INTERPROFESSIONAL EDUCATION AND PRACTICE

INTERPROFESSIONAL EDUCATION AND PRACTICE

Université Laval

Dr. Lesley BainbridgeUniversity of British Columbia

OVERVIEWIntroductionEmerging evidenceConceptual framework and applicationsExamples of IPE approachesA “new” lens for collaborationQuestions and discussion

IntroductionHistoryDriversWhy now?Why me?Why you?

EMERGING EVIDENCE

EMERGING EVIDENCE

Evidence for IPCCollaborative practice strengthens health systems and improves health outcomes.Health leaders who choose to contextualize, commit and champion interprofessional education and collaborative practice position their health system to facilitate achievement of the health-related Millennium Development Goals (MDGs).Evidence clearly demonstrates the need for a collaborative practice ready health workforce, which may include health workers from regulated and non-regulated professions.

EMERGING EVIDENCE

Improved outcomesA team-based approach to health-care delivery maximizes the strengths and skills of each contributing health worker. (Mickan SM. Evaluating the effectiveness of health care teams. Australian Health Review, 2005, 29(2):211-217.)IPC can assist in recruitment and retention of health workers and possibly help mitigate health workforce migration. (Yeatts D, Seward R. Reducing turnover and improving health care in nursing homes: The potential effects of self-managed work teams. The Gerontologist, 2000, 40:358–363.)

Improved workplace practices and productivityImproved patient outcomes Raised staff moraleImproved patient safetyBetter access to health-careIn both acute and primary care settings, patients report higher levels of satisfaction, better acceptance of care and improved health outcomes following treatment by a collaborative team.

EMERGING EVIDENCE

Collaborative practice can improve:

access to and coordination of health-services

appropriate use of specialist clinical resources

health outcomes for people with chronic diseases

patient care and safety

References:

Hughes SL et al. A randomized trial of the cost-effectiveness of VA hospital-based home care for the terminally ill. Health Services Research, 1992, 26:801–817.

Jansson A, Isacsson A, Lindholm LH. Organisation of health care teams and the population’s contacts with primary care. Scandinavian Journal of Health Care, 1992, 10:257–265.

Lemieux-Charles L et al. What do we know about health care team effectiveness? A review of the literature. Medical Care Research and Review, 2006, 63:263–300.

EMERGING EVIDENCE

Collaborative practice can decrease:

total patient complicationslength of hospital staytension and conflict among caregiversstaff turnoverhospital admissionsclinical error ratesmortality rates

References:Holland R et al. Systematic review of multidisciplinary interventions in heart failure. Heart, 2005, 91:899–906.

Lemieux-Charles L et al. What do we know about health care team effectiveness? A review of the literature. Medical Care Research and Review, 2006, 63:263–300.

McAlister FA et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. Journal of the American College of Cardiology, 2004, 44:810–819.

Mickan SM. Evaluating the effectiveness of health care teams. Australian Health Review, 2005, 29(2):211-217.

Morey JC et al. Error reduction and performance improvements in the emergency department through formal teamwork training: Evaluation results of the MedTeams project. Health Services Research, 2002, 37:1553–1581.

Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve outcomes? A systematic review. Journal of Parenteral and Enteral Nutrition, 2004, 28:251–258.

Teamwork in healthcare: Promoting effective teamwork in healthcare in Canada. Ottawa, Canadian Health Services Research Foundation, 2006 (http://www.chsrf.ca/research_themes/pdf/teamwork-synthesisreport_e.pdf).

West MA et al. Reducing patient mortality in hospitals: the role of human resource management. Journal of Organisational Behaviour, 2006, 27:983–1002.

Yeatts D, Seward R. Reducing turnover and improving health care in nursing homes: The potential effects of self-managed work teams. The Gerontologist, 2000, 40:358–363.

http://www.chsrf.ca/

EMERGING EVIDENCE

In community mental health settings collaborative practice can:

increase patient and carer satisfactionpromote greater acceptance of treatment reduce duration of treatmentreduce cost of carereduce incidence of suicide increase treatment for psychiatric disorders reduce outpatient visits

References:

Jackson G et al. A new community mental health team based in primary care: a description of the service and its effect on service use in the first year. British Journal of Psychiatry, 1993, 162:375–384.

Malone D et al. Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality. Framework for Action on Interprofessional Education and Collaborative Practice Cochrane Database of Systematic Reviews, 2007, Issue 2. (Art. No.: CD000270. DOI: 10.1002/14651858.CD000270.pub2)

Simmonds S et al. Community mental health team management in severe mental illness: a systematic review. The British Journal of Psychiatry, 2001, 178:497–502.

EMERGING EVIDENCE

Terminally and chronically ill patients who receive team-based care in their homes:

are more satisfied with their care

report fewer clinic visits

present with fewer symptoms

report improved overall health

References:

Hughes SL et al. A randomized trial of the cost-effectiveness of VA hospital-based home care for the terminally ill. Health Services Research, 1992, 26:801–817.

Sommers LS et al. Physician, nurse, andsocial worker collaboration in primary care for chronically ill seniors. Archives of Internal Medicine, 2000, 160:1825–1833.

EMERGING EVIDENCE

Health systems can benefit from the introduction of collaborative practice which has reduced the cost of:

setting up and implementing primary health-care teams for elderly patients with chronic illnesses

redundant medical testing and the associated costs

implementing multidisciplinary strategies for the management of heart failure patients

implementing total parenteral nutrition teams within the hospital setting

References:

McAlister FA et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. Journal of the American College of Cardiology, 2004, 44:810–819.Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve outcomes? A systematic review. Journal of Parenteral and Enteral Nutrition, 2004, 28:251–258.Sommers LS et al. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Archives of Internal Medicine, 2000, 160:1825–1833.

REFERENCESBarr H et al. Evaluations of interprofessional education: a United Kingdom review for health and social care. London, BERA/CAIPE, 2000.Barr H et al. Effective interprofessional education: assumption, argument and evidence. Oxford, Blackwell Publishing, 2005.Cooper H et al. Developing an evidence base for interdisciplinary learning: a systematic review. Journal of Advanced Nursing, 2001, 35:228–237.Hammick M et al. A best evidence systematic review of interprofessional education. Medical Teacher, 2007, 29:735–751.Holland R et al. Systematic review of multidisciplinary interventions in heart failure. Heart, 2005, 91:899–906.Malone D et al. Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality. Framework for Action on Interprofessional Education and Collaborative Practice Cochrane Database of Systematic Reviews, 2007, Issue 2. (Art. No.: CD000270. DOI: 10.1002/14651858.CD000270.pub2)between nurses and doctors. Cochrane Database of Systematic Reviews, 2000, Issue 1.

REFERENCESMcAlister FA et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. Journal of the American College of Cardiology, 2004, 44:810–819.Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve outcomes? A systematic review. Journal of Parenteral and Enteral Nutrition, 2004, 28:251–258.Reeves S. Community-based interprofessional education for medical, nursing and dental students. Health and Social Care in the Community, 2001, 8:269–276.Reeves S. A systematic review of the effects of interprofessional education on staff involved in the care of adults with mental health problems. Journal of Psychiatric Mental Health Nursing, 2001, 8:533–542.Reeves S et al. Knowledge transfer and exchange in interprofessional education: synthesizing the evidence to foster evidence-based decision-making. Vancouver, Canadian Interprofessional Health Collaborative, 2008.

REFERENCESReeves S et al. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 2008, Issue 1.

Simmonds S et al. Community mental health team management in severe mental illness: a systematic review. The British Journal of Psychiatry, 2001, 178:497–502.

The primary health care package for South Africa– a set of norms and standards. Pretoria, South Africa, Department of Health, 2000 (http://www.doh.gov.za/docs/policy/norms/fullnorms.html).

Working together, learning together: aframework for lifelong learning for the NHS. London, Department of Health, 2001 (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009558).

CONCEPTUAL FRAMEWORK

AND APPLICATIONS

1. National Competency Framework for Interprofessional Collaboration (CIHC, 2010):

CIHC FrameworkDomains:

CommunicationPatient-focused CareRole ClarificationTeam FunctionInterprofessional Conflict ResolutionCollaborative Leadership

Background:Quality ImprovementSpiral complexity

SimpleComplicatedComplex

Context of Practice

UBC Model2. UBC Model: Exposure, Immersion, Mastery

Exposure: knows aboute.g. shadowing,lectures and workshops

Immersion: knows howe.g. interprofessional placement

Mastery: can teache.g. looked to an an excellent collaborator

A Framework for Interprofessional Education in Health Programs

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EXAMPLES OF IPE

APPROACHES

EXAMPLESOrientation

The educator pathway

The passport

IP-PBL

IP Placements

Standardized Patients

Other

A “NEW” LENS FOR

COLLABORATION

Current modelCo-location of students

Learning “with, from and about” each other

Much of the IPE is extracurricular

Learning together starts early (exposure) and becomes more focused later (immersion).

Schedules and logistics are the main barriers.

IPE is explicit in some programs and implicit in other programs.

Current modelCompetency model is most common.

Learning objectives follow the competency model.

Roles and responsibilities of each profession are central to current IPE.

The clinical setting is seen as an effective place for IPE but so is the academic setting.

“IPE” curricula are common.

The focus is more on the education than the outcomes.

IPE is often seen as an ends rather than a means.

The focus is on the team and less on the individual.

AssumptionsStudents must learn together in order to work together collaboratively.More than one profession is necessary to teach interprofessionally.Early exposure is good.Students must be together to learn how to collaborate.Role clarification is a key part of IPE.A competency based model translates well into learning objectives.

AssumptionsIPE is currently a train that is moving fast.

IPE leads to improved collaboration.

Improved collaboration improves health outcomes.

IPC is cost effective.

The system is changing to embrace IPE and IPC.

If students don’t see it in practice they will not embrace it – it being IPC.

The learning must be clinically relevant.

Potential flawsScheduling barriers create curriculum changes that are more for logistical reasons than good pedagogy or the changes do not occur because of the barrier and therefore IPE is restricted..

Competency based models are useful but do not get beyond the behaviourally obvious characteristics of collaboration.

Role clarification may reinforce stereotyping.

Potential flawsIndividual focus on collaborative practice skills is overshadowed by team based collaboration skills.

The clinical setting is not fully exploited as an IPE opportunity for the individual or the team.

Assessment of performance in collaboration is weak and not well-developed except perhaps in the area of attitudes. But would those scales change if we were to focus on the individual rather than the team?

The long term change in practice because of IPE is unknown to a large extent.

Potential new modelFocus is on training for collaboration.

Uniprofessional learning in the academic setting is used to prepare students for collaboration in clinical settings.

The focus for the training is on:Social capitalRhetoricPerception checkingConflict resolutionBuilding relationshipsNegotiating priorities

Potential new modelEarly educational interventions include single professions and use scenarios, cases, videos, small group work, simulation, virtual patients etc. to establish personal insights into how they as individuals can build a collaborative network/resource network for themselves.

Clinical placements are used as the stage for observations of collaboration, practice in checking perceptions, building social capital, using language to establish a positive encounter etc.

Assessment of student skills in collaboration is defined and quantifiable.

AssumptionsStudents can learn collaboration within their own professions while they build a professional identity.

Putting the “I” in TEAM is important to ensure personal responsibility and accountability for collaborative behaviour.

Long term change will occur if the individual ability to develop and sustain relationships is well trained.

AssumptionsThe clinical setting provides the best stage for practicing collaboration.

A new way of looking at IPC can lead the way to major change without RCT evidence that it works.

The work done to date in IPE lays the groundwork for a new way of looking at it.

While in some circumstances the learning must be clinically relevant, the processes of collaboration are the focus in such a way that they can be transferred from context to context.

Potential flawsNo one will buy into this new model.

The “evidence” argument gets in the way.

It is seen as going backwards into professional silos.

The responsibility for the integration of the new way of addressing teaching collaboration falls to the community partners.

The new model is seen as negating the old model.

It is too difficult to understand and link to the competency-based models.

The train is too far down the track for people to want to look at IPE a new way.

…putting the “I” back in team…

Social capital

Rhetoric or framing

Perspective taking

Negotiating priorities

Resolving conflict

Building relationships

What are they and how do we teach them?

Social Capital “Existing studies have almost exclusively relied upon Putnam’s (1993, 1995,

1996, 1998, 2000, 2001) conceptualization of social capital, which consists of features such as interpersonal trust, norms of reciprocity, and social engagement that foster community and social participation and can be used to impact a number of beneficial outcomes, including health” p 165

“I propose that it would be more useful to conceive of social capital in a more traditionally sociological fashion: as consisting of actual or potential resources that inhere within social networks or groups for personal benefit.” P.166

“This conceptualization is consistent with the social capital theory of Pierre Bourdieu (1986), which emphasizes the collective resources of groups that can be drawn upon by individual group members for procuring benefits and services in the absence of, or in conjunction with, their own economic capital.” P 166

Social CapitalIndividual confounders:• Negotiation skill set• Communication skills• Perceptiveness• Ability to create social trust• Educational level• Hierarchical position• Overall competence

Thoughts

What do we all contribute to the central “pot” in any given clinical case, what can only “we” do, and what do we call upon others to do or take on ourselves as part of the exchange of capital?

Have we viewed the health workplace as a social system and if we do what does that imply for collaborative working relationships?

Do we need to look at social space and symbolic power?

Rhetoric or FramingRhetoric:

The art of effective or persuasive speaking or writing.

Language designed to have a persuasive or impressive effect on its audience...

Framing:

Setting an approach or query within an appropriate context to achieve a desired result or elicit a precise answer.

Rhetoric or Framing“the ability to shape the meaning of a subject, to judge its character and significance. To hold the frame of a subject is to choose one particular meaning (or set of meanings) over another. When we share our frames with others (the process of framing), we manage meaning because we assert that our interpretations should be taken as real over other possible interpretations.” (p. 3)

The Art of Framing (Fairhurst & Sarr, 1996)

Rhetoric or FramingBecoming conscious of a goal purposely but unconsciously predisposes us to manage meaning in one direction or another to communicate our frames . . . We may be conscious of a goal . . . but unconscious of how we will select, structure, and exchange words with another person to achieve that goal. Our unconscious mind makes certain communication options available to us for the framing that we ultimately do. These options are not always ones we would have consciously chosen, as we are painfully aware when we blunder and succumb to ‘foot-in-mouth’ disease. But . . . we can ‘program’ our unconscious toward the selection of certain options over others via priming. (pp. 144–5)

Rhetoric or FramingEffective persuasion:

1. effective persuaders establish credibility

2. they frame their goals in a way that identifies common ground with those they intend to persuade

3.they reinforce their positions using vivid language and compelling evidence

4. they connect emotionally with their audience

(Conger, 1998)

Four ways not to persuade:

1. attempt to make your case with an up-front, hard sell

2. resist compromise

3. think the secret of persuasion lies in presenting great arguments

4. assume persuasion is a one-shot effort

Perspective TakingThe ability to entertain the perspective of another has long been recognized as a critical ingredient in proper social functioning. Davis (1983) found that perspective-taking, as measured by an individual-difference measure, was positively correlated with both social competence and self-esteem. Piaget (1932) marked the ability to shift perspectives as a major developmental breakthrough in cognitive functioning, and Kohlberg (1976) recognized its importance in his classification of moral reasoning.

Galinsky, Moskovitz, 2000

Perspective TakingPerspective-taking also affects attributional thinking and evaluations of others. Galinsky, Moskovitz, 2000

Perspective-taking, however, appears to diminish not just the expression of stereotypes but their accessibility. The constructive process of taking and realizing another person's perspective furthers the egalitarian principles themselves; perspective-taking is an effective reinforcement of contemporary admonitions to consider previously ignored or submerged perspectives as a routine part of social interchange and inquiry. Galinsky, Moskovitz, 2000

Negotiating prioritiesCombined with the limited information we have about the others’ true goals and interests, it is not always obvious what to offer, how to offer it or how to find out what would be worth offering. The way we communicate with each other can have a significant and often unintended impact on the outcome. And the relationships we form or develop during the negotiation process can have a significant impact not only on the present negotiation, but also on potential future negotiations with these parties and with others.

Fairman, 2012

Negotiating prioritiesFactors influencing negotiation:

The power of skill and knowledge

The power of a good relationship

The power of a good alternative to negotiation

The power of an elegant solution

The power of legitimacy

The power of commitmentFisher, 1983

Conflict Resolution

Thomas & Kilman

Conflict ResolutionImportance of the relationship

Relationship BuildingRelationship Centred Care (RCC) is founded upon 4 principles:

(1) that relationships in health care ought to include the personhood of the participants(2) that affect and emotion are important components of these relationships,(3) that all health care relationships occur in the context of reciprocal influence, and (4) that the formation and maintenance of genuine relationships in health care is morally valuable.

Beach et al, 2006

Relationship BuildingThe central task of health professions education—in nursing, medicine, dentistry, public health, pharmacy, psychology, social work, and the allied health professions—must be to help students, faculty, and practitioners learn how to form caring, healing relationships with patients and their communities, with each other, and with themselves.

Report of the Pew-Fetzer Task Force on Advancing Psychosocial Health Education (2006)

So what?This alternative lens seems to me to get at the very heart of collaboration.

It puts responsibility for collaboration within each of us.

It acknowledges the complexity of human interaction across different professional cultures.

It provides each of us with a way to create our own collaborative networks – even in the face of resistance.

It paves the way for truly patient-focused care.

QUESTIONS AND DISCUSSION

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INTERPROFESSIONAL EDUCATION AND PRACTICE