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

Abstract

Centre Conducting Review: University of Newcastle Evidence Synthesis Group: a collaborative centre of the Joanna Briggs Institute Commencement date: October 2010 Expected completion date: June 2011 Background A key function of universities is to prepare graduates for life-long learning in a highly mobile and competitive workforce. Employers in the health sector seek nursing, medicine and pharmacy graduates who have acquired well developed interprofessional learning and practice capabilities to enable them to work both collaboratively and autonomously in complex clinical environments. Such environments require the ability to work as part of a multidisciplinary clinical team and demand effective teamwork and communication skills. Currently, most university-based health professional education is delivered in the traditional discipline specific mode. This approach is limited in its ability to equip graduates with the necessary knowledge, skills or attitudes for effective interprofessional collaboration required for working as part of a complex health care team.1 An educational approach such as interprofessional education (IPE) is required where learners from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes. 2 In the education literature there is little distinction between the terms interprofessional, interdisciplinary, multiprofessional, and multidisciplinary. The prefix ‘multi’ suggests many groups, while ‘inter’ implies some sort of interaction in group.3 In a multidisciplinary health care team, individual health professionals make autonomous or separate decisions.4 In contrast, an interprofessional team comprises different professions with specialised knowledge, skills and abilities; each contributing to a common goal which cannot be achieved when one individual profession acts alone.2 In the clinical arena, this model is also referred to as interprofessional collaboration. Interprofessional collaboration occurs when healthcare health providers, patients and their families work together in the provision of coordinated and integrated care to enable optimal health outcomes.2 An interprofessional team that collaborates effectively is characterised by its knowledge and understanding of each others' roles and the team's ability to appreciate and value the unique contribution made by each profession to patient care.5 In this practice model, joint decision making is valued and each profession is empowered to assume leadership on patient care issues appropriate to their expertise.6 Practice-based interventions that are interprofessionally collaborative such as rounds, meetings and externally facilitated audits have been shown to improve patient outcomes including improvement in safe medication practices and decreased length of hospital stay.7 The fundamental premise of IPE is that if health professional students learn together they will be better prepared for interprofessional collaboration, teamwork, ultimately leading to improved health outcomes.8 Research indicates that t information sharing, determining professional responsibilities, consensus building and setting common patient goals all components of effective communication skills) can be enhanced through IPE.9 Improvement in health professionals' interpersonal and communication skills are associated with improved patient health outcomes.10, 11 Definitions of IPE in the literature are varied and ubiquitous. The following definition by the American Association of Colleges of Pharmacy Interprofessional Education Task Force has been adopted for this review: Interprofessional education involves educators and learners from two or more health professions and their foundational disciplines who jointly create and foster a collaborative learning environment. The goal of these efforts is to develop knowledge, skills and attitudes that result in interprofessional team behaviors and competence.12-14 In Australia, submissions by the Committee of Deans of Australian Medical Schools to the Australian Productivity Commission Review of the Health Workforce highlighted the potential importance of IPE by stating that: “… there is now a growing recognition that medical education needs to be contextualised within the needs of the health workplace and coordinated across the education/training/practice continuum ”.15(p6) Interprofessional teaching and learning was also a key element of health care reform promised by the Australian Federal Government in 2007.16 In addition, several recent government policy documents and independent reports have specifically advocated for inclusion of IPE in clinical education and training. The 2008 publication by the Department of Health and Ageing (DOHA) titled Towards a National Primary Health Care Strategy, contained references to “multidisciplinary teams” and “interdisciplinary learning”.17 One recommendation was “the current and future primary health care workforce is provided with high quality education (undergraduate, postgraduate and vocational) and clinical training opportunities that support interdisciplinary learning”.18(p40) In the same year, Garling's1Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals made clear recommendations supporting IPE approaches, stating that education and training should be undertaken in a manner that emphasises interdisciplinary team based patient centred care. In the United States, the Institute of Medicine (IOM) published the report Crossing the Quality Chasm: A New Health System for the 21st Century. One of the major recommendations of this report is that “health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team”.18 In Canada IPE is being integrated into health professional education curricula 19 while the United Kingdom has mandated the integration of IPE into pre-qualifying curricula.20 The Organization for Economic Co-operation and Development (OECD) and the World Federation of Medical Education (WFME) are example of international organisations that have embraced strategies that facilitate IPE.21 More significantly, the recently published World Health Organization 2Framework for Action on Interprofessional Education and Collaborative Practice has led to an interest in IPE at the global level. Despite this belief in IPE as a key area of health professional development, there remains a lack of systematic evidence of its effectiveness.22, 23 Reviewers have argued that the concept of IPE remains unclear and that there are multiple definitions and objectives.24 Furthermore, the development and delivery of a curriculum that integrates IPE methods requires significant resources therefore, its adoption should be based on evidence of effectiveness.25 Existing reviews of IPE In order to prevent duplication of research, a search of the Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, MEDLINE and DARE databases was undertaken to establish whether or not a recent review on IPE exists. This search identified the following systematic reviews focusing predominantly on IPE: Zwarenstein, et al. 26 Freeth, Hammick, Koppel, Reeves and Barr 27 Clifton, Dale and Bradshaw 28 Hammick, Freeth, Koppel, Reeves and Barr 29 Reeves, et al. 25 One of the earliest systematic reviews was conducted by the United Kingdom Centre for the Advancement of Interprofessional Education (CAIPE) in 2002. 27 It included 217 evaluations of IPE studies thirty percent of which included pre-registration students, however the research setting was often a health care facility rather than a university.27 The majority of the studies focused on continuing professional development at post-registration levels and were undertaken within the workplace or an employment training facilities. The systematic review included nursing, medicine, social workers, pharmacist, physiotherapist and other allied health care professionals. Of note, this review was only based on studies published in Medline, CINAHL and the British Education Index and did not include other electronic databases or grey literature. The reviewers reported outcomes of IPE into six categories: learners' reactions, changes in attitude or perception, changes in knowledge or skill, behavioural changes, changes in the organisation or delivery of care, benefit to patients or clients.27 Although some studies reported positive outcomes, the majority reported mixed results. The authors also report that the majority of the studies included in the review were variants of before-and-after studies and longitudinal studies. Such studies do not demonstrate cause and effect and therefore cannot address effectiveness of IPE interventions. In 2006, the United Kingdom Royal College of Nursing commissioned a literature review of published studies to determine the impact and effectiveness of IPE for primary care professionals28. This review included 20 studies published between 2000 and 2006 that contained some form of evaluation of the effectiveness of IPE in undergraduate courses, university-based modules and work-based team development programmes. The professions involved in IPE were nursing, medicine, dietetics, pharmacy and social work. Evidence suggests some positive findings related to undergraduate pre-registration IPE including; improvement in attitude and perceptions of the contribution of other health care professions; and an increase in knowledge and understanding of the contribution of other health care professionals to patient care.28 Two of the included studies reported some negative findings such as resistance to IPE.28 The authors also highlighted limitations in the study methodologies such as: a lack of control groups; validated instruments were not always used; small samples sizes. Another evidence synthesis was undertaken by Hammick et al 29 using selected bibliographic databases and journals published between 1981 and 2005; the review did not include any grey literature. The review included 21 studies, 15 of which evaluated IPE delivered to undergraduate health professional students, predominantly from medicine, nursing and physiotherapy. Other professions included in the studies were pharmacy, occupational therapy, dentistry, social work and midwifery.29 Due to the different study methodologies and outcome measures, meta-analysis was not possible in this review so the results were presented in a narrative form. 29 The authors provided analysis of IPE outcomes for learner reactions, knowledge, skills, attitudes, behaviour and client care. Collectively, the study results indicated a positive change in students' perceptions in knowledge, skills, perceptions and attitudes. Two studies reported that IPE education programs increased the volume of patients seen, and the comprehensiveness of patient care.29 The most compehensive appraisal of the effectiveness of IPE on professional practice and health outcomes was conducted as a Cochrane review.26 The review considered either randomised controlled trails, controlled before and after studies, or interrupted time-series studies. This review considered 1042 studies but none met the criteria for Cochrane review. The authors concluded that there was no published evidence that IPE promotes interprofessional collaboration, or improves client relevant outcomes. In 2008, an update of the 2000 review identified six studies that compared the effectiveness of IPE with other teaching and learning approaches.25 The participants in the included studies were mainly qualified medical doctors and nurses and other allied health workers such as psychiatrists, medical assistants and therapist. The authors reported mixed results related to patient safety, with two of the six studies indicating no improvements in other outcomes. Four of these studies found that IPE improved the working culture in an emergency department, improved patient satisfaction; decreased errors in the emergency department; improved the management of the care delivered to domestic violence victims; and improved the knowledge and skills of professionals providing care to mental health patients.25 The authors concluded that due to the small number of studies and the heterogeneity of IPE approaches used, general conclusions could not be drawn. Methodological shortcomings The reviews discussed here provide some understanding of the impact of IPE on health outcomes. Although some studies reported positive outcomes, the majority reported mixed results. Some of the reviews only included published studies sourced from electronic databases without exploring other unpublished and grey literature.27, 28 Such review methodologies can lead to publication bias as relevant unpublished studies might have been excluded from the analysis. The majority of the studies included in the reviews did not use rigorous research designs and validated measurement instruments which make it difficult to draw accurate conclusions regarding the effectiveness of IPE interventions. Such studies do not demonstrate cause and effect and therefore cannot address effectiveness of IPE interventions. There is therefore a paucity of evidence specific to the effectiveness of IPE for university based health professions. While there is a slowly emerging body of evidence, the impact of IPE and multidisciplinary approaches to patient care remains uncertain. It is important to note that a lack of sufficient evidence of the effectiveness of IPE does not equate to the ineffectiveness of IPE. Rather, this presents an opportunity for searching, synthesising and summarising the available primary studies in order to determine the effectiveness of IPE in university based health professions education. None of the systematic review explored specifically addressed the effectiveness of IPE in university or tertiary based health professional education. The proposed review will therefore fill this gap by considering the effectiveness of IPE in university or tertiary based settings. For the purposes of this review “effectiveness is the extent to which an intervention, when used appropriately, achieves the intended effect”.30(p11) Review question/objective Objective The aim of this review is to appraise and synthesise the best available evidence on the effectiveness of university based IPE interventions as compared to uniprofessional educational interventions. Review Question This review will systematically examine the evidence to answer the following question: What is the effectiveness of IPE in university based health professional programs? Inclusion criteria Types of participants The review will consider studies that include students of two or more undergraduate and post graduate health professions engaged in IPE regardless of gender, age and disciplines Types of intervention(s)/phenomena of interest The review will consider studies that include any university based pedagogical approaches to IPE. Types of outcome Any objectively measured or self-reported educational outcomes and/ professional competencies related to IPE assessed by validated instruments such as the Readiness for Interprofessional Learning Scale (RIPLS) and the Interdisciplinary Education Perception Scale (IEPS) will be included in the review. Type of studies Although properly designed randomized controlled trials (RCTs) are considered the gold standard to use for evidence of effectiveness 30, such methods are not always feasible and practical in all settings.31 The systematic review will therefore primarily consider (RCTs). However, in the absence of RCTs, other research designs, such as non-randomised controlled trials and before and after studies, will be considered. This approach will enable the identification of current best evidence regarding the effectiveness of IPE in health professional programs. Search Strategy Methods of review The search strategy aims to find both published and unpublished studies, limited to the English language. A three-step search strategy will be utilised in this review. Initially a limited scoping search of MEDLINE and Proquest databases will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe each article retrieved. Initial terms to be used are: Collaborative learning Competencies Curriculum Health professions education Practice Student Teaching Each of these terms will be searched preceded by the terms interprofessional, interdisciplinary, multiprofessional, and multidisciplinary. The second step will involve searching electronic databases using several combinations and permutations of key words and index terms identified by the initial literature scoping. All the electronic databases will be searched from their inception dates to current. Using a defined search and retrieval method, the databases to be searched are: AMED CINAHL Cochrane Database Dissertation and Theses EMBASE ERIC [email protected] MEDLINE ProQuest Nursing Journals PsycINFO The following will be hand searched to find any additional articles: Journal of Interprofessional Care Mednar Directory of open access journals ProQuest - ProQuest Dissertations & Theses Database Conference Proceedings Lastly, reference lists of all included literature will be searched for any additional relevant studies. The bibliographical software package EndnoteTM will be utilised to manage all references as it facilitates the importation of references from electronic databases as well as the linkage of references into the Joanna Briggs Institute (JBI) Comprehensive Review Management System (CReMSTM) for assessment of methodological quality using the JBI critical appraisal tools. These guidelines have been developed to minimise bias and establish validity of the findings. Critical Appraisal Papers selected for retrieval will be assessed for methodological validity by two independent reviewers prior to inclusion in the review. For this process, the reviewers will use the critical appraisal instrument from the Joanna Briggs Institute, known as the Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Where agreement is not reached between the reviewers, a third reviewer will be consulted. Data Extraction Data will be extracted from the papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The extracted data will include specific details about the interventions, populations, study methods and outcomes of significance to the aim of the review. Data Synthesis Quantitative papers will, wherever possible, be pooled in statistical meta-analysis using the JBI-MAStARI instrument. All results will be subject to double data entry to minimise errors. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative summary form. Acknowledgements: Support for this project has been provided by the Australian Learning and Teaching Council (ALTC) Ltd, an initiative of the Australian Government Department of Education, Employment and Workplace Relations. The views expressed in this paper do not necessarily reflect the views of the ALTC. Conflicts of interest Nil