4 Medical education in an interprofessional context
Before-and-after study A research design in which data are collected before and after an ‘intervention’ such as interprofessional education.
Before-during-and-after study Similar design to a before-and-after study except it entails collecting data at some point during the intervention.
Collaborative practice Collaborative practice in health and social care occurs when multiple professions provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care across settings.
Continuous Quality Improvement; see Quality improvement
Curriculum (without a pronoun) This is used as an overarching term for all those aspects of education that contribute to the experience of learning, including aims, content, mode of delivery and assessment.
Evaluation The systematic gathering of evidence to enable judgement of effectiveness and value, often to promote improvement.
Interprofessional education Where groups of learners from different professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.
Intervention A consciously developed and implemented activity, such as interprofessional education, that attempts to improve or change outcomes of some form such as interprofessional collaboration.
Knowledge translation Knowledge translation is a dynamic and iterative process that includes synthesis, dissemination, exchange, and ethically sound application of knowledge to improve health, provide more effective health services and products, and to strengthen the health care system.
Multiprofessional education Members of different professions learning alongside each other without interaction between them.
Practice Includes both clinical and non-clinical health-related work such as diagnosis, treatment, surveillance, health communications, management, and sanitation engineering.
Professional An all-encompassing term that includes anyone with knowledge and/or skills to contribute to the delivery of care.
Quality Improvement An approach that is based on a manufacturing philosophy and set of methods for reducing time from customer order to product delivery, costing less, taking less space, and improving quality. Common forms of QI activities include Continuous Quality Improvement and Total Quality Management.
Review Literature reviews are collections of previously conducted research or evaluation studies. Reviews may be exploratory, narrative, critical, or systematic.
Scoping review An exploratory type of review that aims to undertake a broad scope of a particular field before more extensive review work can be undertaken.
Total Quality Management; see Quality Improvement A culture within an organisation that is aimed at continuous improvement of educational quality.
Uniprofessional education When members (or students) of a single profession learn together.
Traditional ways of delivering medical education to students and qualified practitioners are being questioned. In addition to clinical knowledge, both pre- and post-qualification learners need other attributes to work effectively within the health care system and provide high-quality care. Those attributes include strategies for communicating and working with non-medical professional groups involved in the delivery of care. Interprofessional education (IPE) gives learners opportunities to develop the attributes and skills needed to work collaboratively with other professions. This chapter has five sections exploring issues pertinent to IPE, which include its emergence and aims; different learning and teaching approaches; organisational elements needed for effective IPE; evidence of its effectiveness; and the application of social science theory to IPE. The implications of IPE for medical education are integrated throughout the chapter. The concluding section highlights some future directions for interprofessionalism.
This first part outlines why IPE has emerged within medical and health professions education (e.g. nursing, occupational therapy, social work), and what it sets out to achieve. Globally for over three decades, health policy makers have identified IPE as having a key role in improving health care systems and outcomes (e.g. World Health Organisation, 1976), but it is over the past ten years in particular that IPE has come to the forefront of research, policy, and regulatory activity on an international level. IPE, whether before or after qualification, is defined as
‘When two or more professions learn with, from, and about each other to improve collaboration and the quality of care’ (Centre for the Advancement of IPE – www.caipe.org.uk/about-us/defining-ipe).
This definition applies to learners before and after qualification. The promotion of this type of education stems from the complexity and multifaceted nature of patients’ health care needs and the health care system, and research demonstrating that effective collaboration amongst multiple health care providers is essential for the provision of effective and comprehensive health care.
Problems with communication and collaboration amongst different health care professionals have been well documented and continue to be a concern. For example, failures of collaboration were at the centre of well-publicised health and social care enquiries in the UK, such as the excessively high mortality of children undergoing cardiac surgery in Bristol and the death of Victoria Climbié, a child whose repeated physical abuse continued despite the involvement of various social agencies. A study of interprofessional (IP) teams in Sweden found that poor collaboration between health care professionals impacts on patient care and service (e.g. Kvarnstrom, 2008). Studies in the USA and Canada demonstrated the impact of communication problems on work processes and patient safety in surgical settings (e.g. Williams et al, 2007). In a US sentinel event alert of infant death and injury during delivery, communication issues were identified as a root cause in 72 per cent of the 47 cases identified (The Joint Commission, 2004).
The collective picture emerging from the literature is that doctors, along with other health and social professionals, need to develop attitudes, knowledge, and skills, which equip them to work effectively together if they are to deliver safe, high-quality patient care. It has been argued that a traditionally isolated approach to health professions education in both the pre-qualification (medical school) and post-qualification (from graduate to continuing medical education) stages fails to promote IP collaboration; hence the need for IPE.
Policy documents in various countries have delineated a role for IPE. For example, policy makers in the UK re-emphasised their commitment to it in the white paper A Health Service of all the Talents published in 2000. This outlined the future of education for the health and social care professions to support team working, flexible working, streamlined workforce planning and development, a maximum contribution from all staff towards patient care, and the development of new, more flexible carers (Department of Health, 2000). A number of health policy documents have been produced in Canada outlining the role of IPE within a Pan-Canadian Health Human Resources Strategy (see Box 4.1).
Box 4.1 Health Canada’s statement on IPE
Available at: http://www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/interprof/index-eng.php
“Changing the way we educate health providers is key to achieving system change and to ensuring that health providers have the necessary knowledge and training to work effectively on interprofessional teams within the evolving health care system.”
A sign of the emergence of IPE has been the creation of courses, programmes, and offices in higher education institutions in the United Kingdom, Canada, United States, continental Europe, and Australia (Barr et al, 2005). The Royal College of Physicians and Surgeons of Canada CanMEDS framework outlines competencies needed for medical education and specialty practice organised around seven roles: Collaborator; Medical Expert; Communicator; Health Advocate; Manager; Scholar; and Professional (see: http://rcpsc.medical.org/canmeds/index.php). Similar frameworks are being adopted in other countries. In the UK, for example, the government’s Modernising Medical Careers lists the following requirement of the curriculum for postgraduate education and training:
‘The requirement for trainee doctors to learn a range of skills including communication, the undertaking and use of research, time management, team-working, leadership, quality and safety improvements, and use of evidence and data’.
Likewise, teamworking and communication skills are advocated for inclusion in patient safety education
(see: www.dh.gov.uk/en/Aboutus/MinistersandDepartmentLeaders/ChiefMedicalOfficer/Archive/FeaturesArchive/DH_4107830).
Health care organisations are also supporting IPE initiatives. For example, Barr et al (2005) report on programmes in the United Kingdom and United States, where primary care practices and medical centres have made a commitment to support health care improvements through initiatives that include IPE. Involvement of the medical profession in IPE programmes is essential, given the key role physicians play in IP collaboration. Furthermore, leadership from the medical community is critical, given the complexity of implementing such initiatives. In response, medical schools, associations, councils, practices, and organisations are recognising and supporting IPE for their students and practicing physicians. In a study comparing medical student learning about patient safety uniprofessionally versus interprofessionally, all students increased their knowledge, but those who participated in IPE gained added value and were better able to position their learning within safe IP team-working (Anderson et al, 2009).
Building on Part 1, we probe in more depth a range of pertinent learning and teaching approaches. Specifically, we explore when to deliver IPE, the need for an interactive approach, initial activities, informal learning, IP group composition, programme focus and status, and facilitation.
There is an ongoing debate about when is the most effective time to implement IPE. It has been found that students entering their first year of a prequalification programme already have established and consistent stereotypes about other health and social care professional groups (Barr et al, 2005). It may seem logical, therefore to deliver IPE at this early stage if negative effects of professional socialisation, such as hostile stereotyping, are to be prevented. Others, in contrast, have suggested that post-qualification IPE is more effective because participants have a firmer professional identity and understanding of their role. In a recent survey of pre-registration students from eight health care groups, including medicine, from three higher education institutions in the UK, the strength of professional identity in all professional groups was high on university entry but declined significantly over time in some disciplines. Students’ readiness for IPE was also high at entry but declined significantly over time in all groups except nursing (Coster et al, 2008). Students’ readiness and the existence of professional identities relatively early in their education argue for early and ongoing IPE.
It has been suggested that IPE should be part of an individual’s ongoing professional development, starting pre-qualification and continuing throughout their career (Barr et al, 2005). Given that the objectives and nature of IPE differ according to the stage of learning, this seems appropriate; it could be used initially to prepare students for collaborative practice while, delivered at a later stage, it could reinforce early learning experiences and further support IP collaboration in practice.
The definition of IPE outlined previously stresses the need for interaction between participants as this interactivity is believed to promote development of the competencies required for effective collaboration (Barr et al, 2005). Educational strategies that enable interactivity are therefore a requirement. Barr et al (2005) outline different types of interactive learning methods (Box 4.2).
The literature contains numerous examples of such learning activities. For example, Freeth et al (2009) in the UK report a one-day simulation-based course for obstetricians, obstetric anaesthetists, and midwives to improve IP working in obstetric care. The focus of the course is on non-technical aspects of care and their influence on patient safety. The course involves an initial orientation to the environment, simulation scenarios, and facilitated debriefings.
Combining different interactive learning methods can make IPE more stimulating and interesting and contribute to a deeper level of learning. For instance, the Seamless Care IPE programme in Canada, which aimed to develop IP patient-centred collaborative skills of students from medicine, dental hygiene, dentistry, nursing, and pharmacy, involved an orientation workshop, ongoing educational sessions, and an 8-week clinical placement with an IP student team (Mann et al, 2009). In an evaluation of IP clinical placements for teams of medical, nursing, occupational therapy, and physiotherapy students, it was reported that leaving the clinical learning environment to spend time reflecting upon experiences in interactive classroom activities deepened students’ understanding of issues and processes related to IP teamwork (Reeves, 2008). The particular learning methods used depend on the objectives of the education initiative, the participants, and the resources available. Different students may be more or less familiar and experienced with particular learning methods, such as online learning or simulation, which can be challenging in an IPE programme.
When a group comes together for the first time to undertake IP learning, attention should be paid to the initial interactive processes of group formation. The use of an ‘ice-breaking’ session may help facilitate group cohesion. Ice-breaker sessions allow learners to focus interactively on professional stereotyping or professional assumptions they bring. For example, one study reported that students entering medical school considered nurses to be more caring and doctors more arrogant, and considered nurses to have lower academic ability, competence, and status, although comparable life experience (Rudland and Mires, 2005). Ice-breaker sessions are particularly helpful in unpacking and exploring issues of professionalism (e.g. boundary protectionism) that are central to any collaborative venture. They are also helpful in team-building, especially when a group of learners has not worked together before. These sessions can be useful in allowing established IP teams to unpack issues linked to hierarchy and power differentials that surround their daily practice. Existing problems within established teams, however, can make IPE programmes less effective.
Opportunities for informal learning – when learners meet socially and discuss aspects of their formal education – are a useful part of IPE. Informal learning can allow individuals to exchange ideas and obtain guidance from their peers, work colleagues, or managers. Informal learning activities can be explicitly built into an IP programme by including, for example, opportunities to discuss educational experiences informally during breaks. Informal learning can also occur as an ‘unplanned’ outcome of an IP initiative. In the evaluation of a community-based module (Reeves, 2008), medical, nursing, and dental students used pubs and cafes after their formal learning sessions to discuss informally and reflect upon their IPE; they saw this informal learning as a valuable part of their shared experience.
There are important differences in informal IP clinical placement learning. Informal learning opportunities in clinical contexts can be influenced by individual professional and organisational cultures as well as by students’ confidence levels (Pollard, 2009). Informal learning opportunities and mentorship during them play large roles in students’ learning and development.
Arguably, effective IP interaction requires a balance of professions. An equal mix of members from each profession is ideal because a group skewed too heavily in favor of one profession may inhibit interaction as the larger professional group can dominate. For programmes of longer duration, interaction is enhanced if learners work together within a stable group, with few established members leaving and/or new people joining the group. Furthermore, at the post-qualification level, the participation of all relevant professions is likely essential if the IPE is to have an impact on practice.
Ensuring this balance of professions can be challenging. For learners in full-time pre-qualification education, effective timetabling across profession-specific education programmes can be key to creating group stability. Wright and Lindqvist (2008), for example, discussed challenges coordinating IPE for students from eight different professions, including medicine, and the inevitability that students from some professions could only attend two of the three workshops because of conflicts with clinical placements. They noted that this caused friction as some students viewed incomplete attendance as a lack of commitment.
Some studies have noted the challenges of physician participation in IPE programmes and the need to ensure their presence given their key role in supporting changes in IP collaboration (Goldman et al, 2010). In post-qualification initiatives, learning activities can be affected by the demands of clinical work, especially if sessions are held near learners’ clinical areas or the programmes occur over a number of weeks. One way of overcoming this difficulty is to offer IPE off-site. This may provide a more conducive learning environment and opportunities for important processes of informal learning; it is an expensive option, however, especially as one needs to secure clinical cover for the team. A recent study of an IP programme within maternity care revealed that sufficient representation from each of the professions was important for discussions concerning IP working and team processes yet there was sometimes only one physician, and participants were disappointed not to hear the physician perspective (Freeth et al, 2009).
For effective interactive learning to occur, the group size should not be too large because it is harder for larger groups to have high-quality interactions. IPE programmes generally report group sizes of between five and ten learners (Reeves, 2008). Fiscal restraints, nevertheless, may cause difficulties in creating such small group learning formats. As will be discussed later in this chapter, organisational support is critical to scheduling students from different professional groups and enabling health providers to attend IPE programmes.
There is evidence that IPE is more effective when principles of adult learning are used (e.g. problem-based learning, action learning sets), learning reflects real-world practice experiences (Barr et al, 2005), and interaction occurs between participants. With other research, health professions education, and policymaking colleagues, we are currently conducting a scoping review of IPE programmes, which has found a range in the focus of programmes. Some focus mostly on generic IP skills while others focus on IP skills within the context of particular clinical topics and/or settings.
Combining learning activities designed to promote collaborative outcomes with activities designed to promote more profession-specific outcomes can be problematic as learners experience uncertainty regarding the overall aim of the IPE. This issue emerged during work on an IP placement for medical, nursing, occupational therapy, and physiotherapy students (Reeves, 2008). In order to offer students a holistic insight into the clinical environment, students were offered both collaborative interactive learning activities such as team problem-solving and profession-specific activities such as drug administration – a task that only nursing students undertook. For students on this placement, the inclusion of both collaborative and profession-specific learning activities produced tension as it was found difficult to participate actively in both types of activity. After feeding this finding back to the group responsible for developing the placement, it was agreed to review this part of the placement in order to reduce the tension.
Making participation in IPE voluntary can give the message that it has a low status in relation to profession-specific learning, which may in turn reduce learners’ commitment to it. In addition, if IPE is not assessed in a way that gives it equal weight to profession-specific education, its status can again be diminished. Eliciting public support from professional leaders and recruiting high-quality educators may help improve its status. Making attendance compulsory and scheduling flexibly can prevent logistic challenges from becoming a barrier to effective IPE. For physicians, continuing medical education credits may also provide the needed status, and therefore incentive, to encourage participation. Nevertheless, practitioners undertake IPE on a voluntary basis, so the incentive is to further their own professional development and/or enhance the coordination and delivery of patient/client care.
Facilitating IPE calls for skill, experience, and preparation to deal with the various responsibilities and demands involved. It is ideal to train facilitators from the diverse faculty involved, and the number of facilitators required can be large, particularly in a pre-qualification context, depending on the number of students. There are various attributes required for this type of work, some of which are outlined in Box 4.3.
In line with other forms of small group education, facilitators need to focus on team formation and maintenance, create a non-threatening environment, and help all members participate equally, but these aims are more challenging in an IP context given the history of social and economic inequalities, and friction that exists between the different health and social care professions. Friedson’s (1970) work provides an understanding of those imbalances. He argued that all occupational groups actively engage in a process of professionalisation through engagement in a ‘closure’ project. The aim of this project is straightforward – to secure and then protect exclusive ownership of specific areas of knowledge and expertise to secure economic reward and status enhancement effectively. As medicine was the first of the occupations to engage successfully in a professionalisation project, participants claimed the most highly prestigious areas of clinical work – the ability to diagnose and prescribe – which ensured their dominant position over other health and social care professions. Exploring this theme more recently, Pecukonis et al (2008) argue that different professional cultures shape different definitions of health, wellness, and treatment success, as well as power differences. They argue that IPE is limited by profession-centrism, which must be addressed through a curriculum that promotes IP cultural competence.
This section aims to explore how organisational elements interplay with the development and implementation of IPE within medical education, and the need for faculty development.
Organisational support is crucial to the success of an IPE programme. To instill a positive attitude in students, the organisation and its faculty have to demonstrate their support (Wilhelmsson et al, 2009). The leadership must have interest, knowledge, and experience. Given the resources required to develop and implement IPE, institutional policies and managerial commitment are also crucial. Such leadership and ‘buy-in’ are needed from all participating departments within an organisation.
The particular type of organisational support required depends on the stage of education. Large numbers of students, professional accreditation requirements, and inflexible curricula are challenging aspects of pre-qualification IPE. Most pre-qualification programmes for medicine and nursing have cohorts of between 100 and 200 students, though occupational therapy and physiotherapy programmes typically have cohorts of just 20–60 students. Large numbers create the logistic difficulty of finding a suitable location. Differences in course timing create further problems. Obtaining approval from each of the participating professions’ regulatory bodies and resolving issues of accountability add further complications.
Planning post-qualification IPE tends to be less problematic because there are fewer institutional barriers, though institutional support is required to foster a positive attitude and give staff the time and resources to attend. Organisational support is also critical if any knowledge gains are to be successfully translated into practice.
In addition, finance needs to be carefully considered during the planning of any IP initiative. Because it tends to span a number of different departmental budgets (Reeves, 2008), agreement over financial arrangements can be a major hurdle.
Developing IP curricula is a complex process, which involves health care workers and educators from different faculties, work settings, and locations. Involving faculty from the different programmes is crucial so that all have a sense of ownership. Equal representation ensures that no one group dominates the planning and skews the initiative in any one direction; it is challenging, however, to ensure adequate representation from smaller faculties. As developing IPE takes considerable time and energy, group members need to have dedication and enthusiasm. When programme development depends on the input of a few key enthusiasts, however, the long-term sustainability of a programme is at risk because key individuals may move to other organisations. In the evaluation of an IP clinical placement for nursing, medical, occupational therapy, and physiotherapy students, it was found that sustained enthusiasm of steering group members was critical to overcoming practical issues such as joint validation and the establishment of pilot placements. Without group effort of that sort, IPE cannot be developed and implemented (Reeves, 2008).
The election of a project leader to coordinate group activities and ensure progress is important. Organisers must have IP skills and they need to arrange regular meetings that consider all perspectives (Reeves, 2008; Wilhelmsson et al, 2009). Group members need to share their aims and assumptions about the initiative to ensure that they all work towards a common goal. When differences are identified, they need to be discussed and resolved. Regular planning meetings allow group members to update one another and jointly solve problems.
Sustaining IPE can be equally complex and requires good communication among participants, enthusiasm for the work being done, and a shared vision and understanding of the benefits of introducing a new curriculum. Organisations need constantly to evaluate, revise, and discuss IPE in the organisation and remind all members that the general goal of IPE is to foster IP practice (Wilhelmsson et al, 2009).
Faculty development is needed for those involved in developing, delivering, and evaluating IPE. For most educators, teaching students how to learn about, from, and with each other is a new and challenging experience. Like students, faculty may also feel a tension between IP and uni-professional issues, which may challenge their professional identities. Faculty development may reduce feelings of isolation, develop a more collaborative approach, and provide opportunities for faculty to share knowledge, experiences, and ideas (Rees and Johnson, 2007).
The growing number of faculty development programmes offer similar preparatory activities, such as understanding the roles and responsibilities of the different professions, exploring issues of professionalism, and planning learning strategies for IP groups. IPE faculty development programmes must enable individuals to promote change at the individual and organisational level, and must therefore target diverse stakeholders and address leadership and organisational change (Steinert, 2005). To ensure that faculty maintain their facilitation skills, faculty development must be ongoing. Team teaching with more experienced colleagues can help develop facilitation skills, coupled with regular opportunities for discussion and reflection. When it is impossible for a person to be formally trained, it is advisable for them to seek informal input from a colleague more experienced in this type of work. For IPE to be successfully embedded in curricula and training packages, the early experiences of staff must be positive, which will ensure continued involvement and receptiveness to student feedback.
During the past decade, a number of systematic reviews have examined evidence for the effectiveness of IPE. They had different inclusion criteria and therefore examined different studies although there was overlap. We recently conducted a critical appraisal and synthesis of the evidence base (Reeves et al, 2008), which included six systematic reviews identified by an electronic search for published and unpublished reviews. The following section reports on this synthesis.
The six reviews reported the effects of over 200 studies spanning the period 1974–2005, differing in methodological quality and reporting a range of outcomes, but sharing a common definition of IPE (‘two or more professions learning with, from, and about each other to improve collaboration and the quality of care’). Five were undertaken by similar review teams and five shared similar (methodologically inclusive) inclusion criteria (Reeves et al, 2008). Five employed a similar approach to recording outcomes. Barr et al (2005) modified Kirkpatrick’s four-point typology (learners’ reactions, acquisition of knowledge/skills/attitudes, changes in behaviour, and changes in organisational practice), to the six-point typology shown in Box 4.4.
Box 4.4 Barr et al modified Kirkpatrick typology
Given the broad range of types of evidence (quantitative, mixed methods, and qualitative studies), we adopted an interpretive approach to synthesising the evidence-base. This allowed a variety of methodologies to be synthesised to illuminate different elements of the social world.
Table 4.1 outlines the types of studies included and outcomes examined in each review; below, we summarise the main points in relation to the programmes, quality of studies, and outcomes of the six reviews.
Table 4.1 Key details relating to the findings and quality of evidence in IPE reviews
| Review | Types of studies | Reported outcomes |
|---|---|---|
| Barr et al | 19 studies (7 pre-qualification, 12 post-qualification) based in a range of practice settings | Reactions and attitudes; handful of studies reporting changes to organisational practice/patient care |
| Cooper et al | 30 studies (all pre-qualification) based in a variety of practice settings | Short-term self-reported changes to attitudes, beliefs, knowledge, skills |
| Reeves | 19 studies (all post-qualification), range of different IPE programmes based in mental health settings | Short-term changes to individual knowledge/skills and organisational practice |
| Barr et al | 107 studies (20 pre-qualification, 85 post-qualification, 2 mixed) based in a variety of practice settings | Changes to individual knowledge, and skills some reporting changes to organisational practice and delivery of patient care |
| Hammick et al | 21 studies (14 pre-qualification, 6 post-qualification, 1 mixed) based in a variety of practice settings | Changes in learner reaction, knowledge, and skills acquisition |
| Reeves et al | 6 studies (all post-qualification) based in a range of settings | Changes in professional practice and patient satisfaction |
The synthesis shows that IPE was delivered in a variety of acute, primary, and community care settings and addressed a range of chronic (e.g. asthma, arthritis) or acute (e.g. cardiac care) clinical conditions. While different combinations of professional groups participated in the programmes, medicine and nursing were most often involved. IPE was generally delivered as a voluntary (i.e. elective) learning experience to participants and few programmes included any form of formal academic accreditation. Duration varied from 1–2 hour sessions to programmes delivered over a period of months; most lasted between one and five days. Programmes were more commonly delivered to post-qualification learners (typically physicians and nurses) in their workplaces, although IPE is increasingly being delivered to pre-qualification learners as a classroom or practice-based activity. IPE programmes used a variety of different combinations of interactive learning methods but seminar-based discussions, group problem-solving, and/or role play activities were the most common.
Quality improvement principles were often drawn upon within post-qualification IPE programmes. In general, IPE programmes assessed learning formatively, typically using individual written assignments and/or joint/team presentations, which provided a collective account of learners’ IP experiences. Most programmes drew, implicitly, upon adult learning principles developed by authors such as Knowles, Schön, and Kolb (Reeves et al, 2008).
The majority of studies provided little discussion of methodological limitations associated with their research. As a result, it was difficult to discern their biases. In addition, a number of studies offered only limited descriptions of the interventions, which made it difficult to detect whether reported changes were actually attributable to the programme delivered.
Most studies paid little or no attention to sampling techniques or study attrition. There was a tendency to report short-term effects of IPE on learners’ attitudes and knowledge. As a result, there is only limited information about the longer-term impact of IPE, particularly on organisational change, patient care, and educational processes.
There was widespread use of non-validated instruments to detect the impact of IPE on learner and/or patient satisfaction. While such tools can support local quality assurance, they are of limited research value. Measures to detect changes in individual behaviour were particularly poor, often relying on simple self-reported descriptive accounts. Self-report is of limited value because it describes only a person’s perception of change. Most studies were undertaken in single sites.
Despite weaknesses in the evidence, there were some encouraging aspects too. Most notably, there was use of quasi-experimental research designs (e.g. before-and-after studies; before-during-and-after studies); most studies gathered two or more forms of data (typically survey and interviews); and there was growing use of longitudinal designs, which could establish the longer-term impact of IPE on organisations and patient care (Reeves et al, 2008).
Most studies found that learners enjoyed their IP experiences. Such studies also reported positive changes in learners’ perceptions of changes in their views of other professional groups, views of IP collaboration, and/or changes in the value attached to working collaboratively with other professions. In addition, they reported positive changes in learners’ knowledge and skills of IP collaboration, usually related to an enhanced understanding of roles and responsibilities of other professional groups, improved knowledge of the nature of IP collaboration, and/or the development of collaboration/communication skills.
Few studies reported changes in individual behaviour, usually reported as practitioners working more collaboratively with colleagues from other professional groups. Of studies which did provide evidence at this level, positive changes in individual practitioners’ interactions were usually cited. A number of studies reported positive changes to organisational practice, usually changes to IP referral practices/working patterns or improved documentation (i.e. guidelines, protocols, use of shared records) related to the organisation of care. A small number of studies reported changes to the delivery of care to patients/clients. They typically reported positive changes to clinical outcomes (e.g. infection rates, clinical error rates), patient satisfaction scores, and/or length of patient stay.
In general, studies of pre-qualification IPE reported changes in attitudes, beliefs, knowledge, and collaborative skills. Post-qualification studies report learner-oriented changes but they also reported changes in organisational practice and patient care. Box 4.5 summarises the findings of the synthesis:
Box 4.5 Summary of findings from IPE evidence synthesis
As the synthesis indicates, evidence for the efficacy of IPE rests upon a variety of different programmes (in terms of duration, professional participation, etc.), methodologies, and methods (from experimental research studies to mixed methods and qualitative studies) of variable quality, as well as a range of outcomes (e.g. reports of learner satisfaction to changes in the delivery of care). While the quality of evidence for IPE is currently limited, higher-quality studies are increasingly being published (Reeves et al, 2008).
Social science theory can inform the development and evaluation of IPE initiatives, yet there has been minimal explicit use of it to date, apart from the implicit use of adult learning principles noted above. Barr et al (2005) identified three foci at which social science theories could be situated:
This section describes and discusses social science theories that are relevant to each of these foci.
The three theories discussed in this section – contact theory, social exchange theory, and negotiation theory – provide ways of supporting effective interaction between different groups.
Contact theory is based on Allport’s (1979) studies of prejudice between different social groups, and his conclusion that contact between their members is the most effective way of reducing tension between them. Experience demonstrated, though, that simply bringing individuals from different groups together was insufficient to effect change. Allport identified three conditions that had to be addressed for prejudice to be reduced: equality of status between the groups; group members working towards common goals; and cooperation during the contact. More recent work added three other conditions in the context of IPE: positive expectations by participants; successful experience of joint working; and a focus on understanding differences as well as similarities between themselves.
Social exchange theory (Challis et al, 1988) explains social change and stability as a process of negotiated exchanges between parties. According to it, all human relationships are formed according to a subjective cost–benefit analysis and comparison of alternatives. This theory can provide insight into the nature of relationships amongst different professionals during an IPE programme and help develop individuals’ understandings of their relationships with others in work settings (Barr et al, 2005).
Negotiation theory was developed by Strauss (1978) to help explain how formal roles are transgressed by informal trade-offs between individuals’ own goals and those of others. This theory can be used to explain how negotiations shape the nature of IP relations between health providers and also how negotiations affect the development and delivery of IPE. This theory becomes more complex within the context of IPE when negotiations are IP and/or inter-organisational as well as interpersonal.
Workgroup mentality and team learning theories are presented to help understand how they can support IP team learning.
Workgroup mentality theory (Bion, 1961) is based in a psychodynamic perspective, which aims to explain unconscious processes in a group unable to deal with its ‘primary task’. According to this theory, groups avoid making decisions to save members having to address potentially divisive issues. Stokes (1994) and others have extended this theory to IP relations. Stokes suggested that IP team meetings can frequently be unproductive as a false sense of collaboration prevents members from dealing with potentially difficult issues. IPE programmes with a group dynamic format can enable participants to reflect on unconscious forces that shape IP relations within the group, with the aim of increasing their understanding of such forces in their workplace.
The concept of a learning team developed from the concept of a learning organisation (Senge, 1990); the team learning concept aimed to help high-performance teams develop. Typically, members of a team do not wholly trust one another and share collective goals, but members of a learning team develop a shared commitment, have mutually agreed goals, and share a concern for the well-being of the team. In relation to IPE, team learning can help transform a loosely affiliated work ‘group’ of health care professionals into a more effective IP ‘team’, whose members trust one another and share a commitment to collective goals and the welfare of their colleagues (Barr et al, 2005).
This section discusses theories that can be used in the context of IPE to improve services and the quality of care. The theories described are systems theory, activity theory, and discourse theory.
Von Bertalanffy (1971) developed the concept of ‘system’ as a response to the limitations of specialist disciplines in addressing complex problems. It could be applied across all disciplines, from physics and biology to the social and behavioural sciences, seeing wholes as more than the sum of their parts, interactions between parties as purposeful, boundaries between them as permeable, and cause and effect as interdependent, not linear. The underlying philosophy of systems theory is the unity of nature governed by the same fundamental laws in all its realms. An intervention by one profession at one point in the system affects the whole in ways that can only be anticipated from multiple professional perspectives.
Systems theory has multiple applications in IPE. It offers a unifying and dynamic framework within which all participant professions can relate person, family, community, and environment, one or more of which may be points of intervention, interacting with the whole. It can also be used to understand relationships within and between professions, between service agencies, between education and practice, and between stakeholders planning, and managing programmes.
Activity theory provides a means to understand and intervene in relations at micro and macro levels in order to effect change in interpersonal, IP, and inter-agency relations (Engestrom et al, 1999). An analysis of activity involves an understanding of individual relationships and how they relate to the macro level of collective and community.
An important component of an activity theory approach is the notion of ‘knotworking’ – a concept that helps describe the nature of collaborative work in which individuals connect – through tying, untying, and retying separate threads of activity during their interactions.
According to Foucault (1972), discourse helps to define a particular culture, its language, and the behaviour of individuals who belong to it. Lessa (2006) helpfully summarises Foucault’s approach, as he states that discourses are knowledge systems made up of ideas, attitudes, actions, beliefs, and practices that influence how individuals think, see, and speak. Koppel (2003) used this approach to uncover prevalent discourses in continuing professional development and IPE. Koppel demonstrated how three main discourses shaped the thinking and behaviour of the main parties in the education field, namely the discourses of management, professions, and education.
Table 4.2 provides a summary of the theories presented above.
Table 4.2 Summary of theories and key authors
| IP foci | Theory | Author(s) |
|---|---|---|
| Preparing individuals for collaborative practice | Contact theory Social exchange theory Negotiation theory |
Allport (1979) Challis et al (1988) Strauss (1978) |
| Cultivating group/team collaboration | Workgroup mentality theory Team learning theory |
Bion (1961) Senge (1990) |
| Improving services and the quality of care | Systems theory Activity theory Discourse theory |
Von Bertalanffy (1971) Engestrom et al (1999) Foucault (1972) |
As illustrated above, the use of theory can give more in-depth insights into the nature of IPE. Theory can be used to inform the format and curriculum of a programme and can also be used to interpret findings. Further research with an explicit use of such theories would provide insight into their value for IPE.
Accumulating evidence of problems with communication and collaboration amongst different health care providers, and the resulting impact on the quality of health care, has stimulated decision makers in education, health care, policy, and research, to invest in IPE. The premise is that IPE will give health care providers the skills and knowledge required to work effectively with other health care providers in the health care system. As a result, IPE initiatives for pre and post-qualification learners, including medical students and physicians, are being developed and implemented across the globe.
Investment in IPE must be based on rigorous evidence of effectiveness, which is gradually accumulating. Systematic reviews show that IPE can have positive effects on participants’ reactions, attitudes, knowledge/skills, behaviours, and practice, as well as patient outcomes, yet many studies have methodological limitations. As the number of studies increases and their methodological quality improves, it is to be hoped the evidence supporting IPE will become increasingly robust. In addition to better methodologies, future research needs to explore more fully the application of social science theories to IPE. As noted, we are conducting a scoping review to map out the IP field at the time of writing, which has delineated three types of IP interventions, which we have termed IPE, IP practice, and IP organisation interventions. Further research will show when it is most effective to use which intervention or combinations of them, in relation to learners’ stage of development, the context, the outcomes desired, and other important factors.
While research has shown how IPE can improve IP collaboration and health care, it is but one factor amongst many. As our synthesis of systematic reviews showed, medical students and physicians are participants whose involvement is essential if knowledge gained from IPE is to be translated into practice. Policy makers in various countries are emphasising that physicians need to be effective collaborators and communicators; IPE is a key strategy to developing those characteristics. As evidence accumulates, we will know better how IPE can most effectively be implemented, and how its implementation influences physicians’ behaviours and clinical outcomes.
Over three decades’ research and experience have shown the value of IPE at both the pre- and post-qualification learning stages. Medical students can benefit from a pre-qualification perspective on the roles of different health care professionals in relation to a particular topic being studied in a classroom and/or placement, while a post-qualification initiative for physicians can address communication issues with other health professionals with whom they work, and support changes in practice. We also have knowledge about different interactive learning methods that can be used in IPE, and about how new technologies can widen the options available. Interactivity is an essential element, but the particular method used must depend on the objectives of the programme and available resources. Attention must be given to the composition and size of IP learning groups and good facilitation is needed. Organisational support and leadership are critical to address the extensive logistic and resource issues associated with IPE, to support faculty development, and to develop a culture that endorses IPE, and facilitates knowledge translation into health care settings. Leadership from medical schools, associations, and organisations is essential to encourage and support medical students and practitioners to engage fully in IPE programmes.
Allport G. The nature of prejudice. Reading, MA: Addison-Wesley, 1979.
Anderson E., Thorpe L., Heney D., et al. Medical students benefit from learning about patient safety in an interprofessional team. Med Educ. 2009;43(6):542-552.
Barr H., Koppel I., Reeves S., et al. Effective interprofessional education: argument, assumption and evidence. Oxford: Blackwell, 2005.
Bion W.R. Experiences in groups and other papers. London: Tavistock Publications, 1961.
Challis L., Fuller S., Henwood M., et al. Joint approaches to social policy. Cambridge: Cambridge University, 1988.
Coster S., Norman I., Murrells T., et al. Interprofessional attitudes amongst undergraduate students in the health professions: a longitudinal questionnaire survey. Int J Nurs Stud. 2008;45(11):1667-1681.
Department of Health. A health service of all the talents: developing the NHS workforce. London: HMSO, 2000.
Engeström Y., Engeström R., Vahaaho T. When the center does not hold: the importance of knotworking. In: Chaklin S., Hedegaard M., Jensen U.J., editors. Activity theory and social practice. Aarhus: Aarhus University Press, 1999.
Foucault M. The archeology of knowledge. London: Tavistock, 1972.
Freeth D., Ayida G., Berridge E.J., et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES): promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. J Contin Educ Health Prof. 2009;29(2):98-104.
Friedson E. Professional dominance: the social structure of medical care. New York: Aldine, 1970.
Goldman J., Meuser J., Lawrie L. Development and implementation of primary care interprofessional protocols. J Interprof Care. 24(6), 2010.
Koppel I. Autonomy eroded? Changing discourses in the education of health and community care professionals. University of London, 2003. Unpublished PhD Thesis
Kvarnstrom S. Difficulties in collaboration: a critical incident study of interprofessional healthcare teamwork. J Interprof Care. 2008;22(2):191-203.
Lessa I. Discoursive struggles within social welfare: restaging teen motherhood. Br J Social Work. 2006;36(2):283-298.
Mann K.V., Mcfetridge-Durdle J., Martin-Misener R., et al. Interprofessional education for students of the health professions: the “Seamless Care” model. J Interprof Care. 2009;23:224-233.
Pecukonis E., Doyle O., Bliss D.L. Reducing barriers to interprofessional training: promoting interprofessional cultural competence. J Interprof Care. 2008;22:417-428.
Pollard K. Student engagement in interprofessional working in practice placement settings. J Clin Nurs. 2009;18(20):2846-2856.
Rees D., Johnson R. All together now? Staff views and experiences of a pre-qualifying interprofessional curriculum. J Interprof Care. 2007;21(5):543-555.
Reeves S. Developing and delivering practice-based interprofessional education. Munich: VDM publications, 2008.
Reeves S., Goldman J., Burton A., et al. Knowledge transfer and exchange in interprofessional education: synthesizing the evidence to foster evidence-based decision-making. [online] Available at www.cihc.ca, 2009. Accessed July 6
Rudland J., Mires G. Characteristics of doctors and nurses as perceived by students entering medical school: implications for shared teaching. Med Educ. 2005;39(5):448-455.
Senge P.M. The fifth discipline the art and practice of the learning organization, ed 1. New York, NY: Doubleday/Currency, 1990.
Steinert Y. Learning together to teach together: interprofessional education and faculty development. J Interprof Care. 2005;19(Suppl 1):60-75.
Stokes J. Problems in multidisciplinary teams: the unconscious at work. J Social Work Practice. 1994;8(2):161-167. http://www.informaworld.com/smpp/title~db= all~content=t713436417~tab= issueslist~branches=8-v8
Strauss A. Negotiations: varieties, contexts, processes and social order. San Francisco: Jossey-Bass, 1978.
The Joint Commission. Sentinel Event Alert: Preventing infant death and injury during delivery. [online] Available at: www.aap.org/nrp/simulation/JCAHOSentinelEvent.pdf, 2004. [Accessed July 6, 2009]
Von Bertalanffy L. General systems theory. London: Allen Lane/Penguin, 1971.
Wilhelmsson M., Pelling S., Ludvigsson J., et al. Twenty years experience of interprofessional education in Linköping – ground-breaking and sustainable. J Interprof Care. 2009;23(2):121-133.
Williams R.G., Silverman R., Schwind C., et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245:159-169.
World Health Organisation. Continuing education of health personnel. Copenhagen: WHO Regional Office for Europe, 1976.
Wright A., Lindqvist S. The development, outline and evaluation of the second level of an interprofessional learning programme-listening to the students. J Interprof Care. 2008;22:475-487.
American Interprofessional Health Collaborative (AIHC). The AIHC offers a venue for health and social professions based in the USA to share information, mentor and support one another as they provide the leadership to influence system change with the implementation of interprofessional education and practice at their individual institutions and organisations.. Available at: http://blog.lib.umn.edu/cipe/aihc/ [Accessed November 2009]
Australasian Interprofessional Practice and Education Network (AIPPEN). AIPPEN aims to provide a forum for sharing of information, networks, and experiences in the area of interprofessional practice and education in health and social care contexts across Australia and New Zealand.. Available at: http://www.aippen.net/ [Accessed November 2009]
Canadian Interprofessional Health Collaborative (CIHC). The CIHC is a Canadian national organisation that provides health providers, teams, and organisations with the resources and tools needed to apply an interprofessional, patient-centred, and collaborative approach to health care. CIHC’s core activities are designed to make them the ‘go to’ resource for these organisations when they require expert advice, knowledge or information on interprofessional collaboration.. Available at: www.cihc.ca [Accessed November 2009]
Centre For The Advancement Of Interprofessional Education (CAIPE). CAIPE, based in the UK, is dedicated to the promotion and development of interprofessional education with and through its individual and corporate members, in collaboration with like-minded organisations in the UK and overseas. It provides information and advice through its website, bulletins, papers, and outlets provided by others, and has a close association with the Journal of Interprofessional Care. Available at: www.caipe.org.uk [Accessed November 2009]
European IPE Network (EIPEN). EIPEN aims to develop and sustain a network in the European Union to share and develop effective interprofessional vocational training curricula, methods, and materials for improving collaborative practice and multi- agency working in health and social care. Available at: www.eipen.org [Accessed November 2009]
Journal of Interprofessional Care. The Journal of Interprofessional Care is the vehicle for worldwide dissemination of experience, policy, research evidence, and theoretical and value perspectives informing collaboration in education, practice, and research between medicine, nursing, veterinary science, allied health, public health, social care, and related professions to improve health status and quality of care for individuals, families, and communities. Available at: http://informahealthcare.com/jic [Accessed November 2009]