Enhancing the feasibility of interprofessional education: Lessons learned from sole precepting in a project-based practicum

Key Points A competent, collaborative, interprofessional team centered on the patient is necessary for quality pain care; however, interprofessional collaborative practice is not yet an integral part of all health professions education programs. Interprofessional education involves 2 or more professions learning "with, from, and about" to enable effective collaborative practice and improve health outcomes. Core competencies and curricular resources are available for interprofessional education and pain and can be adapted for use at all levels of health professions education. 1. Introduction Pain is a complex experience that impacts health, productivity, and well-being. It requires a collaborative team approach with a common language and clear understanding of roles and responsibilities. With few exceptions, a minimum amount of pain content has been documented in health sciences curricula, and much of that has been fragmented by profession and delivered within a crowded agenda of conventional course topics such as anatomy and physiology.21 Most health professionals learn pain management on the job and are often ill-prepared to function as a team member in the real world. Despite documentation of the need for improved education on pain of all types, consistent professional training in pain is not widespread and innovation is warranted. The 2018 IASP Global Year for Excellence in Pain Education is a call to action on multiple levels. The purpose of this report is to describe opportunities for mutual learning through interprofessional (IP) pain education. Interprofessional education (IPE) is a growing trend across health professions and has been defined (Table 1) as when 2 or more professions learn with, from, and about each other to improve collaboration and the quality of care.16 For IP learning to occur, all 3 "with, from, and about" must be present.11Table 1: Operational definitions.2. With others–learning together to facilitate interprofessional collaborative practice The complexity of health care across the globe, technological advances, and modern models of care delivery has created demand for a practice-ready workforce and effective teamwork.31 Medical errors often result from poor communication within and across teams; high functioning teams improve outcomes of care.18 Professional education has not kept pace with increasing demands for collaboration-ready health workers in part because of disjointed, outdated, and static curricula; furthermore, a glaring mismatch of competencies to patient and population needs persists.12 We educate students most often in uniprofessional settings (silos) with little opportunity to learn and practice together. Although learning experiences in the clinic or on a ward offer more opportunities to learn with, from, and about other health care professionals, there may be few role model IP teams in the real environment. Uniprofessional education is inadequate to prepare health care trainees to work in teams and can spur competition rather than cooperation between the professions. Recognizing this struggle, the World Health Organization (WHO) issued a Framework for Action on Interprofessional Education and Collaborative Practice in 2010.34 The report contextualizes existing health systems, commits to implementing principles of IPE and collaborative practice, and champions the benefits of IP collaborations with regional partners, educators, and health workers. Contemporaneously, the Lancet Commissions issued a foundational report12 developed by 20 health profession leaders from diverse countries advancing a common strategy for educational reform in medicine, nursing, and public health. The Lancet Commission calls for education reform that is guided by the desired outcomes of transformative learning and interdependence in education. Transformative learning involves fundamental shifts from fact memorization to synthesis of information for decision making; from seeking professional credentials to achieving core competencies for effective teamwork in health systems; and adaptation of global resources to address local priorities.12 Interdependence stresses the system approach that offers insights into the dynamic and nonlinear nature of a complex system that cannot be gained by studying components of the environment in isolation. This report also underscores the pace, scale, and intensity of globalization impacting interactions of health systems and education. In several countries, collaboration of national associations of health profession regulatory bodies has given rise to recommendations for core competencies for IP collaborative practice designed to guide curriculum development in interactive learning. For example, competencies16 developed by the Interprofessional Education Collaborative (IPEC) in the United States have become part of the global conversation (Table 2). The Global Forum on Innovation in Health Professional Education has hosted a series of meetings engaging stakeholders and policymakers through linked projects and networks in Uganda, South Africa, India, and Europe.8 Updated in 2016, the IPEC competencies integrate explicit population health outcomes with individual care competencies to form an expanded model that targets desirable health system goals. Interprofessional collaboration, in this framework, is the central domain under which the original competencies are arranged. Similarly, the Canadian IP Health Collaborative developed the National Interprofessional Competency Framework in 2010, which has been used in various countries and academic settings.5Table 2: Interprofessional collaborative competency domains.Interprofessional collaboration occurs when learners/practitioners, patients/clients/families, and communities develop and maintain working relationships that enable optimal health outcomes.5 Interprofessional collaborative practice occurs when multiple health workers from different professional backgrounds work together with patients, families, and communities to deliver the highest quality of care. Interprofessional core competencies build on modern educational theory and practice to bring together all health professions with shared language, vision, and goals (Table 3). These competencies are important for positive outcomes, including those we aim for in quality pain care.Table 3: Characteristics of health-focused interprofessional core competencies.10,163. From others—learning from different professions to facilitate collaboration and communication Collaborative approaches are invaluable when pain management is complex, requiring the knowledge and skills of more than one profession. It is logical then, that to work together, future health care workers would benefit from learning together to understand each other's roles and responsibilities and how to communicate using common language. The provision of opportunities for student interaction is fundamental to the learning experience to develop an understanding of the perspective of various professions and to foster a climate of mutual respect and relationship-building values. Interprofessional education requires active learner participation and case-based content that is authentic and foundational to many health professionals.6,26 Although most IPE is focused on prelicensure students, literature is emerging in post graduate clinical education. Themes in the context of back pain in a primary care setting included the context, value of involving the patient, listening, time and learning together.7 The intent is to impact practice and improve quality of health care. 4. About others–attaining competence to use knowledge of one's own role and those of other professions to address pain care needs Pain experience is multidimensional; therefore, pain education draws on not only mechanisms but also a variety of theories such as relational, professionalism, and social constructivism and is grounded in adult learning theory.31,33 The concept of communities of practice and situated learning is also important as students move from learning about their own profession to other professions and members of a team.31 These concepts reinforce a model of multiprofessional team management of pain championed long ago by John Bonica. Learners need to become self-directed, critical thinkers and reflective practitioners, able to function as members of teams, and be good communicators, adaptable to change and continuing to learn through professional experiences.3,22 Interprofessional education is not a replacement for education specific to each profession, a reason to lose individual professional identity, the only innovation needed in the health system, and an end in itself. We do not do IPE for its own sake; we do it to help understand each other's roles and contributions to work together in a real-world practice setting. 5. Barriers to overcome A number of significant barriers must be overcome to successfully implement and sustain a culture of IPE.22,32 Leadership at the highest level is needed for a culture change to be successful. For example, licensure and accreditation requirements do not currently reinforce preparation for collaborative practice in most countries. A survey of 41 countries from WHO's 6 regions representing various income economies reported IPE was often voluntary.27 Moreover, the lack of compulsory IPE and pain competencies for entry-to-practice graduates has implications for advancing skillful and ethical practice; it can limit the capacity of health care professionals to alleviate suffering, foster autonomy, and use resources justly.32 As well, many faculty are trained and familiar with the didactic teacher role rather than how to be an effective IPE facilitator and are not comfortable teaching pain content4; faculty education and development are needed. Faculty and clinician composition in the development and implementation of IPE activities may influence the outcomes of the learning activities.25,33 Evidence is scarce in developing countries, but challenges may be similar including curriculum structure and complexity. It has been suggested that barriers be taken as opportunities to transform approaches to core health problems in developing countries.30 Modifications in physical classroom space, competition for curriculum hours, and coordination of schedules can be challenging. Ideally, students should be introduced to IPE early with learning activities that build on competencies. Curriculum design is an iterative process necessitating modifications of complexity in patient cases and also the challenges of integrating clinical content to meet the needs of all levels of learners.33 Perceived differences in hierarchy, power status, and unequal participation rates among certain health professions have also been described as challenges.24 However, IPE can provide an opportunity to transform the way we socialize students by improving the understanding and respect of each other's unique roles and responsibilities within the team. Of course, the ultimate challenge is to harmonize learning experiences with well-functioning IP teams in clinical practice. Involvement of clinicians in curriculum development and implementation can help to insure real-world pain care and patient-centered modeling.33 6. Defining components of interprofessional education–competencies (learning outcomes), curriculum (learning plans), and content (learning objectives) Competency is the desired outcome of education. Distinct from learning objectives that emphasize gains in factual knowledge, attitudes, and skills, competency places emphasis on students' capacity to act effectively in relevant clinical situations.10 Competency generally includes observable phenomena such as being able to demonstrate the ability to explain a treatment or educate a patient about relevant treatment adverse effects. It also includes appropriate attitudinal and affective qualities to the extent that such are observable, eg, being able to maintain perceptibly compassionate communication while examining a painful part, potentially gauged through the use of interpersonal skills checklists. Core competencies in pain management for health professional education have been established.10 These pain competencies address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models (Fig. 1). A set of values and guiding principles is embedded within each domain. These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of IP learning activities across health professions designed to advance care that effectively responds to pain.Figure 1.: Core competencies for pain management. These core competencies pain assessment and management were developed through an interprofessional consensus process10 to address prelicensure pain management education in all major health care professions that are consistent with the IASP pain curricula outlines. Graphic created by Ian Koebner, PhD. Used with permission University of California Regents or Graphic courtesy of University of California Regents.Pain curricula outlines provide the template that helps to structure learning. Curricula include considerations of sequencing material, developmental appropriateness, and coordination of different health professions' learning activities, so that students from different health profession programs will learn about for IPE at the same time. The IASP Pain Curriculum Outlines15 provide recommended curricula for pharmacy, psychology, physical therapy, occupational therapy, nursing, medicine, dentistry, social work, and IPE. Each is arranged to address 4 main domains and related core competencies including (1) the multidimensional nature of pain, (2) pain assessment and measurement, (3) the management of pain, and (4) pain in specific clinical conditions. The outlines are helpful for establishing courses that provide an integrated foundation in pain at both the undergraduate and graduate levels. With this foundation, students are prepared to understand and approach patients with many forms of pain, as well as provide support to families and caregivers. All IASP curricula outlines including IPE were updated in 2017 for the Global Year for Excellence in Pain Education. Content is the description of what is being taught at the most granular level, eg, what are the learning objectives. Content serves as an important common language necessary to effectively communicate with each other about the specific elements of our uniprofessional and IP learning plans. Three teaching modules that address a number of IASP topics and are adaptable for IPE are available on the Portal of Geriatric Online Education (POGOe.org).20 In the United States, the National Institutes of Health has created a freely accessible portal of pain education online learning modules. Based on a variety of local models of IP collaboration, these modules demonstrate that IPE can take various forms depending on the specific professions engaged and the goals for learning.23 A unique and perhaps most comprehensive program is the 20-hour University of Toronto's Pain IP Curriculum involving students from 7 professional programs. The program's design and implementation components are described in the Pain IP Curriculum Model as (1) dynamic, (2) competency-based, (3) interrelated, and (4) collaborative with the patient focus at the center.33 Experience with the program has informed the creation of an eLearning Pain Education Interprofessional Resource that is internet accessible and available on request.19 As a blended eLearning program, Pain Education Interprofessional Resource has been designed as a self-learning resource to be coupled with facilitated small group, IP, collaborative discussion. 7. Outcomes of interprofessional education Measuring outcomes of IPE can be quite challenging. Large gaps regarding methods, theory, and context remain, and most studies focus on short-term results. The heterogeneity of contexts, variety of interventions, and methodological limitations makes it difficult to draw generalizable inferences about key elements and effectiveness of IPE.17,26 Evaluation should ideally link to clinical practice, but there is a paucity of contextually and synthesized literature regarding outcomes, particularly for pain management.24 University-based IPE using patient scenarios and group work in small teams, as contrasted to didactic lectures, has been shown to be feasible and has led to improved attitudes toward IP interaction and teamwork and improved understanding of health professional roles.24 Studies of IPE have found differences between professions, with students in professions deemed psychosocial were more positive about IPE than students in biomedical career tracks.13 Similarly, Erickson et al.9 found that IP mentorship and group participation improved first year medical students' pain management skills but did not have the same effect on fourth year nursing student performance. Differences were attributed in part to experience in clinical settings but also suggested that combining different levels of students is acceptable if they are of similar age and life experience. A significant positive shift in the pain knowledge and attitudes toward collaboration has been demonstrated through IPE.14,28 Simko et al.29 reported an increased knowledge and understanding of the importance of other profession's role in pain management in an IPE course for nursing and pharmacy students. Other studies have reported high student satisfaction and significant improvement in self-efficacy1 as well as respect for each other's roles and responsibilities.2 Positive changes have also been reported in pain assessment and documentation behaviors from IPE.17 8. Summary The delivery of effective pain management can be complex, requiring collaborative, team approaches that exceed the expertise of any one profession. Interprofessional collaboration is increasingly recognized as a core skill for all clinicians and is beginning to be required by some accrediting bodies for medical, nursing, pharmacy, physician assistant, and social work programs. However, IP collaborative practice is not yet an integral part of all health professions education programs. Recommendations of the WHO34 and other leading organizations recognize IP collaborative practice and education as a central component of transformative improvements in health care. Based on work in a number of global settings, recommendations for educational change to incorporate IP collaboration into practice are available and undergoing further development. Creating IPE learning opportunities is important. The intent of IPE is to produce a collaborative practice-ready workforce to improve the quality of health care. Students should be introduced to IPE early and have developmentally appropriate opportunities throughout a curriculum program. Students can change agents in the real world to continuously improve the way health professionals work together, mentor students and improve the quality of pain care. The quality and rigor of IPE research is inadequate, and research needs to move beyond feasibility and attitudes toward long-term improvements in clinical care. When focused on pain, IPE is likely to provide substantive benefits in the real-world practice setting, but barriers to IPE adoption, including slow adoption of pain-focused competencies and cultural habits, limit uptake. When able to overcome these obstacles, IPE has the capacity to harmonize learning experiences and promote patient-centered socialization of health profession trainees at all levels. Importantly, communicating and assessing innovation in IPE relies on understanding the conceptual education framework built on key elements of competencies (learning outcomes), curriculum (learning plans), and content (learning objectives). Although more work is needed to identify the most effective approaches, and even fundamentally to define meaningful approaches to outcomes assessment, models of education such as IP workshop training and online education exist with positive impact. We leave readers with a brief table of actions they can take to advance and transform health professions' education (Table 4).Table 4: Suggested actions individuals can take to promote IPE.Disclosures The authors have no conflict of interest to declare. D.B. Gordon and B. Hogans hold positions of leadership in their University's NIH Pain Consortium designated Centers of Excellence in Pain Education (CoEPEs). J.Watt-Watson is a principal leader in the University of Toronto's IP curriculum program.

The past decade witnessed momentum toward redesigning the U.S. health care system with the intent to improve quality of care. To achieve and sustain this change, health professions education must likewise reform to prepare future practitioners to optimize their ability to participate in the new paradigm of health care delivery. Recognizing that interprofessional education (IPE) is gaining momentum as a crucial aspect of health care professions training, this article provides an introduction to IPE programs from three different academic health centers, which were developed and implemented to train health care practitioners who provide patient-centered, collaborative care. The three participating programs are briefly described, as well as the processes and some lessons learned that were critical in the process of adopting IPE programs in their respective institutions. Critical aspects of each program are described to allow comparison of the critical building blocks for developing an IPE program. Among those building blocks, the authors present information on the planning processes of the different institutions, the competencies that each program aims to instill in the graduates, the snapshot of the three curricular models, and the assessment strategies used by each institution. The authors conclude by providing details that may provide insight for academic institutions considering implementation of IPE programs.

Attitudes toward Healthcare Teamwork between Osteopathic Medical Students in an Interprofessional or Intraprofessional Clinical Education Program

So Long, Silos

BackgroundFaculty members play crucial roles as facilitators of learning for effective inter-professional education (IPE). However, faculty attitudes are reported to be barriers to successful implementation of IPE initiatives within health care education settings. This study aimed to investigate the following: 1) health care faculty members’ attitudes toward interprofessional collaboration (IPC) and IPE; 2) factors affecting faculty members’ perception toward IPC and IPE; and 3) health care professionals’ perceptions toward factors that hamper the quality of IPC, and whether IPE is a possible remedy for the situation.MethodsA survey was administered to medicine, nursing, midwifery, and dentistry faculty members at 17 institutions in Central Java Province, Indonesia. Respondents were asked to rate their attitudes toward IPC and IPE using a previously validated “Attitude toward Interprofessional Health care Collaboration and Education” scale. To help interpretation of the survey results, 4 monoprofessional focus groups (FGs) were conducted and 3 key participants who could not be present at the FG meetings were interviewed. We conducted a statistical analysis on the quantitative data and performed a thematic content analysis of the qualitative data using ATLAS Ti (version 7).ResultsThe total response rate was 74.1%. Nurses’ mean scores for attitudes toward IPC and IPE were higher than those of other health care professionals. The main problems of IPC identified from the FG were as follows: 1) differing perceptions of the needs of patients among professionals; 2) unequal participation in decision-making; 3) lack of face-to-face interaction; and 4) overlapping of roles and responsibilities. Faculty members agreed that IPE has the potential to remedy these challenges as long as opportunities are provided to inculcate equal power and contribution in meeting patients’ needs.ConclusionThese findings indicate the necessity of convening faculty development programs regarding IPC and IPE. Additionally, innovative strategies must be developed for the implementation of IPC and IPE in a variety of academic settings.

Evidence-based practice collectively involves research evidence, clinician expertise, and patient preference while making health care decisions. Due to health care reform legislation, there is grea...

Interprofessional Education: Fad or Imperative

Celebrating the Culture of Interprofessional Collaboration in Athletic Training

The relationship between interprofessional education experience and perceptions, values, and attitudes towards interprofessional collaboration in dietetics practice

BackgroundEffective interprofessional collaboration (IPC) is essential for the delivery of chronic care. Interprofessional education (IPE) can help support IPC skills. This makes IPE interesting for GP practices where chronic care is delivered by GPs together with practice nurses, especially for GP trainees who have to learn to collaborate with practice nurses during their training. The aim of this study is to gain insights in how IPE and IPC occur between GP trainees and practice nurses during the delivery of chronic care in GP training practices.MethodsWe conducted a qualitative research using semi structured focus groups and interviews with GP trainees, practice nurses and GP supervisors. All respondents were primed to the subject of IPE as they had followed an interprofessional training on patient-centred communication. The verbatim transcripts of the focus groups and interviews were analysed using thematic analysis.ResultsDespite the overall positive attitude displayed by respondents towards IPE and IPC, the occurrence of IPE and IPC in GP training practices was limited. Possible explanations for this are impeding factors such as limited knowledge, prejudice, lack of role models and a hierarchical organisational structure. Contributing to IPE and IPC use was the integration of IPE in daily practice, e.g. via recurring scheduled meetings.ConclusionWe found a limited occurrence of IPE and IPC in GP training practices. Our results show a discrepancy between respondents enthusiasm for IPE and IPC and their actual behaviour. IPE activities have to be initiated in GP training practices, otherwise, despite good intentions, IPE and IPC will be ineffective.

The effectiveness of interprofessional education in university based health professional programs: A systematic review.

The effectiveness of interprofessional education in university based health professional programs: A systematic review

BackgroundAn increasingly ageing population and the resulting multimorbidity is a growing challenge for healthcare systems. A solution to tackle this problem is interprofessional collaboration. Interprofessional education, as an early meeting point, could foster a future successful interprofessional collaboration. So, the aim of our pilot study was to assess whether the “interprofessional collaboration between medical and pharmacy students to improve medication safety in polypharmacy” (PILLE) project changed the perception of medical and pharmacy students towards interprofessional collaboration.MethodsPILLE consisted of three parts: (1) A mandatory 90-minutes interprofessional seminar; (2) A voluntary 120-minutes practical training; (3) A voluntary half-day interprofessional tandem work shadowing at a General Practitioner’s (GP) office. We used a controlled study design. Medical and pharmacy students from the intervention group attended the seminar (1). Medical students of the control group attended an interactive 90-minutes monoprofessional seminar only. Working together on cases was the similarity of both seminars. The students from the intervention group could attend (2) and (3). The outcome of interest was the change in students’ perception towards interprofessional collaboration after participating in PILLE, using pre- and post-questionnaires with the validated German version of Student Perceptions of Physician-Pharmacist Interprofessional Clinical Education (SPICE-2D) instrument. Descriptive and statistical evaluation was conducted. To assess if there is a significant pre-post-difference in the SPICE-2D overall score within the individual groups, paired t-tests were executed. To investigate if there is a significant change in SPICE-2D overall score difference between the medical students control and intervention group, an unpaired t-test was performed.ResultsIn total, 436 students participated: 96 medical students and 116 pharmacy students in the intervention group, and 224 medical students in the control group. The participating students from both professions already had a pronounced positive perception at baseline. All pre-post-mean-differences within the individual groups and between the medical students control and intervention group were not statistically significant.ConclusionParticipating medical and pharmacy students already had a positive perception at baseline. A one-time and short-term mandatory seminar of 90-minutes seems not to be sufficient to measure a change in perception. Future interprofessional education projects should focus on frequent meeting points between students.

Interprofessional collaboration is seen as an indispensable prerequisite for high-quality health services and patient care, especially for complex diseases such as dementia. Thus, the current project aimed to extend interprofessional and competency-based education in the field of dementia care to the previously understudied therapy professions of nutrition, speech-language pathology, and physiotherapy. A three-day workshop was designed to provide specific learning objectives related to patient-centered dementia care, as well as competences for interprofessional collaboration. Teaching and learning approaches included case-based learning in simulated interprofessional case-conferences and peer-teaching. A total of 42 students (n = 20 nutrition therapy and counseling, n = 8 speech-language pathology, n = 14 physiotherapy), ranging from first to seventh semester, finished the whole workshop and were considered in data analysis. Changes in self-perceived attitudes toward interprofessional collaboration and education were measured by the German version of the UWE-IP. An in-house questionnaire was developed to evaluate knowledge and skills in the field of dementia, dementia management and interprofessional collaboration. Participation in the workshop led to significant improvements in the total scores of the UWE-IP-D and the in-house questionnaire, as well as their respective subscales. Moderate to large effect sizes were achieved. All professions improved significantly in both questionnaires with large effect sizes. Significant differences between professions were found in the UWE-IP-D total score between students of speech-language pathology and physiotherapy in the posttest. Students of nutrition therapy and counseling revealed a significant lower level of self-perceived knowledge and skills in the in-house questionnaire pre- and post-testing. The pilot-study confirms the effectiveness of interprofessional education to promote generic and interprofessional dementia care competencies and to develop positive attitudes toward interprofessional learning and collaboration in the therapy professions, thus increasing professional diversity in interprofessional education research. Differences between professions were confounded by heterogenous semester numbers and participation conditions. To achieve a curricular implementation, interprofessional education should be expanded to include a larger group of participants belonging to different professions, start early in the study program, and be evaluated over the long term.

Pursuing Excellence: Innovations in Designing an Interprofessional Clinical Learning Environment.