2013

http://informahealthcare.com/jicISSN: 1356-1820 (print), 1469-9567 (electronic)

J Interprof Care, 2013; 27(S2): 63–68! 2013 Informa UK Ltd. DOI: 10.3109/13561820.2013.795933

Designing new collaborative learning spaces in clinical environments:experiences from a children’s hospital in Australia

Julie E. Bines1 and Peter Jamieson2

1Department of Paediatrics, University of Melbourne, Melbourne, Australia and 2Office of Provost, University of Melbourne, Parkville, Australia

Abstract

Hospitals are complex places that provide a rich learning environment for students, staff,patients and their families, professional groups and the community. The ‘‘new’’ Royal Children’sHospital opened in late 2011. Its mission is focused on improving health and well-beingof children and adolescents through leadership in healthcare, research and education.Addressing the need to create ‘‘responsive learning environments’’ aligned with the shift tostudent-centred pedagogy, two distinct learning environments were developed within the newRoyal Children’s Hospital; (i) a dedicated education precinct providing a suite of physicalenvironments to promote a more active, collaborative and social learning experiencefor education and training programs conducted on the Royal Children’s Hospital campusand (ii) a suite of learning spaces embedded within clinical areas so that learning becomesan integral part of the daily activities of this busy Hospital environment. The aim of this articleis to present the overarching educational principles that lead the design of these learningspaces and describe the opportunities and obstacles encountered in the development ofcollaborative learning spaces within a large hospital development.

Keywords

Collaborative, education, health and socialcare, interprofessional education,interprofessional learning

History

Received 22 November 2012Final Revision 14 February 2013Accepted 7 April 2013Published online 23 May 2013

Introduction

Hospitals are complex places. The public face of the hospitalincludes the doctors, nurses and other health professionals (e.g.occupational therapists, social workers); however, behind theseclinicians exist a platform of non-clinical services that provide theinfrastructure necessary for the hospital to function. Hospitalsprovide a rich learning environment for students, staff, patients,their families and care givers, professional groups, for communitybased healthcare workers and for those who seek skills in themanagement of people with a range of healthcare needs. There isa longstanding ethos of teaching and learning within the medicalsector as portrayed in the Hippocratic Oath taken by many doctorson graduation. However, what has been less well understoodis how to maximise this potential and enhance the quality of thelearning experience within the busy clinical environment.Although many hospitals are affiliated with a University, unlikeuniversities the core business of hospitals is to treat patients. As aresult, education, although it is recognised as valuable, often takesa back seat to clinical care and research. However, as hospitals arebecoming increasingly aware of factors influencing quality andsafety, the publication of these outcomes in benchmarkingactivities, and the need to attract and retain a highly competentworkforce, the importance of education and professional devel-opment of staff has been evident (Aiken et al., 2012; Robertet al., 2011).

In the future development of Hospitals there is a uniqueopportunity to learn from innovative educational environmentsacross the higher education sector and adapt these concepts to theclinical context to facilitate the teaching and learning experiencefor students entering the healthcare system as well as to facilitateeffective professional development of staff and interprofessionalactivities. The aim of this article is to present the overachingeducational principles that lead the design of these learningspaces and describe the opportunities and obstacles encounteredin the development of learning spaces within a large hospitaldevelopment.

Background

The Royal Children’s Hospital (RCH) Campus is comprised ofthree key partners: The Royal Children’s Hospital, The Universityof Melbourne Department of Paediatrics and the MurdochChildrens Research Institute. The Royal Children’s Hospital is apremier tertiary care paediatric hospital in Australia servicing theannual birth cohort of �65 000 infants in the State of Victoria.The RCH also provides specialist paediatric surgery and medicalcare for children from around Australia and from the Asia-Pacificregion. The role of education in achieving this vision is articulatedwithin the mission statement ‘‘The RCH improves the health andwell-being of children and adolescents through leadership inhealthcare, research and education’’ (www.rch.org.au).

The ‘‘new’’ RCH opened in late 2011. The site is unique,placed within a natural parkland with ready access to publictransport on the edge of central Melbourne. The new developmentis a new stand alone facility metres down the road from theoriginal hospital buildings. The close proximity to the Universityof Melbourne within the Parkville Precinct adjacent to other

Correspondence: Julie Elissa Bines, MBBS FRACP MD, University ofMelbouune, Australia, Paediatrics, Flemington Rd, Parkville, Melbourne,3052, Australia. E-mail: julie.bines@rch.org.au

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prestigious medical research Institute and hospitals providing anopportunity for potential collaboration and sharing of resources.The RCH has been designed as a child- and family-friendlyhospital with abundant light and colour and features a range ofinteractive playgrounds, a coral reef aquarium, a meerkatenclosure, a bean bag theatre, interactive science displays andan education and entertainment system at each patient bed(see: http://www.rch.org.au/uploadedFiles/). The inpatient wardsare distributed across five levels with each ward taking on thenames of a native animal or plant. A total of 80% of roomshave a view of the parkland and the remaining 20% have acourtyard view. The hospital has also been developed withconsideration of new technologies within the operation theatresand imaging suites. The hospital has been built as a public privatepartnership under the Victorian Government’s PartnershipVictoria model which means that the RCH operates the hospitaland provides all clinical services, staffing and teaching andtraining and research services, while the private sector finances,designs, constructs and maintains the new hospital building for a25-year period.

Considerations in the planning the developmentof learning spaces

The original scope and vision of the RCH education facilitieswithin the ‘‘new’’ RCH Campus was to provide:� An integrated centre that is aligned with the strategic vision

of the hospital and its partners,� A centre of excellence in the provision of education for child

and adolescent health,� A state of the art facility that provides flexible, innovative

environments for teaching and learning inspiring the nextgeneration of healthcare professionals.Through meetings of key stakeholders the priorities were

established and developed, supported by expertise in the design ofnew generation learning environments and the pedagogy of highereducation from The University of Melbourne. Adopting the viewthat ‘‘we can facilitate deeper and richer learning when we designspaces with learning in mind’’ (Chism, 2006), and the growingpush to consider the entire campus as a learning environment(Kenney, Dumont, & Kenney, 2005), the University’s strategyasked:� What does it mean to learn in a campus-based setting in an

increasingly online world?� How can the physical environment be designed to enhance

student learning and the quality of the student learningexperience?Reviewing evidence of a fundamental change in higher edu-

cation pedagogy, Barr & Tagg (1995) describe a transition froman ‘‘instruction paradigm’’ to a ‘‘learning paradigm’’ and anincreased emphasis on the student. Addressing the need to create‘‘responsive learning environments’’ aligned with the shiftto student-centred pedagogy, Aravot says for learning to occur,‘‘a plethora of human capacities must be harnessed.’’ This is saidto include all of the senses, reason, emotion, imagination,intuition, motivation, memory, creativity and communication(Aravot, 2009). A concern with student learning, according toTinto (2003), requires us ‘‘. . . to consider how the educationalenvironments or conditions we construct engage students inways which bring to the fore their understanding, and activelyengage them in a communal discourse . . . ’’ (p. 29). The researchwhich formed the basis of what has become known as the‘‘student learning’’ discourse originated in Sweden and theUnited Kingdom in the 1970s, which eventually inspired furtherstudies including key work undertaken in Australia and HongKong (Biggs, 1998; Bowden, 1986; Entwistle & Hounsell, 1975;

Marton & Saljo, 1976; Ramsden, 1988, 1992). Over severaldecades, numerous studies into student learning in universitieshave been conducted in a range of academic disciplines acrossvarious national and cultural contexts. The studies have trans-formed our understanding of effective learning and the conditionsunder which learning is more likely to be improved.

An essential finding, standing in sharp contrast with thetraditional didactic, instructional pedagogy of higher education,was the recognition that most importantly in learning, it is whatthe ‘‘student does’’ that matters most (Biggs & Tang, 2007).In recent times, higher education pedagogy also has beenincreasingly influenced by the ‘‘social constructivist’’ view oflearning which sees knowledge as being constructed in a socialcontext, and not simply the product of individual effort orintelligence. From this perspective, effective learning thereforeinvolves a variety of active, problem-solving experiences thatengage the learner in the ‘‘social,’’ rather than the ‘‘individual,’’development of knowledge. According to Chism (2002), the‘‘constructivist’’ view of learning:

. . . implies the need for small-group meeting spaces, projectspaces, spaces for whole-class dialogue where the studentsas well as the teacher can be seen and heard, spaces wheretechnology can be accessed easily, spaces for display of ideasand working documents, and spaces that can accommodatemovement and noise. What’s more, the spaces are likely not allto be in traditional academic classrooms. Spillover spaces inwide corridors or lobbies outside classrooms, outdoor spaces,and spaces that include possibilities for food and Internetaccess are all needed (p. 10).

Within the literature on the pedagogy of higher education,there also has been a growing recognition of the variation instudent learning styles and the impact of individual preferencesfor learning in specific ways (Schmeck, 1983). A study under-taken by the Scottish Funding Council identified three ‘‘keylearning styles’’ which it believes should be used to conceptualisenew learning spaces. They are: learning by reflection; learningby doing; and learning through conversation (AMA, 2006). Thestudy identified seven types of ‘‘new environments for learning’’:group teaching/learning; simulated environments; immersiveenvironments; peer-to-peer and social learning; clusters; individ-ual learning; and external spaces (AMA, 2006).

The design of new generation learning environments also hasbeen influenced by research findings outside of education whichhave sought to understand the relationship between individualsand the built environment. Scott-Webber (2004) has appliedthe findings of environmental behavior research to the designof learning spaces, and offers a suite of generic spatial typesto enable distinct behavioral outcomes for learners. She contendsthat the university needs ‘‘environments for applying know-ledge’’; ‘‘environments for creating knowledge’’; ‘‘environmentsfor communicating knowledge’’; and ‘‘environments whereknowledge is used for decision-making’’ (Scott-Webber, 2004).

Furthermore, a number of complementary research traditionshave addressed the person-space nexus in psychological andphysical terms, which has given further impetus to thinking aboutthe characteristics and qualities of new types of learning spaces(Graetz & Goliber, 2002; Yudell, 1977). Through their physicalform, the use of color and materials, and the level and qualityof light, constructed spaces stimulate the ‘senses and the mind’(Exner & Pressel, 2009). Such environmental elements of asetting can have a direct impact on the motivation and cognitiveperformance of individuals, either positively or negatively(Ardener, 2006; Graetz & Goliber, 2002). Graetz (2006) observesthat there can be an emotional impact on the learner from the

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physical characteristics of learning environments which can have‘important cognitive and behavioral consequences.

Research indicates that the design of a physical setting caninfluence the occupant’s perception of what it means to functionwithin that environment as the space is ‘‘read’’ in terms of thecues it provides regarding its intended function and the behaviorrequired of those within it (Lawson, 2001; Monahan, 2000).McWilliam (2010) argues individuals entering a learning space‘‘receive strong messages about what their experience of learningis likely to be’’ (p. 9).

Design of the learning spaces

Based on the theoretical principles outlined above, two distinctapproaches to the development of the teaching and learningspaces were implemented. First, a dedicated Health Education andLearning Precinct (HELP) was created and located to be readilyaccessible to staff but also highly visible to the public asacknowledgement of the integral role of education within theRCH. Importantly, teaching and learning spaces were alsoembedded within specialist clinical areas within the hospital,including wards, emergency room, ICU and the operative theatre.The aim of these areas was to incorporate teaching and learningwithin the day-to-day activities of the hospital – to take educationto the bedside where it is likely to be most effective in improvingpatient outcomes and the impact of the learning experience.

Developing a dedicated health education and learningprecinct (HELP)

HELP is an integrated precinct of formal and informal learningspaces providing a suite of physical environments to promotea more active, collaborative and social learning experiencefor education and training programs conducted within the RCHcampus. Located on the first level of the RCH, HELP wasdesigned to reflect the changes in Learning Environment Designbeing implemented more widely across The University ofMelbourne campus since 2006. In that period the University hascreated a range of exemplary, award-winning classrooms, librariesand student learning hubs to accommodate more engaging andeffective approaches to teaching and learning.

The HELP is defined by a central axis linking classroomsand joining a Library and a staff-student lounge at either end.The precinct comprises the following key components:� A suite of seven collaborative learning classrooms, varying

in capacity from 12 to 80� A 280 capacity lecture theatre� A simulation centre including a high technology simulation

laboratory, a technical skills laboratory and a clinical consult-ation room

� Ten traditional meeting/tutorial rooms, varying in capacityfrom 12 to 30

� A small formal library for research and study purposes� A staff-student lounge serving as a hospitality facility and a

setting for informal learningAt the core of HELP are the collaborative learning classrooms

that have two primary functions – (i) to enable more student-centred formal learning to occur; and (ii) to promote informallearning activity in out-of-class times. In this way it is intended toattract and retain students within the precinct by blurring thetraditional boundary between ‘‘formal’’ and ‘‘informal’’ learning,and to provide a more vibrant learning community for the mutualbenefit of academics/teachers and students.

The collaborative classrooms in HELP represent a newgeneration of spatial types intended to promote small-group,interactive and problem-based learning. The critical pedagogicaldecision around which the classrooms have been conceived, is the

view that effective small-group learning should typically involveda maximum of six students. A small-group of six enables theteacher to construct various combinations of student interactions(e.g. multiples of pairs and triplets) at any one table, enablingvariation in activity with minimal disruption to classroomarrangement and furniture layout – this is particularly importantwhere space is at a premium and student movement is not easilyaccommodated. Second, as groups increase in size beyond six,so too does the likelihood that students at risk will become lessengaged in the learning process.

A feature of the classrooms is the two very different formsof small-group table designed to accommodate six students.One table provides a long rectangular surface with rounded endsand offer students two fitted computers at either end to promotecollaborate IT-based learning. The other table features a triangu-lar ‘‘plectrum’’ shape and has no installed IT devices. Both tablesprovide scope for students to use personal technologies.In eachcase, the tables are designed to address a fundamental classroommanagement issue for teachers, by enabling the ready transitionfrom ‘‘presentation mode’’ where the teacher (or a student) ispresenting material to the entire class, to self-directed small-grouplearning. The design results in minimal impact on the conductof the class through the simple movement of some studentson castored chairs shifting small distances around the table edgeto take up alternative viewing positions at the tables according tothe mode of learning (see Figure 1).

It is not sufficient for teachers to simply set up small-grouplearning if this results in groups operating completely independ-ently of each other. The HELP collaborative classrooms aredesigned to promote cross-class interaction, including the mul-tiple displays of each group’s work, in order that students benefitfrom the collective knowledge and skills within the entire classgroup. A key finding from the student learning research is thecritical need for learners to be exposed to the different perspec-tives of the full class group of the material being studied in orderto compare their own perspective with those of other students.The awareness of how others understand, or make sense of thematerial, is a pre-condition for students to develop a moresophisticated understanding of that material.

In contrast to the widespread, and often very problematic,adoption of ‘‘flexibility’’ in classroom design, HELP’s collab-orative classrooms are arranged on the presumption that the tableswill not normally be moved – though IT and electrical servicesto the tables can be readily disconnected should the need arise.A further distinguishing feature of several classrooms is thedeliberate use of ‘‘high’’ (and different-shaped) tables in certainlocations to promote improved student sightlines from furtherpoints in the room, and to enable improved verbal interactionacross crowded rooms in whole-of-class student discussions(see Figure 2).

Although the classrooms vary in physical size and studentcapacity, the common aim was to challenge the traditionalorientation of classrooms towards a single ‘‘front-of-house’’position and, where possible, to promote greater teacher andstudent movement around the rooms. The classrooms includevarious forms of ‘‘active surfaces’’ around the perimeter of theroom to promote small-group, active learning – in some cases thistakes the form of digital display screens to accommodate groupuse of computers and other technologies, while in other casesstudents are provided with ‘‘writing walls’’ (see Figure 3).

In addition to its multi-purpose classrooms, HELP providestwo informal learning spaces whose contrasting functions arereflected in their diametrically opposite locations on the centralaxis joining the facility. A small formal, ‘‘in-house’’ librarywas created as an adjunct to much more substantial Librariesand research facilities in the adjacent university precinct. It is

DOI: 10.3109/13561820.2013.795933 Collaborative learning spaces in clinical environments 65

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deliberately designed as a quiet, individual learning andresearch centre. A short walk down the central corridor leadsstaff and students to a generously open, relaxed lounge withhospitality and kitchen facilities. A feature is a large, shelteredexternal balcony offering glorious views to long-establishednative parklands (see Figure 4). It is a place designed to sustainthe social interaction necessary for any effective learningcommunity, while also offering some users a place of choice

where they can learn individually or collaboratively in morerelaxed surroundings.

The simulation centre is compromised of three distinct areas.The high technology simulation laboratory has the capacity fortwo beds for adult, child or infant manikins. One area is set-upfor an emergency room simulation and the other for an operatingroom simulation with the fit-out reflecting that within the relevanthospital area. The simulation is controlled by operators in an

Figure 1. Collaborative learning spaces withintegrated IT capability.

Figure 2. Flexibility for teachers interactingwith students on tables of different heights.

Figure 3. Collaborative learning spacefeaturing tables of varying shapes andheights.

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adjacent control room within direct sight aided by video camerasstrategically placed around the laboratory. The laboratory can beviewed through one-way glass to two adjacent rooms or via video-conferencing to another area in the HELP or elsewhere in thehospital. The aim of this laboratory is to provide simulation forteam based exercises requiring high technology. Such exercisesmight include disaster response, specific operative proceduresor skills requiring a high level of team interaction. The technicalskills laboratory is a wet laboratory to enable the training ofbasic laboratory skills, clinical skills such as catheter insertionthat involve liquids and part-task training using manikins for lifesupport training or specific skills such as placement of intercostalcatheters. A clinical consultation room is fit-out to reflect thespecialist outpatient consultation suite. However, in addition ithas video cameras to record the simulated consultation in orderto provide feedback. This room is primarily used to teachcommunication skills and the response to common events thatmay occur within a clinical consultation.

Development of teaching and learning spacesembedded within the hospital

Patients are our richest teaching resource and therefore maintain-ing proximity to the ‘‘action’’ is ideal at almost all levels ofeducation. This allows learning of not only the scientificprinciples of the recognition of disease and treatment but alsoinsights to the professional culture of being a good clinicianand effective interprofessional team member, the ‘‘art’’ of clinicalcare and the other subtle skills critical to be a good clinician.

The nature of the busy hospital environment makes it verydifficult for individuals or interprofessional teams to dedicatesignificant time in their day for education, away from their directclinical responsibilities. Although study days are available undersome healthcare awards this is certainly not uniform acrossall disciplines or available for staff who are employed on limitedcontracts or on casual employment arrangements. However, thesestaff all have a role to play in providing high quality care topatients. Students are usually very keen to be engaged in directclinical care and dragging them out of the clinical environmentfor teaching is sometimes interpreted as a missed opportunity tolearn.

The design of the wards lends well to teaching. Eighty-fivepercent of patient rooms are single and the remaining 15% doublerooms. This provides an environment where patient interviewsand examination can be conducted in privacy for families with

individual students or in rounds with groups of students. Thesingle rooms can also be used to simulate medical emergenciesor events without interfering with the function of the ward anddisturbing other families. At the RCH in each ward there is adesignated teaching or meeting room. This room is addition tothe central clinical office or ‘‘write-up’’ room, separate to theward office for nursing managers and ward based staff andseparate to the parent interview rooms and play rooms. It has nopatient services such oxygen supply or suction and is equippedwith a table, a single computer and data projector and whiteboard. The intention of this room is specifically for teaching ordebriefing for students and staff. As there are over 120 dedicatedmeeting rooms across the RCH Campus there are many othermore suitable options for meetings not directly associated withward and teaching activities in other areas.

Although a dedicated high technology simulation centrehas been developed within the HELP, their are distinct advantagesof conducting some simulation exercises within the environmentwhere these events are likely to occur, involving the group of staffthat are likely to be directly involved. This can be used to assessthe preparedness of the environment for an event that may occurin the future or to up-skill a specific interprofessional teamin preparation for an expected event – for example a patient athigh risk of a particular adverse event. Placing the simulationwithin the normal daily environment often has a marked impacton individual and team performance and is a highly effectivemethod of learning. Simulation exercises can be conducted inthe ward – such as cardiac arrests or anaphylactic shock. Thesingle rooms greatly enhance this opportunity. Dedicated roomsfor simulation exercises have also been developed in specialtyareas including the Emergency Room and the Intensive Care Unitto address specific skill requirements in those areas. Althoughthe operating theatres have not been developed with specificSimulation rooms, simulation exercises have been conducted in aroutine theatre designated for this purposes and within theatreswhere new equipment has been installed to train staff in thecorrect and safe operation of this equipment.

There are many possible options for the use of the availablespaces within the hospital for a range of teaching and learningactivities. The medical student-led ‘‘teddy bear’’ hospital is acommunity project where children bring their teddy bear to beexamined by the medical students and learn about the hospital.For the students it provides a wonderful opportunity to learnhow to engage with healthy children and learn normal childdevelopment, as well providing a community education and

Figure 4. Staff and student lounge.

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fundraising event. This is a very popular activity for students andchildren alike.

Concluding comments

The primary focus of the RCH development was the developmentof a state of the art children’s hospital with an emphasis onclinical care and the interface between the children and theirfamilies and the hospital environment. The project was developedas a public–private partnership. These factors inevitably drove theoverall design and priorities for space allocation and resources.Although it was acknowledged that education was includedwithin the design brief and there was engagement of keystakeholders in the design development, strong advocacy wascritical throughout the duration of the project to achieve theeducational aspirations outlined in the brief. Being a ‘‘small partof a big project’’ presented challenges, however in this projectthere was a genuine desire by all to achieve a great outcome forthe students, staff, patients and their families of the hospital aswell as for the community of Victoria and this ultimately resultedin the development of innovative learning spaces on the RCHCampus. Although these collaborative spaces providenew opportunities for collaborative interactive learning, not allteachers have easily adapted to take full advantage of the optionsoffered by these spaces. A series of targeted workshops are beingconducted to assist teachers explore the spaces and consider how acollaborative approach may enhance their learning objectives andthe learning experience. Evaluation of the spaces in context of thelearning and teaching experience is currently being conductedwith the aim to understand the impact on the learning andteaching experience and outcomes as well as to inform theplanning for future learning spaces within a clinical environment.

Declaration of interest

The authors declare no conflict of interest. The authors alone areresponsible for the writing and content of this article.

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