Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 23 CSSHE SCÉES Canadian Journal of Higher Education Revue canadienne d’enseignement supérieur Volume 45, No. 2, 2015, pages 23 - 40 Preparing Students in Professional Programs for Rural Practice: A Case Study Julia Brook, Neil Hobbs, Denise Neumann-Fuhr, Anne O’Riordan, Margo Paterson, & Jane Johnston Queen’s University Meagan Troop University of Guelph Abstract Understanding the supports and constraints available in rural communities is integral to the education of professionals who choose to practise in rural settings. Previous research has indicated that many professionals do not have an accurate understanding of rural contexts and how rural settings impact personal life and professional practice. To address this gap, an interprofessional course centring on professional practice in rural and remote communities was developed. This course was designed to be reflective of rural practice, not only in content but also in the way the course was delivered. Findings from this case study indicated that students’ understanding of the complexity of rural settings was enhanced on multiple levels. The interactive and experiential nature of the course allowed students to develop working relationships that increased both their understanding of the value of interprofessional collaboration as well as the professional opportunities that are available in rural areas. Résumé Comprendre les soutiens accessibles dans les communautés rurales et leurs contraintes fait partie intégrante de la formation des professionnels qui choisissent de pratiquer en milieu rural. Des recherches antérieures ont indiqué que de nombreux professionnels n’ont pas une compréhension adéquate des contextes ruraux ni des répercussions de ces paramètres sur la vie personnelle et la pratique professionnelle. Pour combler cette lacune, un cours CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 24 interprofessionnel centré sur la pratique professionnelle dans les collectivités rurales et éloignées a été créé. Ce cours se veut le reflet de la pratique rurale, non seulement dans son contenu mais aussi dans sa façon d’être enseigné. Les résultats de cette étude de cas ont indiqué que la compréhension qu’ont les élèves de la complexité du milieu rural a été renforcée à plusieurs niveaux. La nature interactive et expérientielle du cours a permis aux étudiants de parfaire leurs relations de travail, ce qui a augmenté à la fois leur compréhension de la valeur de la collaboration interprofessionnelle ainsi que celle des occasions professionnelles disponibles dans les zones rurales. Introduction and Literature Review Understanding the supports and constraints available in rural and remote communities is integral to the education of professionals who support those living in rural settings (Winters & Lee, 2010), since the concerns of professionals in rural areas are often different from urban-based professionals (Scharff, 2010; Shreffler-Grant & Reimer, 2010). It may, in fact, be reasonable to consider that learners in rural and remote communities have worldviews and cultures that are very different those of professionals choosing rural venues as practice settings (Martin, 2003; Durie, 1995). While programs that focus on recruitment to rural areas abound (c.f., Bettles, 2012; De Hoyos & Green, 2011), little attention is given to the particular skills required and experiences one may encounter when working in a rural area. Previous research has indicated that many professionals do not have an accurate understanding of how rural contexts and settings impact personal life and professional practice (Fisher & Fraser, 2010). Furthermore, misunderstandings about rural culture may have an adverse effect on retention of professionals, and lead to high degrees of turnover and predictable problems with continuity of professional care. It therefore seems appropriate that, in order to better equip its graduates, postsecondary professional programs address issues facing professionals who practise in rural areas. Such endeavours may ultimately lead to improved recruitment and retention of rural professionals. Defining Rurality Statistics Canada (2001, 2006), has defined “rural” as “the population living in towns and municipalities outside the commuting zone of larger urban centres i.e. outside the commuting zone of centres with [a] population of 10,000 or more”; however, limitations to such definitions are important to identify and explore. Because each rural and remote setting is defined by a unique set of geographical, cultural, and economic determinants, no two rural communities can be considered identical in nature. This uniqueness is important to identify. Rural communities are also economically, geographically, and socially qualitatively different from urban communities; thus the natural and human supports and constraints that impact rural residents are different from those in urban areas (De Hoyos & Green, 2011; Flora & Flora, 2008). One might posit that rural environments may be seen as culturally different, and such differences may become markedly so in more remote areas in Canada, just as they are in other parts of the world. We believe these differences are significant educational learning points for students in a course focusing on rural com- CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 25 munities. Flora and Flora (2008) assert that while rural communities may differ from one another, there may be other issues they have in common, such as persistent poverty due to lack of economic opportunities. Other issues such as , suburban sprawl in rural areas near cities, rapid growth encroaching on natural amenities (environmental issues are increasingly part of rural consciousness), and cultural dislocation when people in rural communities are displaced by urban sprawl, the introduction of new industry or the need to move to another location in search of employment, among others. Developing infrastructure to mitigate these issues often requires creative thinking in order to capitalize on the often-limited human and physical resources that are available to those living and working in these small communities (Barter, 2008; Winters & Lee, 2010). Considering how professionals in rural areas can capitalise on the human and physical resources that are present in rural communities was a central tenet of this course. Educating about “Rurality” Considering that living and working in rural areas is qualitatively different from living in urban areas, it is important that professional programs introduce these differences to their students. Strasser and Neusy (2010) assert that “producing more health-care providers and expecting the excess to spill over from the cities into rural areas has been shown not to solve the rural medical workforce shortage” (p.1). Rather, what is required are educational programs tailored to working in rural areas by addressing the characteristics of rural communities, their health service needs, and the nature of rural practice (Medves et al., 2008a; 2008b; Strasser & Neusy, 2010). Winn, Crisholm, and Hummelbrunner (2014) explored the factors that influenced the recruitment and retention of rehabilitation therapists working in northern Ontario by surveying audiologists, occupational therapists, physiotherapists, and speech–language pathologists. They found that, in addition to family ties, employment opportunities, and lifestyle options, respondents’ exposure to rural courses during their training was a key determinant in recruitment to rural areas. Winn et al. (2014) determined the rural education program, “exposes students not only to rural education but also to other identified recruitment factors such as positive lifestyle options and professional networking” (p. 2621). Similarly, findings from Australia demonstrating that teachers are not well equipped to work in rural areas prompted the introduction of a rural practicum component in their training in hopes of supporting teachers training to work in rural Australian schools (Lock, 2008). Survey results from students enrolled in this program found participants’ knowledge of rural areas and the skills needed to work in these locations were enhanced. Literature related to preparing professionals for working in rural communities acknowledges the importance of explicitly addressing the unique characteristics and needs of rural life and work. In so doing, students gain experience by focusing on some of the needs and concerns unique to rural areas while also providing opportunities to experience the benefits of rural life. By developing practice experiences in rural settings, students are exposed to the challenges and benefits of working in these areas in multiple ways—they are able to expand their understanding beyond the textbook through first-hand encounters of rural places, and once understanding the rural context, they may be able to develop their clinical knowledge in new ways. CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 26 Professionals working in rural settings are often challenged to provide services with reduced or little support, and in practice conditions that are variable, complex, and broadly defined (MacKinnon, 2014). Creative approaches to provision of care are often required in order to surmount the barriers that distance presents. As a result, guiding new professionals in the development of a unique skill set that is both creative and expansive is necessary for effectively managing the work of rural and remote practice. We believe that, while rural-based programs are an integral part of educating professionals to work in such areas, urban-based institutions also have a role to play in preparing their students for work in rural and remote locations. To address some of these needs, a course focusing on rural professional community practice was developed by an interprofessional group associated with faculties and schools of medicine, theology, nursing, rehabilitation therapy, law, and education at an urban university in Ontario, Canada. A foundational concept embraced at the outset was that interdisciplinary collaboration is an integral component of rural practice. The aim of a course emanating from this concept was to introduce students to the unique issues facing rural communities in general, and to familiarize them with the supports and constraints facing professionals choosing to live or work in rural communities. We recognized that an educational journey such as this would go beyond providing mere facts and figures, and would not be complete without experiential learning that exposed students to some unique aspects of rural life. With this in mind, a set of experiences and understandings was created that would better prepare students for the multifaceted nature of life and work in rural areas. Carper’s Ways of Knowing We wanted students to generate knowledge by devising spaces for them that would incorporate multiple ways of knowing and actively engage ideas associated with working and living in rural areas. We chose Carper’s (1978) ways of knowing as a specific framework for addressing this educational process “as the “need to examine the kinds of knowing that provide [a] discipline with its particular perspectives and significance” is according to Carper, important to understand (p. 31). Carper’s original model has been discussed and modified since its creation (cf., Johns, 1995; Mantzorou & Mastrogiannis, 2011), but we found her original four domains of knowing useful for understanding how students learn about engaging with ideas linked to working and living in rural areas. In her original model, Carper (1978) identified four domains of knowing: empirical, aesthetic, ethical, and personal. • Empirical knowing “includes facts, organized descriptions, conceptual models, and theories which explain and predict relationships” (Mantzorou & Mastrogiannis, 2011, p. 253). • Ethical knowing refers to that which is viewed as right or wrong, a moral obligation or judgment, expressed through codes of conduct, standards of practice, and ethics in decision making. • Aesthetic knowing refers to the “direct feeling of experience” Mantzorou & Mastrogiannis, 2011, p. 253). Often subjective and unique to the individual learner, “it integrates experience within a context of discovery” (Schaefer, 2002, p.287). Some refer to this as the intuitive dimension—“the immediate knowing of something that CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 27 does not appear to involve conscious reasoning” (Schaefer, 2002, p.287). Others consider intuition a part of the realm of personal knowing. • Personal knowing refers to knowing of the self; it “focuses on the discovery of self and others through reflection, synthesis of perceptions, and connecting with what is known” (Schaefer, 2002, p. 287). Personal knowing allows for new (idiosyncratic) and creative ideas to emerge through unanticipated moments of new insight. Schafer, among others, has subsequently identified further subcategories of knowing that include: • Experiential knowing, defined as “reflection in action, learning by doing, and being open to reflection on what one has experienced by doing” (Schaefer, 2002, p.287). • Interpersonal knowing defined as “increased awareness…through intense interaction or being with the other.” Through interpersonal knowing, “connection between self and others” is promoted and enhanced (Schaefer, 2002, p.287). • Intuitive learning or that which is not related to conscious reasoning (noted previously). Although Carper’s (1978) model originated in scholarly literature from the nursing discipline, we postulated that this model is applicable to understanding the learning taking place in an interdisciplinary course such as ours, one that included students from theology, education, and nursing. We also hypothesized that professionals learning about work in interdisciplinary contexts would need to rely on multiple ways of knowing to fully understand their professional context as well as the cultural multiplicities of rural environments. Thus we strove to create a course that asked students to rely on multiple ways of knowing. We also wanted the experiences of the course to facilitate creative processes and generate ideas that would allow students to apply these ways of knowing in new and unexpected ways; ultimately we hoped this would lead to the enhancement of their professional practice. Course Context: Professionals in Rural Practice Professionals in Rural Practice: An Interdisciplinary Approach was offered as an intensive two-week course in spring 2012. Students met on campus daily for 3 hours; during the weekend, they travelled to a rural community for a two-day immersion experience. Fourteen students from theology, nursing, and education registered for the course. In addition to their diverse educational backgrounds, students’ ages varied, and almost half were training for a second career. Approximately one-quarter of the students had grown up in rural areas, while the others were from various metropolitan centres. There was an attempt made to have as many faculty as possible attend teaching sessions, including the intramural weekend field trip. The intent was to provide a model of an interprofessional relationship among teachers, and not just among students. The weekday sessions introduced students to aspects of rurality that were deemed significant for them, no matter what their professional background. These rural aspects were seen as a prelude to what professionals would need to know for rural practice. The subjects included aspects of rural economic development and decline, resource access for those CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 28 living in poverty, perceptions of rural life including those of the local First Nations, the need for mentoring (sometimes across professional boundary lines), the importance of interprofessional partnerships, establishing professional boundaries in rural practice, preventing professional burnout, developing community resilience, and supporting diversity. Sessions consisted of a traditional lecture followed by small-group activities, with three to four student teams created by instructors to intentionally include members from different discipline areas. Case-study activities were primarily used as a means to segue from the traditional lecture into a discussion of the issues. These team-based discussions provided students with an opportunity to determine how they would react to these issues if they were working rurally. Instruction was shared among interprofessional faculty members from the planning team. Expertise of the faculty members drew from both their professional knowledge as well as from their experiences living and working in various rural communities. These experiences were often woven into the sessions to provide further insights into the issues being addressed. Guest speakers were also invited to lead various sessions. Students and faculty spent a weekend in a rural area where orchards and vineyards abounded alongside artisans and cottagers. Students ate local food, toured the local town, and heard about the experiences of artisans, farmers, politicians, and a minister. They also heard from members of an interdisciplinary team that included members from health care, education, and police services that were addresing illicit drug use in the community. All these participants shared their experiences of living in a rural community and serving a rural population. Opportunities to interact more informally with these members of the community were also created during this weekend field trip. Course Assessments As with the class sessions, the assessments were designed in a way that allowed students to draw upon multiple ways of knowing and, in particular, to synthesize their prior knowledge with the empirical, aesthetic, and ethical knowledge they had gained in the course. The course instructors designed these assessments so that, as an intended learning outcome, the students’ personal knowledge would be enhanced and enriched through the application and synthesis of ideas. Students were given four assessments: a reflective journal, an interview experience and follow-up report, a small team presentation, and an academic paper. Each of these assessments was designed to encourage students to explore and present their ideas using a variety of structures and to critically reflect on and integrate the ideas presented to them throughout the course. Each of these assessments is described below. Reflective Journal. Students were asked to keep a reflective journal documenting their responses to at least three classroom sessions and one rural field trip. For the first entry, students were asked to write their first impressions of what living and working in a rural area might be like. The last journal entry was a summary of how they felt their understanding of the nature of rural life and professional practice had changed over the time frame of the course. Students were invited to use prose, poetry, and pictures to document their knowledge, experiences, and feelings. This assignment was designed to capitalize on the interactions between empirical and ethical knowledge garnered from the course. Aesthetic knowledge developed through working with these ideas in small groups and by exploring how these new ideas resonated with their prior experiences. CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 29 Interview Report. Students were grouped in pairs and were asked to conduct a 30-minute interview with a professional currently living or working in a rural area. Students worked together to develop the questions for the interview and submitted a fivepage report summarizing their impressions from the interview. This assignment was designed to allow students to explore the experiences of others living and working in rural settings. They integrated this information into a broadened sense of understanding that incorporated the empirical and aesthetic knowledge they acquired through the course, as well as their own prior knowledge and experience. Team Presentations. Student groups were asked to develop a 10-minute presentation profiling an issue facing professionals in rural communities. The groups decided on the method of presentation as well as the content. This assignment was regarded as an opportunity for students to learn from each other (especially across professional boundaries) by providing a simulated context of interprofessional teamwork. Through the process of working together, students generated empirical and aesthetic ways of knowing in a manner that provided opportunities for new personal ideas and experiences (personal knowing) to emerge. Major Paper. Students wrote a 10- to 15-page paper about a rural issue of their choice. This paper allowed students to explore a topic of interest to them and to examine how these issues would and could impact their life and work. Again, this assignment was designed to integrate both empirical and aesthetic ways of knowing. Method Case Study Methodology An exploratory case-study methodology (Stake, 2010; Yin, 2009) was employed to capture the contents, delivery, and consequent experiences of students in order to gain a deeper understanding of how the course content and the delivery of course topics impacted the students’ understanding of their professional practices. Case studies facilitate multiple data collection techniques from diverse sources and allow for multiple realities and ideas to be explored within a particular setting (Patton, 2002; Stake 2010). Timmons and Cairns (2009) argued that case-study research creates knowledge and understanding, and that the flexibility of case studies allows researchers to capture various elements that contribute to understanding of the phenomenon under investigation. The following research questions guided this study: 1. In what ways did the course content, course structures, and instructional approaches, contribute to students’ ways of knowing about living and working in rural areas? 2. What features of the course were of particular importance in facilitating a deep, meaningful learning experience for students? 3. What inherent challenges did the instructors face in the design and development of a rural course set in an urban context? Ethical Approval Ethical approval was received from the Queen’s University General Ethics Board in April 2012, prior to the course start. Students were invited to participate in the research CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 30 study at the beginning of the course by one of the authors, who was not an instructor in the course. Students were assured that every effort would be made to ensure their identity would remain confidential, and their work would not be used for research purposes until after the course had ended and grades were submitted. Instructors for the course were also invited to participate, and they agreed to allow the summaries of the planning and debriefing meetings to be used as data for this research paper. Unit of Analysis and Participants The unit of analysis for this case study is the Professionals in Rural Practice course, and the researchers were participant–observers. Five of the authors were course instructors, and one of the authors was a doctoral student who also participated as an educational researcher. The educational researcher acted as a participant–observer in the context of conducting a larger qualitative study, which examined creativity as an enabler for transformative learning in graduate-level courses. The use of participant–observers allowed for the gathering of insights into interpersonal behaviours and motives (Yin, 2009), and as participant–observers, we were able to gather perspectives from multiple vantage points. In addition to the participant–observers, students registered in the course were invited to participate in the dissertation research study, which served to confirm many of our findings (Troop, 2013). Data Collection We gathered information about the course using course documents from the instructors’ and students’ perspectives. Course documents offered a rich description of course content, associated teaching and learning strategies, and their alignment with both learning outcomes and assessments. Course documents related to the course design, including the course outline, summaries from course planning meetings, and reflections following the course experience. In addition, the participant-researcher attended the majority, and in some cases, all the classes and participated in the weekend field trip. Following the sessions, informal discussions took place with all the instructors, and some instructors reflected critically on their experiences of teaching and participating in the course events in journals or teaching notes. Course documents related to the students’ experiences included an analysis of the students’ course journals. At the beginning of the course, students were asked to describe their existing perceptions of interprofessional work and rural living. During the course, they were asked to write four journal entries responding to course activities during both weekday and weekend experiences. In their final journal entry, students were asked to describe how their perceptions of interprofessional collaboration, and working and living in rural areas had changed, if at all. Students were graded on their ability to connect their ideas (positive or negative) to the sessions. Use of these documents provided first-hand accounts of the students’ experiences and allowed the researchers to examine the extent to which the course enhanced students’ understanding of rural practice. CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 31 Data Analysis These data were analyzed to provide a rich understanding of the aspects of the course that resonated with the students and examined how they felt the course shaped their thinking about rural life and work. Two levels of qualitative data analysis ensued. First, the course documents and reflective journals were analyzed using emergent themes to create a detailed picture of the structure of the topics, delivery methods, and assessments used in this course. Second, the data analysis consisted of coding guided by the literature related to Carper’s ways of knowing to gain an understanding of how the course contents were experienced by the students in multiple dimensions. The coding of the data was completed by one researcher and the codes were verified by a second researcher. Discrepancies were discussed between the two members and consensus was obtained. The trustworthiness of the data was enhanced by using multiple data collection strategies and by having multiple researchers analyze the data as it built consensus and increased inter-rater reliability (Patton, 2002). Findings Inclusion of Multiple Ways of Knowing Carper’s ways of knowing—empirical, aesthetic, ethical, and personal—were evident in the content of the course in the following ways. Empirical knowledge included exploring rural definitions, poverty law and its application in rural contexts, building rural economies, the nature of mentorship and professional burnout, and the guideline provision for setting professional and personal boundaries (Canadian Interprofessional Health Collaborative, 2010). The empirical content was delivered through a lecture-style format and supplemented with course readings. Students were then asked to explore these empirical ideas through a series of case studies presented to the class. During case-study discussions students were often introduced to the ethical dimensions of rural situations. In particular, cases that were not defined as clear-cut and that involved some ethical decision making in grey areas of practice were introduced as potential areas of challenge. To augment development of this way of knowing some resources on professional and ethical behaviour were provided as an optional supplementary component for students in a self-study online module format. The direct feeling of experience, a part of Carper’s aesthetic ways of knowing, was modelled to students by sharing storied experiences by faculty and guest speakers. The field trip to a rural community also allowed students to experience a rural context and the experiences of community members in a tangible and visceral way. Finally, the unanticipated moments of new insight referred to as “personal knowing” surfaced through the creative problem-solving process of small-group work, as well as through new insights disclosed in personal reflections. Here, evidence of the kind of creative thinking that mirrors rural life and the kind of thinking that is required to address unique rural challenges, surfaced repeatedly. CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 32 Elements That Contributed to Success Three themes emerged that contributed to changes in perceptions overall, specifically in reference to the value of interprofessional education and practice. The three themes were (a) linking empirical knowledge with other types of knowledge, (b) including students from a variety of disciplines, and (c) creating structured opportunities for students to work together. Linking Empirical Knowledge with Other Types of Knowledge. Students appreciated the opportunity to experience activities that cultivated and enabled an integration of multiple ways of knowing. When faculty members include their personal experiences into the course content, the credibility of the instructor and the relevancy of the content was enhanced. This was exemplified by a student’s journal comment: “I love this guy, he obviously loves his product. There’s something authentic about [him]” (Student). Conversely, as noted by one student, the credibility of some speakers came into question, based on the manner in which they told their stories: I feel at a bit of unease after this presentation, [because] I feel as though he was not completely honest in his presentation. I believe he glorified the idea of living and working rurally and overlooked any of the limitations there might be. (Student) If students thought these experiences were too good to be true, the perceived lack of integrity of the speaker negatively impacted the knowledge that the speaker was trying to impart. Furthermore, in some sessions, where lecturing of content pervaded and personal sharing was limited, many students commented that they were unable to gain a sense of the applicability of the content to their particular profession. I had been struggling to focus because it was becoming increasingly difficult to find the connection between the lectures that I had listened to and how this applied to my own field . . . While definitions and illustrations can be helpful I started getting frustrated because there did not seem to be any heart, just theory. (Student) It seemed that the presentation of empirical knowledge alone did not meet the needs of the students. They needed to see how the empirical knowledge related to the other ways of knowing. If this did not occur, they seemed to question the validity of the information. Including Students from a Variety of Disciplines. Students’ notions of what constituted interprofessional collaboration was challenged by the cadre of students taking the course in the year that was studied (2012). For many students from the health sciences, interprofessional collaboration referred only to working with other health-care professionals. Some students in health care programs were perplexed by the notion that professionals from other disciplines could their practice: as one student noted: “I very much enjoy interprofessional workshops and working in interdisciplinary settings, which I find [it] somewhat confusing to [include] theology students” (Student). Similarly, the age range of the students was quite broad and included both students who had graduated from high school just three years prior to taking to the course to those who were training for their second career after several decades in their first. I noticed I was learning alongside adults, some who are much older than me. Now in all technical terms I am an adult, but I never really consider myself one, preferCJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 33 ring the label “university student” to “adult,” and I was now very aware of the wide representation of ages present in our small classroom . . . A quick flash of worry crossed my mind as I panicked that I would not be able to connect with the adults in the room and that this might be an awkward and disconnected experience. My worries were quickly dismissed as my seatmate [who was older than me] was extremely friendly and very easy to talk with. (Student) The diverse student teams were challenged to expand their notions of what constituted interprofessional collaborations and, over time, increased their confidence in being able to work with a wide array of colleagues. Exposure to multiple perspectives also challenged their thinking in new and personally meaningful ways. There have been so many situations already in the past week [when] I have heard a question posed in which the answer given back is [not] what I would have considered. I am enjoying being challenged every day to think broadly, as well as assert my own opinions, about a wide range of topics instead of just memorizing drug names. (Student) The idea of interdisciplinary collaboration included embracing diverse ideas and experiences beyond the scope of one’s own professional mindset. In addition to learning to rely on expertise from each profession, students learned that their own experiences as well as others contributed to a collective bank of knowledge, mutually-shared interests, and a diversity of human experiences to draw on. Creating Structured Opportunities for Students to Work Together Understanding the potential of interprofessional collaboration was gained through the team-based work completed by students. Organizing students into interprofessional teams created a paradigmatic framework of a true-to-life rural experience, wherein negotiation and consensus building were required for students to succeed in the assigned task. One student reflected on this complex process of working with other professionals: What I did learn was that problems will always occur when one professional makes assumptions about another professional, because this was a recurring place of tension within my group. In other words it is important to allow professionals to speak about their own field. Although one may have had experiences in another professional’s field, making the assumption that they know the field as a result is problematic, and not particularly polite. This continued to be a difficulty we had to face over and over again . . . Along with this I think it is important to realize that every individual, even those from the same field, do come from their own unique background and bring their own unique perspective. As a result of this there needs to be a cooperative effort to develop language that reflects all the professions represented. This is something that we worked really hard on, and I think we eventually were happy with our results, but this was by no means an easy process. (Student) As the above student account notes, interprofessional teamwork is not an easy or a straightforward process. Much negotiation and critical dialogue is required, and this was CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 34 prevalent in much of the teamwork in this course. Overall, in the context of interprofessional teamwork students gleaned many insights into the possible supports and barriers that one may encounter through these types of activities, despite some of the challenges they encountered in the process. Personalization of New Learning Students’ prior rural experiences were diverse: some had grown up in rural areas; some had worked in these areas; still others had limited rural encounters prior to this course. For those who had come from rural Canadian communities, their communities differed in terms of size, distance to a metropolitan area, and locally based economic industry. For those who had grown up in a large urban setting, trips to the country tended to be limited to holiday experiences. At the outset, few students indicated they were seriously considering working in a rural context. However, by the end of the course, many had changed their minds, and some had even reached the point of making serious inquiries about the prospect of working rurally. Of particular interest were those who had indicated at the beginning of the course that, “[I did] not feel that there is much drawing my attention to coming back to the town [where I] grew up” (Student). However, by the end of the course this student had reconsidered this notion and noted in his final journal entry that, “I am thoroughly glad I took this course because not only do I feel encouraged to work in rural settings but I [also] feel that I have a new appreciation for interprofessional practice and collaboration, and I will actively seek out opportunities in the future.” (Student) The course experiences helped students re-imagine ideas about the potential working opportunities in rural areas and the valuable role that interprofessional teams can play in these areas. Moreover, this change took place in a relatively short time. In reflecting on the weekend intramural presentation on interdisciplinary team activities targeting illicit drug use, a student commented that, [This course] has given me confidence in interprofessional collaboration, [in how to] clarify my role to other professionals, and in creative problem solving. More than that confidence, it has given me a workplace to desire, one in which interprofessional is not only encouraged but relished. I’m dreaming rural! (Student) Throughout all learning activities, all participants—students, faculty, and community members—were listened to and valued. While the content was representative of rural issues, the delivery of the course was a microcosm of a rural community: small in numbers, big in spirit, willing to listen to others, and willing to solve problems in useful and original ways. As noted by one student, “I learned a great deal about rural life from the first-hand experiences of my classmates and instructors” (Student). Students experienced new and different ideas that resonated with them at individual and collective levels. Students demonstrated aspects of creativity when they developed CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 35 cogency from new or unexpected topics they were presented with, or when they restructured perspectives on topics that they had encountered earlier in their education. Additionally, the course offered students many opportunities to develop their own meaningful interpretations of the content, thereby supporting the emergence of a creative process that led to deep, transformative learning outcomes (Kaufman and Beghetto, 2009; Moon, 2000; Troop, 2013). “In the past two days, I can already say that my knowledge regarding rural and remote living and working has expanded drastically” (Student). Course topics resonated with many of the students. For some, numerous ideas presented about living and working in rural areas infiltrated casual conversations outside the classroom. This resulted in the integration of new learning into the students’ frame of reference, thereby shifting their level of understanding from academic to personal. As one student noted in her journal, I think I have heard everyone say at one point or another “last night I was talking to so and so about this after what we discussed” or something similar. I think this is one of the most valuable parts of the course, in which we can take new-found knowledge of how to look at any problem from multiple perspectives and engage others to do the same. (Student) In the end, many students articulated a desire to pursue work in rural communities, armed with an understanding of the richness that is to be found there. Bringing Rural to the Urban University Much of this course consisted of on-campus work in a traditional classroom setting where we addressed various issues related to living and working in rural areas. While each instructor had lived and worked in different rural and remote areas and framed their teaching with these experiences in mind, we felt that we were still unable to capture the breadth of diversity present among rural areas. Rural and remote areas face different challenges based on their geography, industry, population, and distance to urban areas. As such, we could introduce these ideas, but were unable to adequately represent the diversity in geography and industry that is present in rural and remote Canadian communities. Furthermore, as a two-week intensive course, we were limited in the scope and depth of exploration of topics presented. Recognizing that not all rural areas are the same, we hoped that the diversity of activities and our focus on multiple ways of knowing would underscore the fact that developing both relationships as well as unique ways to solve problems was a principle that one would need to apply in all rural areas. The course represented one of the only courses at this institution that included instructors from different faculties. In addition to these instructors, over thirty residents and professionals from surrounding rural communities shared their experiences with students during on-site guest presentations, the interview assignment, and the weekend field trip. Faculty members attended several meetings to plan the curricular components of this course leading up to its delivery. In addition, one faculty member also organized the first week of the course, including the weekend field trip and recruitment of community members to participate in classroom sessions as guest speakers. A second faculty member organized the second week of the course, including the interview component. CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 36 The drive to support young professionals in learning about rural and remote areas was the primary motivation for most of the paraticipating instructors, and the success of this course was due, in large part, to their passion and voluntary efforts. In short, the modelling of the rural ethos of caring and contributing to community was apparent in the time that faculty members gave to plan and facilitate this course experience. The sustainability and consequent strengthening of such a course requires a clearer vision, and potential re-vision, of postsecondary approaches. Logistically speaking, the allocation of course load and planning time to facilitate shared leadership among faculty members is paramount. Last, but not least, the sustainability of the course demands creative collaboration in order to model the interprofessional nature of practice in rural communities. Discussion and Conclusions Findings from the research conducted in the Professionals in Rural Practice course indicate that students’ understanding of the complexity of rural settings was enhanced. The interactive and experiential nature of the course allowed students to develop interprofessional working relationships that not only increased their understanding of the value of interprofessional collaboration but also enhanced their confidence in being able to actively engage in these types of partnerships. Including learners and educators from disciplines outside of health sciences allowed students to gain a richer understanding of how diverse professions also support patient/client care. This was further enhanced in a subsequent 2013 iteration of the course, where students from health sciences, education, and theology were joined by participants from the law faculty as well as graduate students studying public health and epidemiology. Course activities encompassed, and continue to include, empirical, aesthetic, ethical, and personal knowledge in the examination of rural professional practices. The course also asked students to demonstrate their own understanding within each of these domains. The course provided empirical knowledge, inclusive of accurate and contemporary research on rural issues and rural life. This was balanced by the provision of others’ personal experiences working in rural areas, thus providing richness and authenticity to the material presented. Together, these types of knowledge provided a holistic picture for students to examine life in rural areas. Similarly, assessments and course sessions were also designed to provide students with opportunities to share their ideas about empirical, aesthetic, ethical, and personal understandings. The diversity of experiences allowed for creative ideas and activity to emerge that relied on multiple ways of knowing. By supporting the development of creativity, we reinforced the notion that solving problems in rural areas often involve considering issues in a new light and using human and material resources in novel ways. Students learned that to solve these problems, one must rely on empirical, aesthetic, personal, and ethical ways of knowing. Through these encounters, students’ creative ideas and insights were developed, and these insights allowed students to re-imagine rural living and to envision themselves in both rural and interprofessional contexts. In summary, this course offered a positive learning space where students could create new knowledge from the ideas and experiences presented, thus helping them to become 21st-century professionals. CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 37 References Barter, B. (2008). 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Beyond big and little: The four-C model of creativity. Review of General Psychology. 13(1), 1–12. Lock, G. (2008). Preparing teachers for rural appointments: Lessons from Australia. The Rural Educator, 29, 24–30. MacKinnon, K. (2014). Rural Nursing in Canada. In Realities of Canadian nursing: Professional, practice, and power issues, (4th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins. Mantzorou, M., & Mastrogiannis, D. (2011). The value and significance of knowing the patient for professional practice, according to the Carper’s patterns of knowing. Health Science Journal, 5(4), 251–261. Martin, K. (2003). Ways of knowing, ways of being and ways of doing: A theoretical framework and methods for Indigenous re-search and Indigenist research. Journal of Australian Studies, 76, 203–214. Medves, J., Paterson, M., Chapman, C., Young, J. Tata, E., Bowes, D., Hobbs, N, McAndrews, B., O’Riordan, A. (2008a) An interprofessional course preparing learners for life in rural communities. 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The distinctive nature and scope of rural nursing practice: Philosophical bases. In C. A. Winters, & H. J. Lee (Eds.), Rural nursing: Concepts, theory, and practice (3rd ed.), 249–268. New York, NY: Springer . Shreffler-Grant, J., & Reimer, M. A. (2010). Implications for education, practice, and policy. In C. A. Winters, & H. J. Lee (Eds.), Rural nursing: Concepts, theory, and practice (3rd ed.), 437–446. New York, NY: Springer. Stake, R. (2010). Qualitative research: Studying how things work. New York, NY: Guilford Press. Statistics Canada. (2001). Rural and small town Canada: Analysis bulletin. No. 21006-XIE. Retrieved from http://www.communityaccounts.ca/CommunityAccounts/ca_ google_maps/PDF_Links/Stats_Canada_Definition_of_Rural_2006.pdf Statistics Canada. (2006). Data and definitions. Retrieved from http://www.statcan. gc.ca/pub/21-006-x/2007007/6000446-eng.htm Strasser, R., & Neusy, A. J. (2010). Context counts: training health workers in and for rural and remote areas. Bulletin of the World Health Organization, 88, 777–82. Timmons, V. & Cairns, E. (2009). Case study research in education. Encyclopedia of case study research. Thousand Oaks, CA: Sage. Retrieved from http://www.sageereference.com/casestudy/Article_n36.html. Troop, M. (2013). Traversing Creative Space, Transforming Higher Education: A Contemporary Curricular Vision of Teaching and Learning (Unpublished doctoral dissertation). Queen’s University, Kingston, ON. Winn, C., Crisholm, B., Hummelbrunner, J. (2014). Factors affecting recruitment and retention of rehabilitation professionals in Northern Ontario, Canada: a A cross-sectional study. Rural and Remote Health, 14, 2619 – 2625. Winters, C. A., & Lee, H. J. (Eds). (2010). Rural nursing: Concepts, theory, and practice (3rd ed.). New York, NY: Springer. Yin, R. (2009). Case study research: Design and methods (4th ed.). Thousand Oaks, CA: Sage. Contact Information Julia Brook Faculty of Education Queen’s University [email protected] CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 39 Julia Brook is an adjunct assistant professor at Queen’s University, where she teaches education classes in the School of Music and Faculty of Education. She has conducted research on rural music education and explored the educational experiences of Indigenous artists. She was an instructor in the Professionals in Rural Practice course from 2011–2013. Neil Hobbs was an assistant professor in family medicine at Queen’s University (1987– 2007) and he has been a family physician for over thirty years, practising in rural Ontario, New Zealand, Newfoundland and Labrador, and the Northwest Territories. Neil is a Certificant/Fellow of the College of Family Physicians of Canada, and he earned a Bachelor of Arts medical sciences from Cambridge, UK, and graduated MB BCh in 1973. He then trained in family medicine in Oxford, UK, (1977–1978). Neil was involved with the Professionals in Rural Practice course since its inception, and he also has strong interests in rural practice, narrative, and palliative care. Denise Neumann-Fuhr is a term adjunct faculty member at Queen’s University, School of Nursing, in Kingston, Ontario. She has an undergraduate degree in nursing from McMaster University in Hamilton, Ontario and an MA in the field of Transpersonal Psychology from Sofia University in California. The majority of Denise’s 30-year nursing career has focused on health-care delivery in First Nations communities located in rural and remote Canada. She was the lead coordinator for a Queen’s University-based course on Professionals in Rural Practice: An interdisciplinary Approach, conducted in May 2012 and again in Fall 2013. Anne O’Riordan’s professional career in occupational therapy began over 30 years ago. She joined the School of Rehabilitation Therapy at Queen’s University 18 years ago and now splits her time between the school and the Office of Interprofessional Education and Practice. Anne coordinates learning experiences for students to enable them to collaborate successfully with one another, as well as with persons with health challenges in order to gain a deeper understanding of barriers and enablers in their lives. Anne has been involved in international projects in Bosnia-Herzegovina and Bangladesh, and teaches at the Bader International Study Centre in the UK. Meagan Troop is an educational developer at the University of Guelph. As a pedagogue and researcher, Meagan has worked extensively with undergraduate and graduate students, and with faculty to enhance their instructional practice. Meagan graduated from Queen’s University with a PhD in curriculum studies, where her doctoral research examined several graduate courses and the high-impact educational practices that were deemed as transformative by students and instructors alike. With an interest in transformative learning, adult learning, and development and creative pedagogies, Meagan feels privileged to have collaborated with the team of instructors in the Professionals in Rural Practice course. Margo Paterson became Professor Emerita, Occupational Therapy Program School of Rehabilitation Therapy, Faculty of Health Sciences at Queen’s University, effective July CJHE / RCES Volume 45, No. 2, 2015 Preparing Students in Professional Programs for Rural Practice/ J. Brook, N. Hobbs, D. Neumann-Fuhr, M. Troop, A. O’Riordan, M. Paterson, & J. Johnston 40 2013. Her academic credentials include an MSc in community health and epidemiology (1994) from Queen’s University and a PhD in health sciences from the University of Sydney, Australia (2003). She was the director of the Office of Interprofessional Education and Practice in the Faculty of Health Sciences from 2009–2012 and the chair of the Occupational Therapy Program 2005–2009 and 1999–2000. She is currently executive director of the Association of Canadian Occupational Therapy University Programs (ACOTUP).  Jane Johnston is a registered nurse, faculty member, and former project manager for Interprofessional Education at the Queen’s University School of Nursing in Kingston, Ontario. From 1987–2005, Jane was the director of a regional multidisciplinary community acquired-brain-injury program. At Queen’s University Jane has participated in developing, delivering, and sharing information about the Faculty of Health Sciences interprofessional education curriculum including the courses Professionals in Rural Practice and Global Studies in Health and Disability. CJHE / RCES Volume 45, No. 2, 2015