitness for purpose. A WBL approach acknowledges that learning at work comes from a number of sources, the main focus being that knowledge and skills are made visible and can be externally assessed. WBL draws on previously acquired formal knowledge, contextualises it and adapts it to the current context.
Box 1 presents a summary of the benefits and challenges of WBL.
The delivery of WBL can take many forms and focuses on the process rather than the product of learning. Practitioners take responsibility for identifying and exploring topics relevant to their individual, team and primary care context. However, practitioners need to deepen their participation in team learning and be willing to view their practice with fresh eyes.[25,32] Thus the direction of learning is moving away from traditional externally approved learning, defined by educational institutions, to a greater emphasis on and Acknowledgement of the validity of WBL, with the focus on individual choice and motivation.
These new ways of learning in practice contrast to the traditional transmission of information by utilising adult learning approaches, small group work and critical and active learning. The strategies can include reflective diaries, clinical supervision, action learning, e-learning, personal development plans, project work, individual coaching and mentorship.[32,39,40]
A positive culture of learning is required to support collaborative working and a commitment to working interprofessionally, across traditional boundaries. In recognition of the changing context of care, staff need access to resources and skills to develop their professional knowledge. The organisational culture should foster trust, good communication and challenge existing practice.
Box 2 summarises a range of factors that can affect an organisation’s learning culture.
Through critical reflection and evaluation of WBL there is potential for a changing frame of reference regarding professional identity, with practitioners being in a prime position to influence their professional communities.[45,46] This can be a dynamic process with members taking an active and participatory role contributing a mix of skills, experiences and professional ‘cultures’. The understandings and perspectives created are thus viewed as authentic and valid. The practitioner is engaged in a spiral of learning with past experiences, knowledge and a cultural and social history.
Successful WBL needs to engage practitioners able to recognise learning opportunities, and who are willing as well as able to communicate their professional knowledge. It does, however, require ownership by individuals and teams. Collaborative practice, through which a team can evolve into a community of practice, is one route to engage practitioners in WBL.
In the context of primary care, the concepts of WBL and IPE have been explored from the perspective of the development needs of registered practitioners. The third theme from our search is collaborative practice. In terms of health care this has been defined as occurring ‘when multiple health workers provide comprehensive services by working together synergistically along with patients, their families, carers and communities to deliver the highest of care across settings’ (p. 13). When considering collaborative practice and the significant relationships involved, it is noted that the key relationships are within a profession, with other professions, new partners, policymakers, the public and with patients. This requires further development in terms of children, individuals, families, vulnerable groups and communities to acknowledge the changing health and social care agenda.[2,50,51]
Collaboration can be perceived by some as individuals within a group whose sole purpose is to promote their own ideas and interests with limited insight into the needs of other members. In addition it has been found that for a collaborative approach to be effective there need to be groups made up of individuals from the same cultural background. Although this would provide a means to gain clarity of purpose in terms of specific professions and allow opportunities for confident interprofessional and intercultural relationships, [54,55] it can lead to a different interpretation of collaboration. The culture of collaborative practice has been shown to evolve through building relationships, effective communication, developing practice and leadership.[22,47,56] A strength of any health and social care team or workforce is the ability to practise in an inclusive and collective manner to improve outcomes of care for individuals, families and their communities.[2,22,50]
There has been ongoing discussion surrounding the development of collaborative practice and whether this is created through educational means or through the experience of practitioners.[32,45,57] The introduction of IPE to pre-registration students is seen as one means to support a cultural shift from a more traditional uni-professional approach to care. It may be speculated that with increased use of IPE in undergraduate education, there is the potential for communities of practice to develop by providing the foundation and the means to build on experiences in the practice context.
Building on the work of Wenger, who first coined the term ‘community of practice’ and believed that people learn best in groups, communities of practice in health and social care settings have been described as groups of motivated practitioners who have come together to share knowledge, experience and skills to develop and improve practice. There is international evidence that communities of practice have the potential to address quality issues and practice improvement in general practice.[61,62] Examples of communities of practice in primary care in the UK are relatively limited, and the approach has its limitations. Some examples have demonstrated how health and social care issues can be explored and practice developed.
One route to create a community of practice is through formal education, facilitated for practitioners by an educational institution. Shared learning in interprofessional collaboration has been investigated as a way for professional borders to be crossed and changes in perspective to take place, and as such should be embedded in professional education.[22,47] There is, however, limited evidence of accredited WBL interprofessionally. 
Another route to create a community of practice is through the use of WBL. Once the process has been explored, perhaps with external facilitation, practitioners can work together to share knowledge and experiences, identify learning needs and actively engage in working together to develop a learning culture in the workplace, and thus improve the quality of primary health care.[27,44]
One example of both formal (accredited) and informal (non-accredited) WBL is presented in Box 3.
This example demonstrates IPE, the use of WBL, and practitioners working collaboratively. A positive learning culture is supported, and the team are developing a community of practice.
For primary care practitioners from a mix of professional backgrounds to collaborate effectively, there is a need to learn from each other.
Apragmatic approach is to facilitate IPE in the place in which they work through WBL. This investment and emphasis on life-long learning contextualised within a professional setting recognises the strengths within a team or community of practice.
The process initially requires facilitation and support, from within the team or externally, with practitioners taking ownership of the learning experience. Acknowledging practitioners’ skills, knowledge and experience, this relevant and context-specific learning, has the potential to change primary care practice and positively influence health outcomes for the local community.
Commissioned, not externally Peer Reviewed.