INTERPROFESSIONAL EDUCATION AND PRACTICE

1. INTERPROFESSIONAL EDUCATION AND PRACTICE Université Laval Dr. Lesley Bainbridge University of British Columbia

2. OVERVIEW • Introduction • Emerging evidence • Conceptual framework and applications • Examples of IPE approaches • A “new” lens for collaboration • Questions and discussion

3. Introduction • History • Drivers • Why now? • Why me? • Why you?

4. EMERGING EVIDENCE

5. EMERGING EVIDENCE Evidence for IPC • Collaborative 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.

6. EMERGING EVIDENCE Improved outcomes • A 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 productivity • Improved patient outcomes • Raised staff morale • Improved patient safety • Better access to health-care • In 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.

7. EMERGING EVIDENCE Collaborative practice can improve: • accessto 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.

8. EMERGING EVIDENCE Collaborative practice can decrease: • total patient complications • length of hospital stay • tension and conflict among caregivers • staff turnover • hospital admissions • clinical error rates • mortality 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.

9. EMERGING EVIDENCE In community mental health settings collaborative practice can: • increase patient and carer satisfaction • promote greater acceptance of treatment • reduce duration of treatment • reduce cost of care • reduce 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.

10. 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.

11. 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.

12. REFERENCES • Barr 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.

13. 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. • 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.

14. REFERENCES • Reeves 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).

15. CONCEPTUAL FRAMEWORK AND APPLICATIONS

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

17. CIHC Framework • Domains: • Communication • Patient-focused Care • Role Clarification • Team Function • Interprofessional Conflict Resolution • Collaborative Leadership • Background: • Quality Improvement • Spiral complexity • Simple • Complicated • Complex • Context of Practice

18. UBCModel • UBC Model: Exposure, Immersion, Mastery • Exposure: knows about • e.g. shadowing,lecturesand workshops • Immersion: knows how • e.g. interprofessional placement • Mastery: can teach • e.g. looked to an an excellent collaborator

19. A Framework for Interprofessional Education in Health Programs

20. A Framework for Interprofessional Education in Health Programs InterprofessionalCommunication

21. A Framework for Interprofessional Education in Health Programs InterprofessionalCommunication Patient & Family Focused Care

22. A Framework for Interprofessional Education in Health Programs InterprofessionalCommunication Patient & Family Focused Care RoleClarification

23. A Framework for Interprofessional Education in Health Programs Team Function InterprofessionalCommunication Patient & Family Focused Care Role Clarification

24. A Framework for Interprofessional Education in Health Programs Collaborative Leadership Team Function InterprofessionalCommunication Patient & Family Focused Care Role Clarification

25. A Framework for Interprofessional Education in Health Programs Collaborative Leadership Team Function InterprofessionalCommunication Patient & Family Focused Care Conflict Resolution Role Clarification

26. A Framework for Interprofessional Education in Health Programs Interprofessional Collaboration Collaborative Leadership Team Function InterprofessionalCommunication Patient & Family Focused Care Conflict Resolution Role Clarification

27. A Framework for Interprofessional Education in Health Programs Residency/New Health Professionals Complex Interprofessional Collaboration Clerkship/Fieldwork/ Practicum Collaborative Leadership Complicated Team Function InterprofessionalCommunication Patient & Family Focused Care Conflict Resolution Clinical Clusters/Academic Component Simple Role Clarification

28. A Framework for Interprofessional Education in Health Programs Residency/New Health Professionals Complex Mastery Interprofessional Collaboration Clerkship/Fieldwork/ Practicum Collaborative Leadership Immersion Complicated Exposure Team Function InterprofessionalCommunication Patient & Family Focused Care Conflict Resolution Clinical Clusters/Academic Component Simple Role Clarification

29. A Framework for Interprofessional Education in Health Programs Residency/New Health Professionals Attitudinal Change Complex Mastery Interprofessional Collaboration Clerkship/Fieldwork/ Practicum Collaborative Leadership Immersion Complicated Exposure Team Function InterprofessionalCommunication Patient & Family Focused Care Conflict Resolution Clinical Clusters/Academic Component Simple Role Clarification

30. EXAMPLES OF IPE APPROACHES

31. EXAMPLES • Orientation • The educator pathway • The passport • IP-PBL • IP Placements • Standardized Patients • Other

32. A “NEW” LENS FOR COLLABORATION

33. Current model • Co-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.

34. Current model • Competency 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.

35. Assumptions • Students 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.

36. Assumptions • IPE 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.

37. Potential flaws • Scheduling 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.

38. Potential flaws • Individual 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.

39. Potential new model • Focus 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 capital • Rhetoric • Perception checking • Conflict resolution • Building relationships • Negotiating priorities

40. Potential new model • Early 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.

41. Assumptions • Students 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.

42. Assumptions • The 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.

43. Potential flaws • No 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.

44. …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?

45. 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 servicesin the absence of, or in conjunction with, their own economic capital.” P 166

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

47. 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?

48. Rhetoric or Framing Rhetoric: 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.

49. 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)

50. Rhetoric or Framing • Becoming 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)