WHAT IS INTERPROFESSIONAL EDUCATION?

According to the World Health Organization (WHO), interprofessional education (IPE) is an experience that “occurs when students from two or more professions learn about, from, and with each other” (WHO, 2010). Although having students learn together can improve the health and the safety of patients, workshop planning committee member George Thibault of the Josiah Macy Jr. Foundation, who provided the introductory remarks to the workshop, emphasized that IPE is not a replacement for education specific to each profession. “This is not about totally smudging together the professions and saying they're all the same,” he said, adding that each profession is part of the interprofessional collaboration in order to provide something that somebody else cannot provide. “We still need to rigorously defend and improve the education specific to each profession while we accomplish interprofessional education,” he said.

Another important point Thibault raised is that each health profession possesses its own identity and pride in what it does that is special. An interprofessional identity does not replace this, but rather complements the professional identity. Furthermore, Thibault said that IPE is not the only innovation that is needed to improve patient care and health. It is an important innovation which interacts with other educational innovations to improve health professions education, with a goal of improving the health of the public, but it is not a panacea for all health care system problems. There are many other things that require fixing. Sometimes IPE provides a window into what those other problems are (i.e., regulation, reimbursement, workforce), but it alone will not solve those problems.

Thibault also emphasized that experiential learning is a key element of IPE. Experiential learning refers to the practice of students entering a practice environment to better understand how to work collaboratively in “real-life” situations. Thibault also explained that interprofessional learning is different from multidisciplinary learning, in which students from different professions learn or even work in a group. To be truly interprofessional, he said, an interaction requires purposeful integration and collaboration among the disciplines, whether in an educational or practice environment. Workshop speaker Mark Earnest from the University of Colorado echoed Thibault's remarks, saying, “[W]orking in groups is not the same as learning in teams.” It was noted by a number of participants that educators and care providers often say they educate or work interprofessionally, but when evaluated, the evidence of collaboration is weak or nonexistent.

As was explained by workshop co-chair Lucinda Maine from the American Association of Colleges of Pharmacy, certain key processes—such as communication, cooperation, coordination, and collaboration across as well as within professions—cut across interprofessional education and can be applied to a variety of collaborative work settings. Participant Jody Frost emphasized the need for focusing on a health professional team that includes all of the health professionals that need to be there along with the patient, the family, the caregiver, and the community. “If we're going to walk the talk,” she said, “we need a new language. I would implore us to start talking about change in education and practice around a health professional team rather than a discipline-specific group.”

Recognizing the importance of coordinated care in hospital settings, Matthew Wynia and colleagues researched the qualities of well-functioning teams (Mitchell et al., 2012). They found that members of well-functioning teams share an understanding of the team's goals and that each member understands his or her role within the team. Most important, there is a mutual trust among team members. Ensuring clarity concerning roles and goals is a basic principle of well-functioning teams, regardless of the context within which they are working. Wynia, who was a workshop session moderator, stressed that these qualities correspond to tangible interprofessional skills that should be imparted to students. Such skills include practical techniques to make explicit

• the task and goal of the team,
• who is on the team,
• why certain members are selected to be on the team,
• what the role of each team member is, and
• how the members' roles fit together to accomplish the desired goal.

A workshop participant stated that students who internalize these principles through experiential learning with well-functioning teams will be better prepared to participate in similar collaborative care situations after graduation. He said that this, in turn, will lead to clearer team goals and more precise measurements of improvements in health outcomes. The following sections provide examples of meaningful, experiential learning using different modalities through which students can be educated about the qualities of a well-functioning team.

A Social Responsibility for Collaboration

The authors of WHO's 2010 publication Framework for Action on Interprofessional Education and Collaborative Practice defined a professional within “interprofessional education” as any individual “with the knowledge and/or skills to contribute to the physical, mental and social well-being of a community.” In addressing the social well-being of a community, Sandeep Kishore—who represented one of the student perspectives presented a the workshops—referred to this definition when emphasizing the social responsibility of health professionals to work together to provide optimal services to communities. He went on to say that part of the social responsibility of health professionals is to work together in addressing the “causes of the causes” of ill health that must then be taught to students in an interprofessional manner (see Box 2-1).

BOX 2-1

Sandeep Kishore, Ph.D. Cornell Medical College. Workshop speaker Sandeep Kishore is a student at Cornell Medical College. His mentors exposed him to data from the U.S. Department of Health and Human Services showing that only 5 of the 30-plus years gained (more...)

Knowing the “causes of the causes” sheds light on the inequalities in living conditions that often shape the quality of people's health and health care. Such “glaring gaps and inequities,” according to the commissioners of the Lancet report on health professional education (Frenk et al., 2010), “persist both within and between countries.” Thibault said that no country is immune from this, including resource-rich nations. In particular, Paul Worley from Flinders University in Australia focused on this point in his presentation, which is summarized in Box 2-2.

BOX 2-2

Paul Worley, M.B.B.S., Ph.D. School of Medicine at Flinders University, Australia. The stark divide between the number of health care workers serving urban Australia versus the number serving rural Australia is striking in every provider category except (more...)

Presenters at the workshop offered three examples of interprofessional education grounded in coursework and experiences that teach social responsibility. Jan De Maeseneer from Ghent University described how students at his university learn about social determinants and health inequities by traveling to impoverished communities in Ghent, Belgium, to learn with students from other disciplines. Stefanus Snyman and Marietjie de Villiers from Stellenbosch University in South Africa described how they use the unifying structure of the WHO International Classification of Functioning, Disability and Health Framework¹ (ICF) in clinical care settings to bring different student and faculty professions together around a holistic assessment of the patient. And Elizabeth Speakman described the Health Mentors Program at Thomas Jefferson University, which involves students from different professions learning about the social, cultural, and environmental conditions in which their clinic patients live. Details of each of these presentations are given below.

Jan De Maeseneer, M.D., Ph.D. Ghent University, Belgium

In the third year of their health professional education at Ghent University, students are exposed to impoverished communities in Ghent, Belgium, to learn with groups of students from medicine, social pedagogy, sociology, and health promotion. Each team explores its assigned neighborhood to observe the characteristics of that neighborhood and the composition of its population. According to De Maeseneer, who is the chair of the Ghent University Educational Committee for the undergraduate medical curriculum, the teams then collect medical data as well as nonmedical indicators such as criminology data, which tell a lot about the quality of life in certain neighborhoods.

Students later come together in a group to discuss the information they collected and observed. This is where culture clashes can arise between medical and social science students, De Maeseneer said, because medical students often want to solve problems immediately, whereas social science students are more apt to analyze the problem, consider the determinants, and question whether the problem is something that can be addressed by their group. He added that these discussions expose students to different ways of thinking about health predicaments and the thought processes of other disciplines.

Although Ghent University has been offering this community-based experience for 10 years, it has not gotten any easier. Indeed, De Maeseneer said, the logistics are even more daunting now than they were at the beginning. The experience involves 84 homes that have to be ready to receive the students, 252 caregivers, and 10 community stakeholders as well as tutors, coordinators, assessors, and panel members. “The logistics are really challenging,” he said, but clearly not impossible.

Stefanus Snyman, M.B.Ch.B., and Marietjie de Villiers, Ph.D., M.B.Ch.B., M.Fam.Med. Stellenbosch University, South Africa

As at Ghent University, the IPE strategy at Stellenbosch University in Capetown, South Africa, is to educate students through a socially accountable IPE program. Stefanus Snyman, the coordinator of interprofessional learning and teaching at Stellenbosch's Centre for Health Professions Education, said that he sees IPE as a tool for equipping students to become change agents in order to improve patient outcomes and strengthen health systems in Africa. He believes that IPE can be a vehicle for transformative learning and that it is an instrument to foster educational interdependence between the health and the educational systems.

The university's IPE strategy (see Figure 2-1) is based on three pillars and is described fully in Appendix C of this report. The first pillar is the integration of graduate attributes or core competencies into the curriculums and the interprofessional assessment of the competencies. The second pillar is the use of the ICF framework as a common language among all professionals at the school in the management of patient care. According to Snyman and de Villiers, using the ICF Framework in the clinical care setting gives students and faculty a unified structure with which to conduct a holistic assessment of the patient. Under each of the four topic areas (body functions and structures, activities, participation, and environmental factors) are five to nine subdivisions that cover a wide range of health-related issues, including mental function, the cardiovascular system, mobility, self-care, support and relationships, and attitudes. As Snyman said, given the expansive list of assessment items in the framework, no one profession could ever manage the full range of needs identified in a managed care plan. And he added that, in using the framework, students and faculty realize they cannot manage the care of a patient alone and begin the process of working together.

FIGURE 2-1

Stellenbosch University interprofessional education (IPE) strategy. SOURCE: Snyman, 2012. NOTE: ICF = International Classification of Functioning, Disability, and Health; IPC = interprofessional care; IPP = interprofessional practice.

The third pillar is health education and harmonization, which requires leadership from the top as well as learners to make the necessary changes. According to de Villiers, this pillar is designed to equip faculty and community preceptors with interprofessional skills and to develop strategies that bring them together to work collaboratively.

Elizabeth Speakman, Ed.D., R.N. Thomas Jefferson University

According to Elizabeth Speakman, co-director at the Jefferson InterProfessional Education Center, the Health Mentors Program at Thomas Jefferson University in Philadelphia has been available to students as long as the university's InterProfessional Education Center has been in existence. This program involves roughly 250 health mentors and roughly 1,300 students from the Jefferson Medical College and the schools of nursing, pharmacy, and health professions, the last of which includes occupational therapy, physical therapy, and couples and family therapy. Each team is made up of students from these different health disciplines, and over the course of 2 years, the students in the teams learn directly from their health mentors—who are patients in the community—about these individuals' health status and living conditions. Speakman said that the work of the students on a team culminates in the fourth and final semester with a visit to their mentor's home in order to experience the conditions and limitations under which their mentor lives.

Following this experience, students are required to write reflective papers. In those papers, Speakman said, students often cite a better understanding of the other health disciplines for their in-depth understanding of the community and the environment in which their patient lives; occupational therapy is often singled out for particular respect because they understand the physical and environmental challenges patients are confronted with outside of the health care facility. Speakman added that students also write about the value of the group leaders who provide guidance on how to communicate effectively with patients and other team members.

Learning IPE Through Patient Safety Activities

Pamela H. Mitchell wrote in the chapter “Defining Patient Safety and Quality Care” that “safety is the foundation upon which all other aspects of quality care are built” (Mitchell, 2008). Linking this notion of patient safety to interprofessional practice, workshop session moderator, Hugh Barr of the U.K. Centre for the Advancement of Interprofessional Education, commented on the recent work of Sexton and colleagues. Those researchers found that improvements in teamwork and culture in intensive care units improved the overall safety climate (Sexton et al., 2011). Using safety as a way to educate students on how to collaborate interprofessionally resonated with a number of presenters at the workshop. Two examples of this approach, from Curtin University and from the University of Missouri, are described below.

At Curtin University, Brewer and Jones developed a framework for IPE curriculum development, which is shown in Figure 2-2. Workshop presenter Dawn Forman from Curtin discussed this framework, which underlies the curriculum and also extends into interprofessional practice. The IPE curriculum starts in the first year, she said, with 23 health professional schools following a model for ensuring client safety and quality. The foundation laid in this first year is built upon in the second, third, and fourth years for each of the programs by having one unit for each profession, which is integrated into each of the subsequent years through workshops, simulation activities, and most importantly, placement activities.

FIGURE 2-2

Framework for IPE curriculum development. SOURCE: Brewer and Jones, in press.

Like Forman, workshop speaker Carla Dyer of the University of Missouri School of Medicine uses IPE patient safety as a way to teach collaboration to her students. She and her colleagues address patient safety and quality improvement using “fall prevention” as the interprofessional teaching modality.

According to Dyer, students first learn about fall prevention through an independent, online study that quickly shifts to a simulation and bedside encounter where students are grouped in dyads consisting of a medical student and a nursing student. The interprofessional simulation first focuses on fall risks in the inpatient setting and then transitions to the home environment. For the bedside encounter, Dyer said, students begin by completing a chart review to gather information about the patient's risk for falls. They then review the home environment and the patient care setting. With this information, the students jointly develop a customized fall prevention plan that is discussed with the patient and his or her family member.

Both the medical students' and the nursing students' skills in assessing patient falls are measured before and after their simulation experiences. The results of this assessment showed statistically significant improvements in responses in all of the measured categories, Dyer said. Students were also asked to reflect on the value of the interprofessional experience through an online module; their answers indicated that they valued this experiential leaning opportunity. Program evaluators also wanted to know whether the intervention was valuable to the patients. Dyer and colleagues reported that roughly 250 patients were involved in the simulation activity over the past 3 years and that 93 percent of patients interviewed since the start of the simulation reported that the experience and their interactions with the students were valuable.

Learning IPE Through Community Service

Workshop speaker Gillian Barclay of the Aetna Foundation encouraged the audience to consider interprofessional opportunities that are community-based and that go beyond health. To explain her point, Barclay drew upon the work that Jack Geiger did in the 1960s in rural Mississippi to describe how agriculture specialists engaged with urban planners and health professionals to place farmers' markets near community health centers. She also said the Aetna Foundation is funding evaluation measures within this unique interprofessional space to see how the agriculture experts, the urban planners, the physicians, the managers, and the chief executive officers of these community health centers develop sustainable farmers' markets. This is the sort of culture shift to which students should be exposed, Barclay said, and it was the sort of interprofessional education offered to students in North Carolina under the direction of J. Lloyd Michener and his colleagues at Duke University (see Box 2-3 for a summary of Michener's presentation at the workshop).

BOX 2-3

Durham and Duke: A Story of One Community's Journey Toward Health. J. Lloyd Michener, M.D. Duke University School of Medicine

Key Messages Raised by Individual Speakers

• Learning in groups is not the same as learning interprofessionally. (Earnest and Thibault)
• An important part of IPE learning is experiential. (De Maeseneer, de Villiers, Snyman, Speakman, and Thibault)
• Interprofessional opportunities that go beyond health can help students understand and address the “causes of the causes.” (Barclay and Kishore)
• It is the “causes of causes” of health that need to be addressed and taught to students in an interprofessional manner. (Kishore)

REFERENCES

• Brewer M, Jones S. An interprofessional practice capability framework focusing on safe, high quality client centred health service. In press. (Journal of Allied Health). [PubMed: 23752243]
• Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–1958. [PubMed: 21112623]
• Marmot M. Health equity: The challenge. Australian and New Zealand Journal of Public Health. 2012;36(6):513–514. [PubMed: 23216483]
• Mitchell P. Defining patient safety and quality care. In: Hughes RG, editor. Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. [PubMed: 21328752]
• Mitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb CE, Rohrbach V, von Kohorn I. Core principles and values of effective team-based care. Institute of Medicine; Washington, DC: 2012. [March 12, 2013]. (Discussion Paper). http://iom​.edu/Global​/Perspectives/2012/TeamBasedCare.aspx.
• Piroska Östlin P, Sen G, George A. Paying attention to gender and poverty in health research: Content and process issues. Bulletin of the World Health Organization. 2004;82(10):740–745. [PMC free article: PMC2623023] [PubMed: 15643794]
• Seligman M. Flourish: A Visionary New Understanding of Happiness and Well-Being. New York: Free Press; 2011.
• Sexton JB, Berenholtz SM, Goeschel CA, Watson SR, Holzmueller CG, Thompson DA, Hyzy RC, Marsteller JA, Schumacher K, Pronovost PJ. Assessing and improving safety climate in a large cohort of intensive care units. Critical Care Medicine. 2011;39(5):934–939. [PubMed: 21297460]
• Snyman S. Stellenbosch IPE strategy; Presented at the IOM Workshop: Educating for Practice; Washington, DC. November 30. 2012.
• WHO (World Health Organization). Framework for action on interprofessional education and collaborative practice. 2010. [March 4, 2013]. http://www​.who.int/hrh​/resources/framework_action/en/index​.html.

Footnotes

1

The WHO International Classification of Functioning, Disability and Health is one of several WHO classifications on health that has been endorsed by the international community to provide meaningful comparisons between and among populations and countries. This tool separates health into four areas: body functions, body structures, activities and participation, and environmental factors. When the four areas are combined, they create an ideal framework for assessing the bio-psycho-social-spiritual health and well-being of a patient.