Transcript
Interdisciplinary Education For Collaborative, Patient-Centred Practice
Research and Findings Report
February 20, 2004
University of Toronto Universite de Montreal Institute for Clinical and Evaluative Sciences McGill University York University London South Bank University City University University Health Network - Toronto Western Hospital CBR Consulting
Prepared and Submitted by: Project Leader: Ivy Oandasan, MD, CCFP, MHSc - Assistant Professor and Research Scholar at the Department of Family & Community Medicine, University of Toronto and Toronto Western Hospital, University Health Network. Danielle D’Amour RN, PhD Associate Professor, Faculty of Nursing at Université de Montréal, Director of FERASI Centre and Researcher at Groupe interdisciplinaire de recherche en santé (GRIS) Merrick Zwarenstein, M.B., B.Ch., M.Sc., M.Sc (Med.) Senior Scientist, Institute for Clinical & Evaluative Sciences, Principal Investigator, Knowledge Translation Program, Continuing Education, and Associate Professor, Department of Health Policy, Management and Evaluation, at the Faculty of Medicine, University of Toronto. Keegan Barker, BA, M.Ed Research Associate, Department of Family & Community Medicine, Toronto Western Hospital, University Health Network Margaret Purden R.N., Ph.D. Assistant Professor, School of Nursing McGill University, and Director of the Centre for Nursing Research, Jewish General Hospital Marie-Dominique Beaulieu MD, MSc, CCMF Professor, Chaire Dr Sadok Besrour en médecine familiale, Department of Family Medicine, Université de Montréal and Researcher, Centre de recherche du Centre hospitalier de l’Université de Montréal Scott Reeves, BSc, MSc, PGCE Research Fellow, City University, UK and Senior Research Fellow, South Bank University, UK. Louise Nasmith, MDCM, MEd, CCFP, FCFP Professor and Chair, Department of Family and Community Medicine, University of Toronto Carmela Bosco, Health Policy Consultant and Managing Director, CBR Consulting Liane Ginsburg, PhD, Assistant Professor, School of Health Policy & Management, Atkinson Faculty of Liberal & Professional Studies, York University Deborah Tregunno, RN, PhD, CHSRF Post Doctoral Fellow, Faculty of Nursing, University of Toronto
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Interdisciplinary Education for Collaborative Patient-Centred Care Definitions It is recognized at this time that there are many terms being used amongst those who are advancing the areas of interdisciplinary education and collaborative practice. The authors of this report respect the use of other terms intended to convey the same meaning but recognize that consensus is needed in the future. As the most controversial terms being used are “interdisciplinary versus interprofessional education” the authors chose to use these terms interchangeably. The authors of this report feel that there is a need for a common understanding to be developed for the terminologies to be used in the future and urge that less time be placed on the debate on terminology and more to the implementation of the values and concepts related to interdisciplinary education for collaborative patient-centred care henceforth to be given the acronym in this report “IECPCP”.
Interprofessional/Interdisciplinary Education “occasions when two or more professions learn from and about each other to improve collaboration and the quality of care” (CAIPE, 1997 revised)
Collaboration “an interprofessional process of communication and decision making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the client/patient care provided” (Way & Jones 2000)
Collaborative Patient-Centred Practice “is designed to promote the active participation of each discipline in patient care. It enhances patient and family centred goals and values, provides mechanisms for continuous communication among care givers, optimizes staff participation in clinical decision making within and across disciplines and fosters respect for disciplinary contributions all professionals” (Health Canada, 2003)
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Table of Contents EXECUTIVE SUMMARY
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PREFACE
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ACKNOWLEDGEMENT
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CHAPTER ONE: INTRODUCTION Background
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International Context of Interdisciplinary Education for Collaborative Patient Centred Care (IECPCP)
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Historical Context of IECPCP in Canada
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The Development of this Report
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Towards a Common Language
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Road Map for the Report
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CHAPTER TWO: EFFECTIVENESS OF PRE-LICENSURE INTERDISCIPLINARY EDUCATION AND POST-LICENSURE COLLABORATIVE INTERVENTIONS Introduction and Purpose
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Methods
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Reviews
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Results
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Discussion
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Conclusion
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Summary
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Chapter References
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Chapter Appendices
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CHAPTER THREE: KEY ELEMENTS OF COLLABORATIVE PRACTICE & FRAMEWORKS: CONCEPTUAL BASIS FOR INTERDISCIPLINARY PRACTICE Introduction
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Literature Review Strategy
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Collaboration – Definitions and Concepts
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Theoretical Frameworks of Collaboration
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Collaboration Determinants
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Policy Levers Towards collaborative Practice Projects
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Conclusions
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Chapter References
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Chapter Appendices
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CHAPTER FOUR: KEY ELEMENTS OF INTERDISCIPLINARY EDUCATION Introduction
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Methodology
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Defining Interdisciplinary Education in Context
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Interdisciplinary Education Competencies
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Learning Context
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Evaluation of IPE: Issues Related to Outcome Measurements of IDE Initiatives & Assessment of Learners
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Summary
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Chapter References
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CHAPTER FIVE: EXAMPLES OF INTERPROFESSIONAL EDUCATION AND COLLABORATIVE PRACTICE: FINDINGS FROM ON-LINE SURVEY Introduction
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Background: On-Line Survey
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Methodology
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Findings of the On-line Survey
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Findings: Interprofessional Education
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Findings: Collaborative Practice
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On-line Survey Limitations
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Discussion of Results
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Observations and Conclusions
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Chapter References
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Chapter Appendices
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CHAPTER SIX: EXAMPLES OF INTERPROFESSIONAL EDUCATION AND COLLABORATIVE PRACTICE: FINDINGS FROM IN-DEPTH INTERVIEWS Introduction
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In-depth Interview Methodology
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Overview of Interview Findings
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Interdisciplinary Key Findings
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Collaborative Practice Key Findings
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What We Can Learn from Interdisciplinary Education and Collaborative Practice Examples
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Summary
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Chapter Appendices
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CHAPTER SEVEN: CULTURAL CONSIDERATIONS IN INTERPROFESSIONAL EDUCATION AND PRACTICE Introduction
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Search Strategy and Results
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Definitions
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Implications of Cultural Diversity for Interprofessional Practice and Education
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Cultural Diversity in Interprofessional Practice
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Cultural Diversity in Interprofessional Education
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Conclusion and Future Directions
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Chapter References
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CHAPTER EIGHT: HEALTH POLICY AND IECPCP Introduction
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Policy Literature Review
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IECPCP Program InitiativesWithin Canada and Abroad
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Policy Barriers to IECPCP
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Policy Enablers for IECPCP
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Policy Levers Supporting IECPCP
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Policy Issues for Consideration
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Next Steps for Policy
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Summary
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CHAPTER NINE: IMPLEMENTING NEW APPROACHES TO INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE: LESSONS FROM ORGANIZATIONAL LITERATURE ON CHANGE Introduction
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Using Organizational Change Theory to Understand Response to Change
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Using Organizational Change Theory to Address Barriers to Interdisciplinary Education and Collaborative Practice
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Conclusions & Recommendations
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Chapter References
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CHAPTER TEN: IECPCP FRAMEWORK A Framework for IECPCP
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The Components of the Framework
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Interdependency Between Interdisciplinary Education and Collaborative Practice
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Interdisciplinary Education to Enhance Learner Outcomes
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Collaborative Practice to Enhance Patient Outcomes
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Research to Inform and Evaluate
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Next Steps
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Chapter References
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CHAPTER ELEVEN: RECOMMENDATIONS FOR HEALTH CANADA
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SUMMARY OF THE REPORT
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APPENDICES OF THE REPORT
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ANNOTATED BIBLIOGRAPHY
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Executive Summary About The Research Report Across Canada, there has been much dialogue about the affordability and sustainability of the country’s health system for more than a decade. As there are many facets to health system renewal, one of the goals of the First Ministers of Health is to achieve an integrated and interdisciplinary approach to primary care.1 This approach would ensure timely access to appropriate health care providers, 24 hours a day, 7 days a week for all Canadians who require health care services regardless of where they live. The 2003 First Ministers’ Accord on Health Care Renewal provided the direction for change. The consensus was that fundamental changes are necessary in order to deliver an effective primary health care system that would see improvements to continuity and coordination of care. Under this direction, the 2003 First Ministers Health Accord identified that changing the way health professionals are educated is a key component of health system renewal. This change will be mobilized through the development and implementation of an initiative on interdisciplinary education for collaborative patient-centred practice (IECPCP). A team of health researchers with expertise and experience in the field of interdisciplinary education and collaborative practice was assigned the task of examining this issue. The team explored current national and international trends impacting interdisciplinary approaches to primary health care, reviewed existing models of interdisciplinary education and collaborative patient-centred care practice frameworks and provided an analysis of their findings to determine what Canada must do to advance IECPCP in our health care system. Under the guidance of the National Expert Committee (NEC) on Interdisciplinary Education for Collaborative Patient-Centred Care and the Office of Nursing Policy of Health Canada, the research team proposed recommendations that take into consideration the current realities both at the policy and organizational level. It is hoped that the recommendations can assist in driving interdisciplinary health care change forward. The research team explored both successful and unsuccessful interdisciplinary education and collaborative practice initiatives within health care practice settings and academic institutions. The findings from a literature review and environmental scan conducted for this report provided the necessary information to develop a framework to define the essential features and determinants for IECPCP. The report covers: •
Current trends of interdisciplinary education for collaborative patient-centred practice in Canada and abroad and what are best practices for patient outcomes.
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A review of existing studies on the effects of interdisciplinary education and collaborative practice for quality of care and patient outcomes.
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Health Canada. Interdisciplinary Education for Collaborative, Patient-Centred Practice. Discussion Paper & Research Report Request for Proposal. October 2003
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Key features in the relationship between, and elements for, successful interdisciplinary education and collaborative practice models
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The barriers to implementing interdisciplinary education and collaborative practice and descriptions of change management strategies to overcome these barriers.
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The enablers that influence interdisciplinary education and collaborative practice.
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Current policies, programs and strategies in health and education that support IECPCP.
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Recommendations on how to advance IECPC in Canada including research priorities.
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A conceptual framework to consider the essential elements and determinants for IECPCP based on available evidence and theoretical considerations.
A database is included with this report highlighting examples of interdisciplinary education and collaborative practice initiatives that currently exist in Canada and abroad. As well, a listing of published articles is provided. Findings and recommendations of this report will be used as the basis for further deliberations by the First Ministers of Health, the NEC as well as Health Canada as a priority for health system renewal.
Overview Research Methodology The research methodology employed in exploring models of interdisciplinary education and collaborative practice was a literature review and an environmental scan. The research team, leaders in interdisciplinary education and collaborative practice, contributed significantly to the research. These individuals were core contributors to the literature review and were instrumental, for example, in the Cochrane Reviews on Nurse – Physician collaboration interventions, and on Interdisciplinary Education and its relationship with patient outcomes as well as the review on Interdisciplinary Education conducted by the Joint Evaluation Team (JET) in association with the Centre for Advancement of Interprofessional Education (CAIPE) in the United Kingdom. The Université de Montréal contributed its expertise in collaboration mainly at the primary care level. With the researchers’ combined extensive background, the team was able to build upon, and share in the knowledge of, their resources in order to begin building a Canadian database on the literature related to this field. In addition, the authors (team members) of each chapter of this report executed their own research activities in addressing specific issues about IECPCP. Their specific research methodologies are described in their chapters. The literature review examined existing interdisciplinary education and collaborative practice models within government, health care facilities, educational institutions, professional and health care associations, and professional licensing bodies in Canada and internationally, including the United States and the European Community.
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Literature Review Sources for literature review included: - published literature (national and international, health sector and non-health sector) - “grey” literature, including: government policy documents, including health and education departments (national, provincial, municipal, as well as international governments) - doctoral dissertations - position papers / policy statements of professional, health, education, and voluntary associations - Primary Health Care Transition Fund, and health transition fund literature - internet / website search The grey literature consisted of a collection of policy papers, reports, articles, and summaries that are generally considered non-scientific. The process used to identify this body of literature was through two listservs, CanMedLib (Canadian Medical Librarians listserv) and MedLib (Medical Librarians listserv) asking members to identify and forward any key documents. This generated only one recommendation that was not appropriate and could not be used. Subsequently, searches were conducted on Google™, PubMed and Medline search engines. Key websites were then identified by team members working on the project. These websites were specifically sought out, and the following keywords were entered separately into the ‘Search’ box for each individual website: multidisciplinary, interdisciplinary, interprofessional and primary care reform: Health Canada Each Canadian province and territory Health and Education Departments World Health Organizations Australian Government National Department of Health and Ageing (i.e. all state and territory health departments United States Department of Health and Human Services New Zealand Ministry of Health United Kingdom Department of Health National Institutes of Health Health Care Associations A research librarian was hired to ensure that all literature, both English and French languages, was collected and collated by each team member and entered into an electronic database. The librarian acted as the central information resource. For this initiative, an examination of the mechanisms used for the literature searches by the team members from their past work was conducted by the research librarian to ensure that all published and non-published information was identified and distributed to the teams for their evaluation. An inventory of program initiatives in interdisciplinary education and collaborative practices database was created and is housed with Health Canada. This inventory will be a resource for individuals embarking upon innovations in the field of interdisciplinary education and collaborative practice. A second database of those individuals and organizations contacted for participation in the environmental scan provides a registry of key individuals with experience in this field. This database is housed ix
with Health Canada. Third, a database of key literature in the field of IECPCP based on published articles and grey literature was generated and is appended to this report. Environmental Scan The environmental scan provided information about what is currently being done in the country related to interdisciplinary education and collaborative practice. The environmental scan highlighted supportive policies in governments, health service and educational organizations; indicated emerging trends and innovations; and provided a sense of the readiness for interdisciplinary education and collaborative practice at the macro, meso and micro levels in Canada. Three methods were executed to gain such comprehensive information: • On-line Survey of identified key informants • Focus Group with NEC-IECPCP committee members • In-depth interviews with individuals involved in representative interdisciplinary education and collaborative practice initiatives Sources for the environmental scan included: • key informants (including national and international contacts), with relevant sources identified by: • Health Canada staff of the Health Human Resource Strategies Division, the Office of Nursing Policy of the Primary Health Care Division • the National Expert Committee • provincial / territorial government officials • international initiatives • educators • health provider organizations • professional associations • Primary Health Care Transition Fund / Health Transition Fund initiatives and projects • Authors of grey literature
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Key Chapter Findings/Highlights The researchers were divided into teams to address specific themes and tasks related to IECPCP. Each of their findings is highlighted in separate chapters within the report. The following provides the highlights of each of the chapters written. Effectiveness of IECPCP Interventions •
Evidence to date, has been found that collaborative practice initiatives that occur at the postlicensure level of training (with practitioners in clinical practice) improve quality of care and patient outcomes in specific populations. The authors of the chapter consider that postlicensure collaboration interventions have the highest priority for research and implementation. The fact that they are workplace-based ensures that stakeholders other than the professions or their organizations have an interest in supporting these interventions.
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Research conducted at the pre-licensure level of training has lacked the rigour needed to understand its impact on patient care outcomes. There is no empirical evidence to date that interdisciplinary education can improve patient care outcomes. Thus more research is needed. The authors strongly recommend that a number of approaches to interdisciplinary education should be tested using contextual, qualitative studies and rigorous quantitative studies to develop models of educational interventions that can be pilot tested and effectiveness evaluated. Given the urgent need to develop educational models, caution is recommended against widespread intervention programmes until the findings of the effectiveness and feasibility of implementing them are tested.
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The research to date measuring the effectiveness of collaborative practice initiatives has been found primarily in hospital based settings. There is a need to develop interdisciplinary collaboration interventions in primary and ambulatory care pilot testing them and moving rapidly into rigorous large scale trials to understand outcomes.
Elements for Collaborative Practice A literature review was conducted on the conceptual basis of collaboration. Findings reveal that collaboration is a complex, voluntary and dynamic process involving several skills. The complexity of the task at hand translates into different levels of collaboration intensity in a constantly evolving fashion. •
Collaboration is related to other concepts such as sharing, partnership, interdependency and power. Teamwork is the main setting in which collaboration takes place.
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In none of the available research papers did we find a true reflection of how to integrate patients in the care team despite the fact that patients are recognized as the ultimate justification for collaborative care.
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Only a few reviewed papers proposed models with a sound theoretical and empirical basis. Three models stand out as possible references for future education and research initiatives.
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The stronger theoretical models of collaboration propose an understanding of the processes of collaboration on hand and the components of the structure influencing the processes.
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Three main types of determinants were identified: interactional, organizational and macro structural determinants. Iinteractional determinants have been studied more extensively than organizational and macrostructural determinants; the latter have been especially ignored.
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It has been shown that within the organizational determinants, formal regulation (definition of rules to be followed by the teams) and leadership have an impact on measured outcomes.
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The policy levers that appear the most likely to help reduce some of the barriers to implementing collaborative care are profession regulation, funding mechanisms and professional compensation methods.
Elements for Interdisciplinary Education •
A literature review was conducted to obtain insight on the elements for interdisciplinary education with respect to competencies, attitudes, values, teaching methodologies, learning practice settings, and faculty development. Findings from the literature review point towards information related to educational processes for interdisciplinary education. However, more research is needed to link the effectiveness of these processes with successful outcomes of interdisciplinary education. There is also a need for more process-oriented research to help address the complexities involved in interdisciplinary education.
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The notion of a spectrum of learning is introduced where pre-licensure students are gradually introduced to concepts related to collaborative practice competencies. Differences between uni-professional, multi-professional and interprofessional teaching strategies need to be understood in order to consider the timing of using these teaching strategies related to the spectrum of learning.
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There is a call for competency based interdisciplinary education where the development of specific knowledge, skills, attitudes and behaviors can guide the teaching strategies employed.
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Teaching strategies should consider the use of educational theory and established models to provide the foundation for the initatives developed. In addition, factors related to the setting of interdisciplinary education, the learners and their readiness or resistance to interdisciplinary education and the form of facilitation used by educators to teach interdisciplinary education should be accounted.
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Currently, there is little in the literature to help educators understand how to facilitate interdisciplinary education in a successful manner and hence there is an urgent need for faculty development in this area.
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Evaluation methods are lacking for both program and student assessments related to interdisciplinary education. These methods need to be developed, using techniques to measure established educational outcome measurements. Currently, the literature reveals most assessments measure primarily attitudes. There is a need to look at other competency measurements and ultimately link the outcome of interdisciplinary education to its effects on patient outcomes.
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There is no evidence to date that interdisciplinary education improves patient outcomes. However, no evidence does not mean ineffectiveness. (Hammick 2000). We need therefore to urgently develop studies to pilot interdisciplinary education initiatives which can help understand the educational processes related to successful methodologies (using qualitative research) and then create methods to further test educational initiatives that can measure its impact on patient outcomes. By doing so, we will finally come to the answer of whether there is evidence for interdisciplinary education.
Environmental Scan Findings On-line Survey •
Surveys were emailed to 550 individuals, and 316 responses were received resulting in a response rate of 57%. One hundred and seventy-seven (177) respondents reported that they had knowledge of an interdisciplinary education (IE) program, and 91 respondents reported of a collaborative practice (CP) initiative. One hundred and sixty-two (162) people went on to describe the interprofessional program, along with 86 who described a collaborative practice initiative.
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Interdisciplinary education initiatives took place almost equally in higher education settings (50%) as in service or mixed settings (49%; a clinical setting with higher education links or vice versa), while the majority of successful collaborative practice initiatives took place most often in service or mixed settings (92%) and rarely in higher education settings (7%).
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Seventeen professions were common amongst programs and initiatives, 27 professions were unique to interdisciplinary education, and 11 unique to collaborative practice.
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Primary care settings and "other" settings had more instances of interdisciplinary education and collaborative practice than either tertiary care or rehabilitative care. Specifically, 40.9 % of interdisciplinary education programs and 41.9% of collaborative practice initiatives were primary care; while tertiary care was 8.5% (IE); 14.5% (CP) and rehabilitation was 7% (IE); 6.5% (CP).
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In both education and practice initiatives, the majority of the programs ran for more than 3 years, and more than 3 times. Funding has a slight (yet non-significant) effect on length of time a program ran in interdisciplinary education.
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Curriculum development was the impetus that drove interdisciplinary education, while Continuous quality improvement was a driver for collaborative practice initiatives.
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A large variety of patient populations were involved in programs/initiatives, with slightly more practice initiatives involving patients.
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There was virtually no comparison made to non-participants of the survey nor was there random assignment in evaluations.
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Programs and initiatives were more often presented at conferences than published In-depth Interviews
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In the twelve in-depth interviews (10 English and 2 French) that were conducted, participants described both successful and unsuccessful IECPCP examples and/or initiatives as well as provided their insight and knowledge concerning both the enablers for and barriers to IECPCP development and implementation. The interview findings concluded that: o Interdisciplinary education and collaborative practice are priorities and funding is available at the macro level from governments and institutional leaders. o Interdisciplinary education and collaborative practice require commitment and support from leaders, in particular, champions, but the sustainability of these programs also requires secondary support. o Interdisciplinary education and collaborative practice are linked to health reform initiatives and address patient and population needs. o There is a willingness for change amongst those involved in interdisciplinary education and collaborative practice over a period of time. o There is a high level of interest in the IECPCP related programs and initiatives. o Although there is a wealth of information existing on current IECPCP initiatives, information it is not readily accessible on their progress.
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Consensus from the in-depth interview participants revealed that more needs to be done to move IECPCP forward in placing it in the mainstream of health care delivery. Suggestions included: o conducting evidence-based research on the integration of IECPCP in all practice settings o exploring new funding models for collaborative practices o effectively addressing social and cultural issues of population groups, and o developing mechanisms to ensure the sustainability of IECPCP program initiatives.
Cultural Diversity in IECPCP •
The lessons learned from the literature with respect to promoting cultural competence in practice setting include the following: o Effective cross-cultural caregiving requires that interprofessional collaboration be extended to pararprofessionals or health care providers and key community xiv
workers who are not currently part of the traditional health care team. o Promoting cultural competency in practice calls for learning opportunities that bring professionals and health care providers (traditional/non-traditional) together to explore ways to collaborate on actual patient care situations. o Securing the support and participation of the community is vital to the sustainability and relevance of health programs and services. The Participatory Action Research model describes a process of building community partnerships and may be adapted to health promotion activities. A successful collaboration is likely to result in the development of innovative services that are an eclectic blend of ideas and perspectives from traditional healing practice and conventional western health care. •
The prominent themes that emerged from the literature on promotion of cultural competency in interdisciplinary education include the following: o Opportunities for interpersonal skill development from an interprofessional or transcultural perspective are lacking or are inadequate in most professional programs. Classroom teaching of cultural content does not address how to provide culturally sensitive care and may in fact oversimplify the cultural care needs of patients. Pedagogical initiatives need to incorporate culture-fair assessment workshops, case-based formats, and interactive sessions with patients and families. o Professional schools should include clinical experiences where students from the different professions work collaboratively in teams providing care to culturally diverse populations. o Students in health care need to be made aware of the contributions all health care providers, particularly the non-traditional health care providers, and how to work more collaboratively with them.
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The review of the literature and the national survey results provide increasing evidence that an interdisciplinary collaborative approach among professionals, health care providers (traditional/non-traditional) and the community is desirable and possibly the only feasible way in which health care can be delivered in Canada’s northern native communities and remote settings. Moreover, the principles underlying such an approach: openness, mutual respect, inclusiveness, responsiveness and understanding one another’s roles should be fundamental to the delivery of culturally competent services to all ethnic minority communities throughout Canada.
Health Policy in IECPCP •
Time constraints, budget allocation, infrastructure, institutional climate and culture are all factors impacting policy issues that need to be discussed in order to move IECPCP forward in the Canadian health care system. There are policy opportunities that can make interdisciplinary education for collaborative patient centred care a reality but need to emerge from Federal, Provincial and Territorial legislative through coherence of existing policies in making universal decisions.
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Based on the review of both published and unpublished literature, a number of barriers have been identified as critical, hampering effective collaboration in primary health care delivery within a health renewal system. An overview of the current systemic barriers, at the government, organizational and individual level is provided as well as addressing specific policy barriers that impede IECPCP including legislative and regulatory frameworks, human health resources, economic, educational and medico-legal liability issues.
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Funding, research, best practice tools, political, education, and legislation are examples of policy enablers/levers that have been used to facilitate IECPCP. While most of these policy levers/enablers have been identified, they have not, however, been fully employed and evaluated to determine (either positively or negatively) their effectiveness in advancing ICEPCP.
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Identified policy issues that must be taken into consideration to further advance IECPCP include to: o Review current health and education training programs o Develop strategies for effective health human resource planning o Review the current regulatory and legislative frameworks on new approaches to integrate collaboration for health disciplines o Establish funding priorities for education, research and practice o Address cultural and political diversity issues o Explore alternative health care delivery concepts
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Despite increasing calls for interprofessional collaboration, particularly in relation to primary health care, there is limited research on effective ways of implementing new mixes of skills and providers in health care delivery settings. New work environments and new divisions of labour call for new approaches to collaboration among health care providers in order to maximize the use of the health workforce. There also is limited information about the health care workplace in terms of its organization, planning, the nature of group practice, payment mechanisms and incentives, and professional responsibility.
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The consensus with many health policy reports is that in formulating policies on IECPCP, there is a need to expand our knowledge base on what is feasible within the current health care and education framework. Although we currently have had sufficient health research expertise that has explored collaborative primary health care, it has only peripherally addressed the impact of IECPCP on human and financial resources. To move IECPCP forward, efforts should be made to evaluate our current policies that frame our health and education system.
Change Management Strategies for Enabler/Barriers •
The literature on organizational behaviour reveals that moving from existing models to new models of interdisciplinary education and collaborative practice poses multiple challenges. For change to occur for IECPCP the following are recommendations: o Change required in the academic and practice setting to implement and evaluate IECPCP will require challenging professionals’ underlying values, assumptions xvi
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and mental models. Experimentation with different forms of interdisciplinary education and collaborative practice requires managers and practitioners to develop a culture supportive of risk taking and shared leadership. Approaches to learning vary, and so successful implementation of interdisciplinary education will require both individual and collective learning. There is not one best model of change that can be applied in this area. Interdisciplinary education and collaborative practice require change in different domains (education and practice) and at different levels in the system (individual/team, organizational, system/policy). More radical changes involving new programs, curriculum changes, and accountability requirements (e.g. accreditation standards) would require substantially more time and would face more substantial barriers. However, it can be argued that these types of structural changes are required to entrench interdisciplinary education and promote collaborative practice over the long term.
Reorganization into a framework where IECPCP becomes the norm will necessarily require clear policy direction, support and incentives (financial or otherwise) to bring key players on board. However, consistent with suggestions for bringing about change in the area of restructuring primary care, policy “direction” must be balanced enough to provide local agents with sufficient flexibility to implement changes in a manner that is consistent with the unique needs and interests of various settings.
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Synthesis and Analysis of Findings Building a body of knowledge While there is promise for the advancement of IECPCP in Canada, there is still much to be learned on its true impact on improving quality of care and patient outcomes. From the literature and environmental scan, available evidence, although limited, supports the finding that collaborative practice can improve patient outcomes in specific patient populations and practice settings. In particular, there is a limited understanding of the impact of collaborative approaches on patient care outcomes at the primary care level of our health care system. There is a need to conduct research with sufficient rigor to provide an understanding of the effect of formalized interdisciplinary education and its both outcomes with learners (students and practitioners) and patient care. We summarize that a body of knowledge in the area of IECPCP is still growing. Canadian educators, researchers, practitioners and policy makers can make significant contributions in increasing our understanding of the essential elements and impact of IECPCP. Through this body of knowledge better models and theoretical frameworks can be developed to advance IECPCP in a way that is based on best evidence. Towards common terminology Based on the experience from international jurisdictions, it is evident that there is a need for common terminology in using the words “interprofessional” or “interdisciplinary” education for collaborative practice among the providers and users of the health care system. The authors have decided to use the terms “interdisciplinary” and “interprofesional” as consensus hs not been reached at this time. We have used the definition developed by the Centre for Advancement of Interprofessional Education in the United Kingdom for “interprofessional education” which defines it as “- occasions when two or more professions learn from and about each other to improve collaboration and the quality of care”. (CAIPE, 1997 revised). Collaboration is defined as an interprofessional process of communication and decision making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the client/patient care provided. Mechanisms must be in place that will enhance better collaboration and communication among health care providers and with patients. A common value system would result in the creation of a common vision for collaborative health and education, thus enhancing collaborative practice (Way & Jones 2000) Clarifying Interdisciplinary Education and Collaborative Practice Outcomes Through our research efforts, it was recognized that there is a need to distinguish the types of outcomes of educational interventions that are conducted. For educators, learner outcomes are of most importance. For health service researchers and policy-makers the interest is more likely on quality of care and patient care outcomes. Although it is recognized that one of the ultimate goals for educational interventions in the health professions is to improve patient outcomes for IECPCP, we realized improving patient outcomes is not solely determined by the formalized educational interventions employed. With this realization in mind, the authors decided that there would be value in distinguishing categorizations for IECPCP related to defined outcomes: “Educational Interventions to Enhance Learner Outcomes” and “Collaborative Practice to Enhance Patient Outcomes”. Although the categorizations separate practice and education, we recognize that they are interdependent upon each other.
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The Interdependency Between Interdisciplinary Education and Collaborative Practice It is noted that interdisciplinary education and collaborative practice may be categorized separately but they are interdependent upon one another. To advance IECPCP, interdisciplinary education and collaborative practice cannot work in isolation. Their interdependence must be clearly understood and consciously promoted. Interdisciplinary education conducted at the prelicensure level of training must take place in settings which house successful collaborative practices by practicing health professionals who can act as role models and provide experiences for students to work collaboratively together. Thus, there is a need to identify and foster collaborative practices that practitioners have both competence and willingness to work collaboratively. Developing collaborative practices will entail the need not only for formalized competency training in collaboration but also organizational and systemic realignment to prioritize collaborative practice in appropriate settings and patient situations. A Vision of Interdisciplinary Education for Collaborative Practice Efforts should be focused on developing teaching processes to develop collaborative competencies (knowledge, skills and attitudes) necessary for our current and future health professionals to work in collaborative practices. It is hypothesized that if health professional trainees and those in practice are provided formalized training related to collaborative competencies (knowledge, skills and attitudes), the potential for a change in workforce patterns may occur. It is, however, recognized that competency alone is not enough for practice change to materialize. Within the workforce there is a need to understand the processes involved at both the organizational and the individual team levels to encourage and sustain collaboration. There needs, therefore to be a vision of how we train health professionals and how health professionals should work together in their clinical settings. The elements of collaboration need to be understood, promoted and sustained throughout the continuum of learning and within the workforce of health professionals practicing in Canada. Competencies related to collaboration will not be enough to change the “silo-like” practices that health professionals are accustomed to. The need to address the complex factors that influence the opportunities to advance IECPCP in Canada is pressing. Determinants Affecting IECPCP at the Macro-meso-and micro level As we have seen, interdisciplinary education and collaborative practice are linked. Thus IECPCP cannot be achieved without addressing the issues arising from the various levels: systemic (macro), organizational/institutional (meso) and health professional practitioner/learner (micro). It is recognized that at the systemic level, decisions made by government (in the areas of education, health and social policies) as well as profession-specific policies (like those from regulatory bodies) all influence the chances for IECPCP advancement for these decision-making bodies can structurally make it possible for IECPCP to become a reality in Canada. At the organizational and institutional levels, leaders and champions can enable change to take place and encourage that interdisciplinary education and collaborative practices are priorities. At the practitioner/learner micro-level, the professional cultural values, which have been embedded amongst the identities of health professionals, cannot be underestimated for they can either enable or impede the actualization of IECPCP. Professional cultural values are systemic. Often learners entering their training programs already have pre-existing stereotypes developed about other health professionals, beliefs that may be further consolidated through exposure to learning experiences and educator role models. Thus, there is a need to consider techniques of influencing
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the professional cultural values of health professionals in ways in which collaborative means of working are considered a priority. If we are to advance IECPCP a collaborative venture must be undertaken by educators, practitioners, researchers and policy makers. Therein lies the means in which the macro, meso and micro-level determinants for IECPCP can be addressed in a coordinated, sustainable fashion. The Patient/Client’s Role in IECPCP IECPCP is a value that is held amongst many of those who are advancing this area forward. The patient’s well-being is central to the notion of IECPCP. Although available evidence to date is limited, it is mounting: collaborative practice does enhance patient outcomes. We know some specific patient populations and health problems that benefit from a collaborative approach to care by health professionals working together in teams nut more research needs to be conducted to identify further when this approach provides best optimization of outcomes. We do know that the complexity of the patient’s health care issues affects the need for a collaborative approach to care. Patients are thus at the center of collaborative care since they are the very reason behind the interdependency of the professionals. This explains the terminology of “Collaborative Practice Patient-Centred Care Practice” used in this report. Patients are simultaneously active members of the teams and recipients of the team care. Their privileged position in the team still depends on their willingness and ability to participate in the planning and delivery of health care. It is unclear at this time how we can best engage patients in our collaborative health care ventures. As IECPCP is advanced, it would be worthwhile to investigate this further, especially taking into account patient and provider cultural and socio-demographic considerations. Research Opportunities Research is needed to understand the complexities related to collaborative practice and how it can be taught or developed amongst health care providers. Much of this explanatory and exploratory research will need to use qualitative research methodology. In addition, clearly developed outcomes or benchmarks for IECPCP need to be established and measured. These include educational competencies (knowledge, skills and attitudes) and collaborative practice outcomes involving patients, professionals, the organization and system. The evaluative evidence to support collaborative practice and its impact on defined outcomes will arise from rigorous evaluation designs such has randomized controlled trials. A research program incorporating and integrating both qualitative and quantitative research methodology should be launched with studies emphasizing different components of the proposed framework (See Chapter 10) within diverse practice settings and different patient populations. In particular the primary care setting should be a priority as studies to date are lacking in this area. The findings of the research conducted in this field must be transparent and disseminated in order for learned lessons to be shared. It will be imperative that duplication of research be kept to a minimum and that opportunities to build upon research work conducted are optimized if we are to advance IECPCP in a coordinated and timely fashion across disciplines, jurisdictional sectors and among health and education sectors.
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An IECPCP Framework From the synthesis of the environmental scan and literature review, this report presents an innovative conceptual framework developed by the researchers that can be used as a template to encourage dialogue among decision-makers, educators, researchers, health providers and Canadians toward the advancement of IECPCP. It provides an understanding of the complexities that will be involved in moving IECPCP forward and the need for all key stakeholders to work together. The framework can be seen in its entirety in Chapter 10.
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Recommendations 1. Adopt a common language for IECPCP a. Develop terminology for IECPCP. b. Define level of training of health professionals. c. Make explicit the types of outcomes that are being considered in any initiative embarked upon. d. Clearly identify types of interdisciplinary education initiatives particularly to level of training. 2. Advocate and support for the education of health professionals that values collaborative patient-centred care. a. b. c. d. e. f. g. h. i.
Coordinate government activities to address barriers to IECPCP. Consult with professional bodies on IECPCP standards and competencies. Develop operating principles of IECPCP. Coordinate academic institutes across disciplines to enhance IECPCP. Review current education and training programs. Identify teaching strategies to be employed that will define outcomes. Develop IECPCP Faculty Development Initiatives. Create ways to address socialization factors. Develop role models for collaborative practice.
3. Advocate and support for patient-centred collaborative practice. a. Research and identify collaborative practice interventions that achieve improved patient outcomes. b. Identify determinants that affect processes of interprofessional collaboration. c. Determine patient’s role in IECPCP. d. Develop evidence-based interprofessional collaboration inventions particularly in the primary care settings. e. Identify the organizational determinants that impact collaborative practice. f. Identify role and responsibilities of health professionals in IECPCP. g. Explore incentives that will foster collaboration. 4. Explore policy initiatives that will advance IECPCP. a. Consult and explore with professional bodies on the impact of scope of practices in IECPCP. b. Review legislation on current and related IECPCP initiatives. c. Review current scope of practice rules and determine implications for malpractice liability within an IECPCP framework d. Determine the benefits of informatics in IECPCP. e. Explore funding models for IECPCP.
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5. Use change management strategies that will facilitate collaboration amongs health care professionals. a. Initiate dialogue with stakeholders in exploring necessary changes to advance IECPCP. b. Determine successful models of change approaches to IECPCP. c. Identify change management approaches that can be easily implemented. d. Consider change management models and determine their application in the current health care system. e. Develop change management policy strategies for IECPCP. 6. Address socio-cultural and diversity issues among population groups with special consideration for Aboriginal health when advancing IECPCP. a. Address cultural and political diversity issues among population groups in advancing IECPCP. b. Explore models that will foster collaboration in culturally diverse communities. c. Develop IECPCP mandate for Aboriginal Health. d. Provide research funding for Aboriginal Health in IECPCP. 7. Build upon current federal/provincial/territorial initiatives that facilitate the development and implement of IECPCP. a. Identify current federal, provincial and territorial initiatives that can be leveraged to achieve and promote the goals of the IECPCP initiative. b. Solicit feedback from stakeholders on the impact of IECPCP in their environments. c. Develop and implement a policy process for IECPCP. d. Consult with community leaders and communities to foster IECPCP. e. Develop a public awareness campaign. 8. Creat a national centre of excellence for IECPCP in Canada. a. Explore strategies to effectively develop and support IECPCP knowledge transfer. b. Establish a repository or a central resource to house key information (publications, research, database) to advance IECPCP. c. Create a forum for information exchange and knowledge transfer. d. Establish a “Research Outcomes Commission” to aid in overseeing research conducted, building a body of knowledge for IECPCP. 9. Build body of knowledge by funding IECPCP research initiatives based on criteria that will facilitate an understanding of the processes and outcomes related to models for IECPCP. a. Actively engage in the establishment of linkages and partnerships with other health research stakeholders. b. Build a body of knowledge related to IECPCP c. Develop and conduct randomized control trials of new interdisciplinary education xxiii
and collaborative practice models.
Future Research Priorities Priorities for conducting and funding IECPCP “Request for Proposals include: 1. Post-licensure collaborative interventions: Recommend studies be conducted measuring: Outcomes a) The Patient –What health problems and/or practice settings (e.g. Primary care) do collaborative practice models improve both individual patient and population health outcomes? b) The Professionals - How does collaborative practice effect job satisfaction and wellbeing, recruitment and retention, productivity, efficiency, and professional development? Gaining a perspective from both patients and providers on their views on IECPCP and its personal impact on them should also be included. c) The Organization- How does collaborative practice impact quality of services in terms of efficiency of health care services (i.e. reduce waiting list and duplication of services), recruitment and retention, patient safety, evidence-based practice and cost effectiveness? d) The System – What cost benefit does IECPCP contribute to the entire health care system. What is the effectiveness of IECPCP in improving efficiencies? What are the population health outcomes? Processes As important to outcome measurements, is the need to conduct research that looks at the dynamic processes that occur related to organizational factors and interactional factors affecting IECPCP. 2. Pre-licensure Educational interventions: Recommend studies that address: Outcomes a) What are the competencies that can be taught to learners? b) What methods can be used to assess students’ competencies? Process a) Teaching Factors - What models for teaching collaborative competencies show the most promise? How can teaching strategies be developed based on theoretical models focsuing on the context of learning and drawing on the role of facilitation? b) Institutional Support - What methods can be measured to demonstrate the effect of institutional/organizational levers to impact interdisciplinary education? How can these methods be developed and implemented? c) Educators – Acknowledging the impact of professional beliefs and attitudes that may be imparted to trainees from educators, what faculty development methods can be developed in order to impart the values of collaborative practice to learners?
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3. Address interprofessional collaboration and education within the context of culturally diverse communities. Research should be conducted to determine: a) What does collaborative practice mean to different communities (what is their understanding and vision of culturally specific collaborative patient centred care?) and how it is received by them? Who would be the health practitioners involved? b) How would collaborative practice best be implemented in various communities? c) What are the distinct features of IECPCP that may or may not work for certain population groups? d) How can IECPCP address gaps in health care access and the provision of continuity of care for certain population groups? e) How can we build bridges between traditional and western medicine for collaborative practice? f) What is the patient’s role in patient-centred collaborative practice and how can we best involve the patient while taking into consideration patient’s views and cultural factors? 4. Research teams must demonstrate collaboration between educators, practitioners, institutional/organizational leaders and policy-makers who have expertise and experience in IECPCP and/or like initiatives. 5. To ensure sustainability of research on IECPCP beyond the 5 years of this initiative, there is a need for consultation with other major research granting agencies to fund interdisciplinary education/practice initiatives in the future. 6. To reduce duplication in research efforts and to ensure that the science of IECPCP is based on rigorous empirical work we support the establishment of a permanent “Outcomes Commission” under the auspices of a national centre for excellence in IECPCP should be developed.
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Canada’s Readiness In Canada, there is substantial momentum for change given the current health reform achievements and initiatives that have taken place over the past decade. All levels of governments, health and education sector institutions and health providers are committed to the need for change; however, implementation is gradual. Canadians are ready for health system renewal. Everyone has a role in deciding how health care services are organized and delivered in their health care system, including interdisciplinary care. There is considerable room for collaboration and co-operation. For many years, the provinces and territories have worked together on common issues of concern, sharing ideas and learning from each other’s experiences, and the area of IECPCP is one that is fertile for such collaboration to occur. Furthermore, the potential for primary health care and the important role it can play in transforming the health care system demands national leadership and national action. An IECPCP policy directive that is patient-centred will play a critical role in developing the health care renewal framework. Timely action is imperative to obtain the commitment and resources that are needed to move IECPCP forward. Governments, institutions, health care providers, educators, researchers, decisions-makers and Canadians must work collaboratively to prioritize the policies and determine what should be done to achieve interdisciplinary education for collaborative practice. Researchers of the report concur that despite the limitations of the research, the current literature review demonstrates that it is feasible to develop an IECPCP framework as part of health system renewal. Findings from the literature review and environmental scan support that there are opportunities for creative more focused research strategies to acquire the answers we need to develop a comprehensive IECPCP framework. Emphasis should be placed on the development and implementation of an IECPCP policy framework by leveraging existing federal/provincial/territorial initiatives. This would take into account the policy levers and enablers necessary to overcome the barriers that have been identified bringing use closer to a health care system that practices and values IECPCP.
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Preface Under this direction, the 2003 First Ministers Health Accord identified that changing the way health professionals are educated is a key component of health system renewal. This change will be mobilized through the development and implementation of an initiative on interdisciplinary education for collaborative patient-centred practice (IECPCP). A team of health researchers, with expertise and experience in the field of interdisciplinary education and collaborative practice, was assigned the task of examining this issue. Under the guidance of the National Expert Committee (NEC) on Interdisciplinary Education for Collaborative Patient-Centred Care and the Office of Nursing Policy of Health Canada, the research team conducted both an environmental scan and literature review on the elements and issues facing the advancement of IECPCP in Canada. A conceptual framework was developed and proposed recommendations and research priorities highlighted. This report summarizes the key findings in interdisciplinary educations for collaborative practice for patient-centred care. It has been prepared by the University of Toronto, University of Montreal, McGill University, The Institute for Clinical & Evaluative Sciences, and York University, London South Bank University and City University led by Dr. Ivy Oandasan, Project Leader.
Acknowledgement The authors would like to thank Dr. Judith Shamian, Executive Director, Office of Nursing Policy, Health Canada, her staff as well as members the National Expert Committee (NEC) on Interdisciplinary Education for Collaborative Patient-Centred Care for their assistance, guidance and invaluable feedback throughout the preparation of this report. The authors would also like to express its appreciation for the contribution made by Laure Perrier, MLIS Information Specialist, Continuing Education, Faculty of Medicine, University of Toronto in creating the Canadian IECPCP database, Rita Shaugnessy, MLS, Library & Information Service, Department of Family & Community Medicine, Rosemary Waterston, PhA student, OISE and Communications Coordinator of the Interprofessional Education Initiative of the Health Sciences and Social Work Faculties, University of Toronto and Lynne Sinclair, InterProfessional Education Leader, Toronto Rehabilitation Institute with the dissemination of the online survey, and Ian Waters, Social Worker, Family Health Center, University Health Network, Toronto Western Hospital. In addition, Leticia San Martin Rodriguez and Marcela Ferrada-Videla, Ph.D students in Nursing Administration, Centre Ferasi, Université de Montréal for their contribution in the research and writing of Chapter 3, Conceptual Basis for Interdisciplinary Practice. The views expressed herein do not necessarily represent the official policy of federal, provincial or territorial governments.
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Chapter One Introduction Background A key goal of the 2003 First Ministers’ Accord on Health Care Renewal (Health Canada 2003) identified changing the way health care professionals are educated as a key component of system renewal. Spearheaded by the Office of Nursing Policy at Health Canada, the call for health care to function in an interdisciplinary manner is being heard. The Interdisciplinary Education for Collaborative Patient-Centred Practice (IECPCP) initiative aims to answer the call for health care professionals to function in an interdisciplinary manner. An interdisciplinary health care team includes members from many disciplines and professions that work together to provide optimal coordinated care for individuals. Interdisciplinary teams are being established and are becoming the standard for providing care in specific contexts: primary care, chronic illness, critical care, mental health, care of the elderly, palliative care (Institute of Medicine, 2001). Collaborative, Patient-Centred Approach to Care: A New Direction for Professional Education and Practice Collaborative patient-centred practice is a practice orientation, an approach to care where health care professionals work together with their patients. It involves the continuous interaction of two or more professions or disciplines, organized into a common effort, to solve or explore common issues with the best possible participation of the patient. Collaborative patient-centred practice is designed to promote the active participation of each discipline in patient care. It enhances patient and family centred goals and values, provides mechanisms for continuous communication among care givers, optimizes staff participation in clinical decision making within and across disciplines, and fosters respect for disciplinary contributions of all professionals. (Health Canada 2003) The patient centered model is ideal to provide a foundation for interprofessional teams collaborating with each other and with patients/clients. It is postulated that teams that collaborate will be better able to deal with the increasing complexity of care, coordinate and meet the needs of the population, keep abreast of new developments (including technological advancements), and respond to the demands of the wider constituency of institutions, tax payers, and governments (Hall and Weaver, 2001; Institute of Medicine, 2001; Bluml et al, 1999). There is agreement among health care professionals about the value of the patient-centered care paradigm and its essential components such that many health care training programs and interprofessional teams have incorporated patient centered care concepts into their clinical, educational, and research activities.
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Historically, the movement away from the traditional-hierarchical approach to patient care and towards a patient-centred collaborative relationship emerged in the past decade along with the rise in health promotion (Feeley & Gottlieb, 2004). More recently, the need for a collaborative approach to care has become critical given the reductions and changes in health care services. These modifications have resulted in increased tensions between consumers and government and health care administrators who determine the nature of health care services. In response there has been a return to more patient-centred care and an increased emphasis on educating consumers in the appropriate use of health services. (Sullivan 1998). The collaborative model of practice is based on a philosophy of caring and a set of beliefs that values a nurturing approach. The key ingredients of a collaborative patient-centred approach include: 1) the sharing of power between partners 2) the pursuit of goals that are the result of discussion and negotiation, and 3) active participation and involvement of the partners in the process of working together (Feeley & Gottlieb). The purpose of the relationship is to help the other individual to grow and develop (Mayeroff, 1972) and support the person’s efforts to take control over their own health (self-care). Both partners in the relationship acknowledge one another’s knowledge and expertise, although it is of a different nature. The partners respect one another and the relationship benefits both individuals by allowing them to learn, gain and grow from the relationship (Feeley & Gottlieb, 2004; Halstead, Wagner, Margo, & Ferkol, 2002). Previous work specifies that patients and professionals entering into collaborative partnerships need to be flexible, respect each other’s potential contribution and expertise, and be open to sharing information and learning from each other. Similar themes have emerged from the work that has focused on providing culturally sensitive care to patients from culturally and linguistically diverse groups. Appreciation and respect for the person’s culture and health care practices, working as equal partners and negotiating a plan of care that takes these beliefs into account have been reported to be the significant features of successful initiatives (Potvin, Cargo, McComber, Delormier, & Macaulay, 2003). It appears that characteristics that are fundamental to a collaborative relationship: dynamic, power-sharing and purposeful are universal irrespective of who the partners may be. This has important implications for professional education and practice. By learning how to partner through interprofessional training opportunities, students first begin to be socialized into a collaborative approach of partnering with others. The interpersonal skills that develop through interactions with peers can then be transferred and reinforced in their working relationships with patients and families and in more complex, culturally diverse situations. Collaboration becomes the basis for all interprofessional and patient-professional relationships and is integral to the individual’s practice. In the practice arena, a shared philosophy of collaborative practice across the disciplines provides the common ground and language towards establishing an interprofessional practice model to successfully engage patients and families in self-care and health promotion activities. The challenge now becomes developing, identifying and
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disseminating models and strategies for education and practice that successfully promote a collaborative approach. In order to foster cooperation among team members, professionals need to be trained in environments that provide experiences that promote collaborative practice. Unfortunately, the majority of educational settings continue to train health professionals in isolation, reinforcing autonomous and separate roles and decision making (Hall and Weaver, 2001). In order to promote and support interdisciplinary practice, educational programs need to be developed that provide an opportunity for various disciplines to work together as team members. Interdisciplinary Educational Models There is a need to develop interdisciplinary educational models based on established pedagogical processes, rigorously evaluated, using consensus driven outcome measures. Many faculties of medicine, nursing and health professional training programs are moving towards teaching interdisciplinary care. However, there has not been a coordinated effort undertaken nationwide to provide guidance related to this process. Yet it is clear that there is a need for an infrastructure within our health care system that supports collaborative practices for professionals in their day to day work. Unless change occurs within the health care system simultaneously with changes in educational institutions, teaching collaborative practices to future students will be futile because lessons learned in the educational and training setting will become rapidly irrelevant if there is not the necessary support and reinforcement of interprofessional collaboration in the health care workforce. There is a need to examine ways of managing change at the governmental health policy levels, the practice organization and educational institutional levels and amongst health care providers. This report identifies the enablers and barriers at the macro, meso and micro levels which need to be addressed through policy development in order to restructure educational processes to promote collaborative practices and for collaborative practices to be developed to enhance patient centered care.
International Context of Interdisciplinary Education for Collaborative Patient Centred Care (IECPCP) Internationally, the World Health Organization (WHO) has been proactive in moving interprofessional education (IPE) forward. In 1973, an Expert Committee reviewing medical education saw interprofessional and traditional programs as being complementary. From this emerged a number of demonstration projects that resulted in this new approach to health professional education becoming entrenched in the WHO strategy to promote “Health for All by the year 2000” (WHO, 1978). Following this, other international organizations such as the Organization for Economic Co-operation and Development and the World Federation of Medical Education adopted strategies to foster experiences in IPE. However, the degree to which these movements influenced national developments seems to differ with the greatest influence occurring in smaller European countries (e.g. Finland, Sweden, Norway, France, Germany) and in developing countries (e.g. Algeria, the Sudan, the Cameroons, South Africa, Thailand) (Barr 2000).
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In the United Kingdom, the emphasis in providing health care in the community led to a number of collaborative models of delivery. Through the 70’s, 80’s, and 90’s, many initiatives in IPE were developed that covered a wide range of health issues. Government policies further reinforced the value of collaboration and thus the need for “shared learning” or “joint training”. The Center for the Advancement of Interprofessional Education (CAIPE) was founded in 1987 to provide a central resource to assist health professional educators in exchanging and discussing new ideas to assist them in creating new initiatives. In Australia, a number of IPE activities have been underway with the University of Adelaide taking a leadership role. The history of interprofessional care and IPE in the United States has been marked by a succession of discrete attempts in response to specific needs in specific settings. Increasingly, networks are being established that are funded by private and public funds for communication and shared learning around new projects. Partnerships have been established that go beyond health care and use a community development model involving a wide range of disciplines in response to the needs identified by communities. However, the lack of systematic study of processes and outcomes of IPE threatens the sustainability of these endeavours given the environment driven by cost effectiveness and cost efficiency.
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Historical Context of IECPCP in Canada In Canada, there have been a number of initiatives supported by Health Canada related to collaborative care. The first was the “Collaboration for Prevention” that began in the early 1990’s and evolved into the “Coalition on Enhancing Preventive Practice”. This initiative was formed by 10 professional health organizations and developed various activities in part funded by the federal government. In 1994, the “Supporting Self-Care” project was initiated by Health Canada and was active until 2002. This program was primarily a collaboration between Family Medicine and Nursing but led to a number of projects that demonstrated how teams of health care providers could work together and involve patients/clients in decision making. In 2000, Health Canada announced that $800M would be provided to support the “Primary Health Care Transition Fund”. A substantial portion of these funds has been distributed through provincial and territorial agreements with the understanding that collaborative care be a major priority. A number of large projects are currently underway. The 2003 First Minister’s Accord on Health Care Renewal identified changing the way health care professionals are educated as a key component of system renewal. Interdisciplinary education for collaborative patient-centred practice has been identified both in the Accord and in the 2003 Federal Budget through Health Human Resources Department as one of three mechanisms to address current and emerging health and human resource issues, and as a mechanism to ensure that health providers have the knowledge, skills, and attitudes to practice in this different paradigm. In order to provide advice to Health Canada on how to achieve this, the National Expert Committee for Interdisciplinary Education for Collaborative Patient-Centred Practice was formed. The mandate of this committee includes: offering advice on current and emerging issues and trends in IECPCP and suggesting areas for further analysis; assisting in overseeing specific activities and projects; and promoting this initiative and creating alliances and partnerships across disciplines and sectors. This report will serve as background information for the National Expert Committee in its task for the next five years in promoting IECPCP in Canada.
The Development of this Report Given the recent IECPCP initiatives developed by Health Canada, spearheaded by the Office of Nursing Policy, and with numerous governmental reports on health reforms, the call for health care to function in an interdisciplinary manner is being heard. Health Canada, through a “Request for Proposal” commissioned a research team to develop a document on the status of interdisciplinary education for collaborative practice with a view to identifying the feasibility of implementing recommendations in the Canadian setting.
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Objectives The aim of this report is to substantiate the IECPCP goals created by the Office of Nursing Policy of Health Canada, by outlining the steps needed to initiate and sustain its objectives to move IECPCP agenda in Canada. This report addresses the following specific objectives from the agenda, as set forth by the IECPCP initiative: •
deliver a clear understanding of the evidence of interdisciplinary care and interdisciplinary education as it relates to improved patient outcomes;
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identify policies and infrastructure that both help and hinder implementation and sustenance of interdisciplinary education and practice;
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identify and understand the educational processes that foster and aid in the development of interdisciplinary patient care in all levels of health-care’s lifelong learners; and
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understand and identify how to foster networks that will promote collaborative knowledge sharing and resource development.
The research report supports the broad IECPCP objectives, by informing the current strategies and initiatives, trends, concepts, experiences, policies, programs, best practices, and research priorities, both within Canada and internationally as they relate to IECPCP. This would also include change management and knowledge transfer strategies. The aim of the research is to identify examples and “learnings” from other sectors, and incorporate these into the analysis that is described in Chapters 5 & 6 of this report. The Research Team The research team that has developed this report is comprised of individuals that have expertise in the field of interdisciplinary education, collaborative practice, change management, knowledge transference and health policy. All team members are health professionals who work, conduct research and teach in this specific area of study. Team members include: Project Leader: Ivy Oandasan, MD, CCFP MHSc - Assistant Professor and Research Scholar at the Department of Family & Community Medicine, University of Toronto and Toronto Western Hospital, University Health Network. Danielle D’Amour RN, PhD Associate Professor, Faculty of Nursing at Université de Montréal, Director of FERASI Centre and Researcher at Groupe interdisciplinaire de recherche en santé (GRIS) Merrick Zwarenstein, M.B., B.Ch., M.Sc., M.Sc (Med.) Senior Scientist, Institute for Clinical & Evaluative Sciences, Principal Investigator, Knowledge Translation Program, Continuing Education, and Associate Professor, Department of Health Policy, Management and Evaluation, at the Faculty of Medicine, University of Toronto.
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Keegan Barker, BA, M.Ed Research Associate, Department of Family & Community Medicine, Toronto Western Hospital, University Health Network Margaret Purden R.N., Ph.D. Assistant Professor, School of Nursing McGill University, and Director of the Centre for Nursing Research, Jewish General Hospital Marie-Dominique Beaulieu MD, MSc, CCMF Professor, Chaire Dr Sadok Besrour en médecine familiale, Department of Family Medicine, Université de Montréal and Researcher, Centre de recherche du Centre hospitalier de l’Université de Montréal Scott Reeves, BSc, MSc, PGCE Research Fellow, City University, UK and Senior Research Fellow, South Bank University, UK. Louise Nasmith, MDCM, MEd, CCFP, FCFP Professor and Chair, Department of Family and Community Medicine, University of Toronto Carmela Bosco, Health Policy Consultant and Managing Director, CBR Consulting Liane Ginsburg, PhD, Assistant Professor, School of Health Policy & Management, Atkinson Faculty of Liberal & Professional Studies, York University Deborah Tregunno, RN, PhD, CHSRF Post Doctoral Fellow, Faculty of Nursing, University of Toronto A strategic grouping of five teams was assembled to address specific issues pertaining to the IECPCP initiative within a specified timeframe as requested by Health Canada. All team members were responsible for gathering the content central to their areas of expertise. Each grouping conducted their own literature reviews and provided written submissions related to their assigned areas that were synthesized to generate an overall literature review of all the components addressed in this document. The following table provides a summary of the team groupings and their specific role in this project initiative. Team Groupings Team 1: Evidence for Interdisciplinary Education and Collaborative Practice Merrick Zwarenstein Scott Reeves Laure Perrier Team 2: Educational Process to Interprofessional Education Ivy Oandasan Scott Reeves Louise Nasmith Keegan Barker Team 3: Elements of Collaborative Practice Danielle D’Amour Marie-Dominique Beaulieu Margaret Purden
Assigned Responsibility • Conduct and provide systematic review of the literature on interprofessional education and collaborative practice and improved health outcomes. • Development of electronic database as a central information resource. • Conduct and provide systematic review on elements of interprofessional education including the relationship between interdisciplinary education and collaborative practice work. • Conduct on-line survey and focus group as part of environmental scan and provide analysis of findings. • • •
Provide an overview of key elements and concepts of collaborative practices and frameworks. Conceive a framework for IECPCP. Provide an assessment of cultural considerations that may impact interdisciplinary education for collaborative patient
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Team 4: Change Management Deborah Tregunno Liane Ginsburg Team 5: Health Policy Carmela Bosco
• • • •
centred practices in health care settings and provide information related to patient-centred care. Provide analysis on successful and unsuccessful change management strategies in promoting interdisciplinary education and collaborative practice and resistance to change. Conduct review of grey literature on health policy initiatives. Conduct in-depth interviews as part of environmental scan and provide analysis of findings. Responsible for overall synthesis of team assignments and development of research report.
Research Approach A literature review and an environmental scan were conducted from December 2003 to January 2004. The environmental scan included both an on-line survey and in-depth interviews with key informants. Findings from the literature review and environment scan serve as the basis for developing this document. A database was created of both interdisciplinary education and collaborative practice initiatives in Canada and beyond. In addition a listing of individuals actively involved in these initiatives was developed and included within the database. These databases are housed with Health Canada. A second database of literature reviewed and found useful for the IECPCP was created and includes both published references and grey literature. (See annotated bibliography) The two databases and the report developed provide a foundation for Canadian educators, researchers and policymakers to begin grounding their understanding of the concepts related to IECPCP and may provide opportunities to embark upon the development of innovative IECPCP initiatives. To ensure quality assurance of the research methodology in meeting the objectives outlined by Health Canada for this report, various steps were taken. Two team members met with the National Expert Committee (NEC) on IECPCP, conducting a focus group session, on November 26, 2003 to gain the members’ perspectives on interdisciplinary education and collaborative practice. The purpose was to ensure that the questions generated from the online survey and indepth interviews met the needs of both the NEC and members of Health Canada involved in the IECPCP initiative. Key questions were posed to NEC members for their input and are appended to this report on page 268. The research team was asked to address major issues concerning IECPCP based on a list of key questions. These questions are appended to this report on page 269. On January 14, 2004, the research team presented its preliminary findings of its literature review and environmental scan to members of the NEC and representatives of Health Canada involved in the IECPCP initiative. The meeting was held to obtain feedback from participants on the research conducted to date and to provide direction on further activities that should be pursued in the report. Subsequently on January 28, 2004, the team met in Toronto to address outstanding research activities and to reach consensus on recommendations and research priorities that the NEC and Health Canada may wish to take to advance IECPCP in Canada.
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On February 17, 2004, team members participated in a meeting with Health Canada staff and authors of commissioned discussion papers on specific aspects of IECPCP in Ottawa. The goal of the meeting was to share and compare information of key findings. Throughout the 10week timeline given to develop this document, the research team held biweekly conference call meetings up until the completion of the report to ensure that timelines were being met and to address issues and concerns regarding the research process. Throughout development of the report the team leader was in regular contact with Health Canada staff to address any specific issues.
Towards a Common Language One of the first things we learn in bringing individuals together from various different backgrounds, including health disciplines, is the need for a common language. As individuals who are interested in promoting IECPCP, we all come to this domain with our own understandings of the concepts embedded within this area of study. Indeed the literature in this field reflects the notion that there are many terms being used interchangeably. For clarity, the following terms are defined used in this report. As one begins reading literature related to interdisciplinary education and collaborative practice, confusion arises as there is a multitude of terms being used. A movement towards using the term “interprofessional” care and education has become the latest trend in those working in this area. This does not negate the fact that many continue to use the term “interdisciplinary”. However there is value in considering the various subtle differences related to the semantics used within this domain. Using the Suffixes “-Professional” vs. “– Disciplinary” The term “discipline” is defined as a “subject that is taught” or a “field of study” whereas profession is described as “a calling requiring specialized knowledge and often long and intensive academic preparation.” (Neufeldt 1990) It is not clear in the literature why there is a movement towards the use of the term “–professional” as the suffix in this domain, although in informal research circles this seems to be the case. It is theorized by some that the movement towards the use of “–professional” has developed because of the need for clarity. In a field like medicine one may have multiple disciplines within one profession. For example, it is not unheard of for a Faculty of Medicine to mount an interdisciplinary initiative inviting only physicians from different fields like internal medicine, psychiatry, and family medicine. No other health professionals would be included. By using the suffix of “–professional” in an “interprofessional” initiative, makes it clear that individuals from different health professions are included. Yet, the suffix “–professional” may exclude other health care providers as well. In thinking broadly of health care delivery with groups of health care providers including Native Healers, acupuncturists and massage therapists one could pose the question, would they be included or excluded in “interprofessional” education or practice initiatives?
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Using the prefixes ‘multi’ vs. ‘inter’ vs. ‘trans’ The prefixes of ‘multi’ and ‘inter’ are often used interchangeably with the suffixes listed above. However there are distinct differences. “Multi”can to refer to partners working independently towards a purpose.(MacIntosh and McCormack 2001) When bringing the suffixes together to become multidisciplinary or multi-professional it refers to team members that function in parallel, for they work relatively independently amongst a group of health care providers(+/health professionals), with little communication between them. The authors describe “Inter” as a partnership where members from different domains work collaboratively towards a common purpose. Each partner’s expertise is added, discussed and evaluated in an atmosphere of sharing and respect. There is often a common purpose in working together which is most often patient care. Interdisciplinary or interprofessional teams function in a collaborative way, where they integrate service, communicate together and develop common understandings. (Johnston and Banks 2000). The notion of synergy is ever present and can often be a defining feature of interdisciplinary/inter-professional teams. In order to fulfil client’s needs, members on interdisciplinary teams open their territorial boundaries to provide more flexibility in the sharing of responsibilities (D’Amour et al. 1999). One other prefix that has been used commonly relates to trans-disciplinary teams. In these forms of teams, health care providers are characterized by the fact that they often experience role blurring where sharing of tasks may be a norm and that the tasks undertaken may or may not be distinct to their typical health professional roles. (Hall and Weaver 2001; Stepans, Thompson & Buchanan, 2002). Trans-disciplinary teams may be thought of as interdisciplinary teams that are functioning with high levels of synergy. Further elaborations on the use of thse terms will be found in Chapter 3. For the purposes of ease and clarity within this document, we will use the term interdisciplinary and interprofessional interchangeably as the literature at this time has not come up with consensus and many references use both term. Both terms will denote the concept of different health care providers (from more than one discipline or profession) working together in collaborative practices or learning together in educational interventions. Collaborative Practice The term collaborative practice emerges whenever we begin talking about interdisciplinary/interprofessional care. Way and Jones have described collaborative practice as “an inter-professional process of communication and decision making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client/patient care provided”(Busing, Way et al. 2000) They describe the synergy as 1 + 1 = 3 denoting that shared care can often provide better patient care than any one individual health care provider can provide alone. Hence, collaboration requires a foundation of interprofessionalism. D’Amour highlights communication issues when she describes collaborative practice as the “structuring of collective action through information sharing and decision making in clinical processes.” (D’Amour et al. 1999)
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Interdisciplinary Education In reference to interdisciplinary education, the authors have decided to use the definition by the Centre for Advancement of Interprofessional Education in the United Kingdom. Interprofessional education is “Occasions when two or more professions learn from and about each other to improve collaboration and the quality of care”. Chapter 4 expands on this definition to consider the differences between multi-inter- and transdisciplinary education which resonates with the discussion above on the differences of the terminology related to clinical practice. As interdisciplinary education spans the continuum of learning from a health professional trainee’s entrance into a training program and extends into continuing education opportunities while in clinical practice, there is a need to distinguish levels of training to describe educational initiatives. The authors of this report have decided to use the terms “pre-licensure” training which occurs while a trainee is in their formal years of training and before receiving a license to practice independently. For Medicine, this would include post-graduate years of training in specialty programs. “Post-licensure” training would denote training that occurs once a health professional is practicing independently. It often takes the form of continuing professional development. It also however would include into graduate level training for health professionals who have gone back to obtain their e.g. Masters of Nursing or Masters of Social Work. Patient - Client It is further noted that although we shall use the term “patient” within this document as it is language that is most common for the researchers involved, the term “client” may be preferred over “patient” particularly for certain health care professionals. The term “client” acknowledges issues of autonomy by individuals who are consumers of health care services. The authors respect the use of this terminology and hence will use the term patient and client interchangeably within the document. Suffice it to say that there is a need to ensure that when using terminology within the area of collaborative practice and interdisciplinary education, it is important to ensure that a common understanding is obtained by all. As long as there is an understanding of why terms are being used and respect for why certain health professionals use certain terminologies perhaps we can reach some form of consensus for a common language to be developed amongst the health professions.
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Road Map for the Report The report is divided into chapters authored by individual team members who had knowledge and experience in the subject matter. To generate a better understanding of the relationship between interdisciplinary education and collaborative practice, each chapter is dedicated to a key issue or component of IECPCPwhich relates to the conceptual framework that is outlined in Chapter 2 & 10. Chapter 2 provides an overview of the evidence and systematic review of the literature on interdisciplinary education and collaborative practice effectiveness in addressing benefits and patient outcomes. Key elements of collaborative practice frameworks and interprofessional education are covered in Chapters 3 & 4 respectively. Both of these chapters outline key concepts, provide examples of models and activities and identify key enablers and barriers to achieving IECPCP. Chapters 5 & 6 provide highlights on specific Canadian examples of models of interdisciplinary education and collaborative practice and what we can learn from these examples as revealed by the online survey and in-depth interviews of the environmental scan. Chapter 7 will address the cultural diversity in interprofessional education and practice and what considerations and implications that should be explored. Chapter 8 is an overview of the current federal/provincial/ territorial policies in health and education that either support or place impediments for further advancement to IECPCP. Exploring change management strategies and knowledge transfer to overcoming barriers to change is the focus in Chapter 9. A conceptual IECPCP framework will be proposed in Chapter 10 followed by a series of recommendations in Chapter 11 including research priorities for the future.
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References Feeley, N., & Gottlieb, L. (2004). Collaborative-partnership: A delicate balance. Toronto: C.V. Mosby. Freeth, D., “Sustaining interprofessional collaboration” in Journal of Interprofessional Care, 2001, Vol. 15, No. 1, p. 37-46 Hall P, Weaver L. Interdisciplinary education and teamwork: a long and winding road. [comment]. Medical Education 2001;35(9):867-75. Boaden N, Leaviss J. Putting teamwork in context. Medical Education 2000;34 (11):921-7. Halstead, R.W., Wagner, L.D., Margo, V, & Ferkol, W (2002) Counselor’s conceptualization of caring in the counseling relationship. Counselling and Values, 47, 34-42. Health Canada. 2003 First Ministers’ Accord on Health Care Renewal (http://www.hcsc.gc.ca/english/hca2003/accord.html). 2003. Higgs J., Jones M, Clinical Reasoning in the Health Professions, Oxford, United Kingdom, ButterworthHeinemann, 2000 Leipzig RM, Hyer K, Ek K, Wallenstein S, Vezina ML, Fairchild S, et al. Attitudes toward working on interdisciplinary healthcare teams: a comparison by discipline. Journal of the American Geriatrics Society 2002;50(6):1141-8. Lilley, S., Clay, M., Greer, A., “Interdisciplinary Rural Health Training for Health Professional Mayeroff, M (1972). On caring. New York: Harper & Row. Mead N, Bower P, Patient-centred consultation and outcome in primary care: a review of the literature, Patient Education and Counseling, 2002, Vol. 40, No. 1, p. 51-61 Potvin, L, Cargo, M., McComber, A. M., Delormier, T., & Macaulay, A. C. (2003). Implementing participatory intervention and research in communities: Lessons from the Kahnawake Schools Diabetes Prevention Project in Canada. Social Science and Medicine, 56, 1295-1305. Request for Proposal. Interdisciplinary Education for Collaborative, Patient-Centred Practice – Discussion Paper and Research Report. Health Canada. October 9, 2004 Stewart, M, Belle, JB, Weston, W, Patient-Centred Care Medicine: Transforming the Clinical Method, Oxon, United Kingdom, Radcliffe Medical Press, 2003 Students: Strategies for Curriculum Design” in Journal of Allied Health, 1998, Vol. 2, no. 4, p. 208-12 Sullivan, T. J. (1998). Collaboration: a health care imperative. New York: McGraw-Hill.
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Chapter Two Effectiveness of Pre-licensure Interdisciplinary Education and Post-licensure Collaborative Interventions By Merrick Zwarenstein, Scott Reeves and Laure Perrier
Introduction In spite of a substantial commitment on the part of many governments and funders of health services to improving collaboration between professionals, there is no easily available, reliable evidence on the effectiveness of alternative interventions to achieve this aim. We conducted a scan of the existing empirical research and summarized the reliable evidence on the effectiveness of the two main interventions directed at achieving collaboration (pre-licensure interdisciplinary education and post-licensure collaboration interventions). Because the field has been mainly value driven to date, we focus entirely on the question of effectiveness, and use a model of evaluation that emphasizes rigorous evaluation designs. The chapter is divided into four parts. The first part of the chapter describes the purpose, aims and objectives of our work. The second part details the process employed to obtain published Reviews of pre-licensure interdisciplinary education and post-licensure collaboration interventions. The third part of the chapter describes a systematic review we undertook to find reliable evaluative studies of pre-licensure interdisciplinary education and post-licensure collaboration interventions (from 2001 to date). We summarize the findings of these studies and discuss their limitations. The final part of the chapter offers conclusions on the findings and recommendations for implementation of pre-licensure education and post-licensure collaboration interventions, and for research in this area.
Purpose This chapter covers one of several questions from the environmental scan and literature. We collect what is known about the effectiveness of interventions aimed at improving collaboration between different health professionals, and thus contributing to high quality patient centred care. The interventions fall into one of two contrasting groups: pre-licensure interdisciplinary education or post-licensure collaboration interventions. The question addressed in this chapter derives from the tradition of summative evaluation. In this tradition of inquiry, evaluation questions are answered using rigorous controlled research designs and objective measures of outcome. The question of the effectiveness of an intervention is a narrow but important one. Other chapters in this report deal with theoretical aspects of these 41
interventions, different models for the design of such interventions, and related barriers, facilitators and policies. Aims and objectives In this study we attempt to answer the following question: Do groups consisting of practitioners or students from several professions, who are exposed to pre-licensure interdisciplinary education and post-licensure collaboration interventions, provide higher quality care than comparable control groups not so exposed? For patient level outcomes this can also be phrased as: Do patients whose practitioners have been exposed to pre-licensure interdisciplinary education and post-licensure collaboration interventions have better health or other patient relevant outcomes than patients of practitioners not exposed to these interventions? The study objectives are: 1. To conduct an overview of published reviews of primary studies of the effects of prelicensure interdisciplinary education and of post-licensure collaboration interventions on quality and outcomes of care. 2. To conduct a systematic review of recently published primary studies of the effects of prelicensure interdisciplinary education and of post-licensure collaboration interventions on quality and outcomes of care.
Methods This chapter offers a scan and summary of the evidence on the effectiveness of pre-licensure interdisciplinary education and of post-licensure collaboration interventions. Because of the short work period for this study, we elected to conduct an overview of existing systematic reviews on these topics; and because of the rapid pace of development in this area we supplemented this with a new systematic review to bring our data collection up to the present date. This is a study of secondary data; no primary field data were collected on effectiveness of the target interventions. For this reason, no ethical issues arose, and no consent or ethical approval was sought. We used the following definitions: Pre-licensure interdisciplinary education is an educational activity that involves students at the undergraduate or post-graduate levels of training before qualification or licensure has been obtained to practice independently. Two or more health and/or social care professions interact to learn more about collaborative practice. We occasionally shorten this to ‘prelicensure education’. Post-licensure collaboration interventions involve qualified members of two or more health and/or social care professions who interact to improve the delivery of care to patients. Intervention study: An evaluation in which a new way of doing something is compared with an existing or alternative way. In relation to pre-licensure interdisciplinary education and 42
post-licensure collaboration intervention, the intervention is usually a new training course in the former, or a new way of encouraging team members from different professions to work together in the latter. Effectiveness: The impact of an intervention on an aspect of care or on a health outcome; may be positive (effective), negative (harmful) or indeterminate (either no difference, or no evidence). Reviews We identified 8 reviews (of which our own prior work comprised four). Five of the 8 reviewed the evidence on the effectiveness of post licensure collaboration initiatives, and 3 examined the effectiveness of pre-licensure interdisciplinary education. We identified reviews that we were aware of. We also contacted experts at the Centre for the Advancement of Education in the UK, and searched a number of databases (Medline, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews (DARE), both on the Cochrane Library) using the MeSH subject heading ‘ relations’ and the publication type ‘Review’. The following reviews were examined and summarized: Freeth et. al., 2002; West et. al., 1996; Cooper et. al., 2001; Reeves, 2001; Schmitt, 2001; Borrill et. al., 2001; Zwarenstein et. al., 2000; Zwarenstein, 2001. 1-8 Systematic Review of recent primary studies We elected to do our own search of the primary literature covering Jan 2001-Nov 2003 inclusive, and to base our search strategy on that of the abovementioned Freeth review (see appendix 2-2 on page 59). We modified the strategy slightly to eliminate duplications and searched the Cochrane Central Register of Controlled Trials (CENTRAL), a register of randomized controlled trials held within the Cochrane Library, rather than the contributing databases (as these are included in the search strategy making up CENTRAL. Since the overriding aim of the Cochrane Collaboration is to create an unbiased source of primary studies for Systematic Reviews, all known controlled trials are included in CENTRAL irrespective of language of publication, or where and when the studies were conducted. Studies are entered into CENTRAL through regular electronic searches of the principal electronic databases (Medline, Cinahl, Embase and other databases in other languages such as LILACS, the index of Latin American publications). Studies are also entered into CENTRAL through two other processes of the Cochrane Collaboration. Each of the more than 50 review groups in the Cochrane Collaboration conduct manual searches of the journals particular to their field, and all the controlled trials caught in this net are included in CENTRAL; furthermore, most Systematic Reviews in the Cochrane library have searched the reference lists in each of the included studies, to identify further controlled trials. Our search used combinations of the following search terms: interprofessional, interdisciplinary, interoccupation, interinstitution, intersector, interdepartment, interorganization, interprofessional relations, professional-patient relations, multiprofessional, multidisciplinary, multioccupation, multiinstitution, multisector, multidepartment, multiorganization.
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Finally, the Cochrane Effective Practice and Organization of Care (EPOC) group is responsible for systematic reviews of health care system interventions (such as pre-licensure education and post-licensure collaboration, and like other Collaborative Review Groups in the Cochrane Collaboration, keeps a register of controlled trials in its area. EPOC maintains a register that houses controlled trials specific to the effects of healthcare interventions. A request was sent to have this register searched and the term used was “interprofessional relations’. By using CENTRAL and the EPOC literature database, results were restricted to more rigorous quantitative studies, including randomized controlled trials, controlled before and after studies, and interrupted time series design.
Results Overview of Existing Reviews:
As noted above, our search found eight reviews (Borrill et al 2001, Cooper et al 2001, Freeth et al 2002, Reeves 2001, Schmitt 2001, West & Slater 1996, Zwarenstein & Bryant 2000, Zwarenstein et al 2001)1-8. (See Appendix 2-1 on page 55 for detailed information of these reviews) The three authors read and classified the 8 reviews under the following headings. (See table 1 for categorization; the reviews are summarized in appendix 1 on page 55) These categorizations were discussed to reach consensus. Table 1: Categorizations for existing reviews 1. Parameters of the review
2. Design details
3. Key findings
4. Conclusions
Focus (pre-licensure interdisciplinary education or post-licensure collaboration); Search strategy to obtain studies; Who initiated the review; Scope (e.g. international or national). Details of included study designs which health and social care professionals participated in the intervention; Nature of intervention under study. The number of studies found and included in the review; Approaches to analysis. Details of any methodological critique Authors narrative conclusions from each review. Our comments/critique on the review; Areas of possible future work
Of these eight reviews: Two report on the effectiveness of interdisciplinary education interventions (Cooper et al 2001, Zwarenstein et al 2001);3,8 Six report on the effectiveness of collaboration interventions from 1955 to 1998 (Borrill et al 2001, Freeth et al 2002, Reeves 2001, Schmitt 2001, West & Slater 1996, Zwarenstein & Bryant 2000).1-2, 4-7
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Collectively, these reviews assessed evidence of effectiveness for interventions aimed at prelicensure interdisciplinary education and post-licensure collaboration interventions which took place from 1955 to 2001. More information on these reviews is summarized in tables and can be found in the Appendix 2-3 on page 60. The review by Freeth2 and colleagues examines the literature on pre-licensure interdisciplinary education and post-licensure collaboration interventions (mainly the latter) using an explicitly described and very wide ranging search strategy. It includes evaluation studies published up to the beginning of 2001. Freeth employs less rigorous inclusion criteria than the equivalent Cochrane review8 i.e. a range of quantitative and qualitative studies and educational, professional and patient care outcomes were included. Following a quality check that assessed methodological quality, 53 studies were found to be of adequate quality for consideration. Similarly, Cooper et al (2001)3 found 30 studies but these were cross sectional, descriptive and largely without appropriate control groups. They do not, therefore, inform the question of effectiveness. The Cochrane review (Zwarenstein et al) which overlaps with Freeth used strict inclusion criteria (that is, evidence deriving from well designed controlled before/after, interrupted time series, randomized or controlled studies) and concluded that there is no rigorous evidence on the effectiveness of either pre or post interdisciplinary education (Zwarenstein et al 2001). Those reviews which succeeded in finding relevant studies were only able to do so because they set the methodological bar for inclusion at a very low level of rigour, or indeed, failed to establish any inclusion and exclusion criteria at all. These reviews cannot therefore provide insight into the effectiveness of interdisciplinary education as the findings from such studies are highly susceptible to bias in interpretation. Our overview of reviews of collaboration interventions found that: Most reviews did not provide detailed descriptions of the interventions they reported. Instead, they focused on describing subsets of studies (e.g. by country, profession and area of clinical work). Most reviews were not systematic in their approach to searching or inclusion. Most reviews did not exclude descriptive studies and poor quality intervention studies. The eight reviews of interdisciplinary education and collaboration found are of little value in providing insight into the effectiveness these two types of intervention. Most were not systematic (no defined search strategy or inclusion and exclusion criteria and therefore are insufficiently rigorous to support the conclusions of the review authors on the effectiveness of the interventions studied. We concluded that existing reviews do not contribute information which can be used to judge the effectiveness of interdisciplinary education and collaboration interventions.
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Systematic Review of Recent Trials The CENTRAL search was conducted on Nov 25, 2003 and retrieved 419 studies. Only articles that focused exclusively on interdisciplinary education or collaborative practice were selected. The electronic abstracts were reviewed by Zwarenstein and 26 were deemed relevant to the systematic review question. The EPOC search results were requested on Nov 24 2003, received on Nov 25 2003, and retrieved 31 studies. The electronic abstracts were reviewed by Zwarenstein and none were deemed relevant to the systematic review question. Among the 26 included studies we found no studies of pre-licensure education. All of the 26 included studies were reports of post licensure collaboration interventions. Following full assessment of the study, 12 of the 26 were excluded for the following reasons: no collaboration (3); no control groups (2); no results (1); duplication (2); contained confounding interventions so that outcome cannot be attributed to the post-licensure collaboration interventions (4). The excluded studies are indicated in the appendix by the remark ‘no’ in the column on inclusion. Of the 14 studies of collaboration interventions that were included, 11 studies showed positive results, while three studies revealed no effects. Post-licensure collaboration interventions were effective in the following areas: Geriatric evaluation and management12; 13 ER care for abused women (staff knowledge but not detection) 14 Sexually Transmitted Infections (STI) screening9 Adult immunisation10 Fractured hips11 Neonatal ITU care16 One study of depression care17 ; but not a second study of depression18 One study of simplifying medications19 but not a second study20. Post-licensure collaboration interventions appeared to have no effect in three studies: Continuity of care for substance abusing patients33; Congestive heart failure15 Care of elderly patients with pneumonia31; The findings were difficult to interpret for a study of stroke care24 as the control group was also organized as a collaborative team.
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Discussion Pre-licensure Interdisciplinary education Although we could find no reliable evidence on the effectiveness of interdisciplinary education, the absence of evidence is not in itself evidence that intervention is ineffective. It may simply mean that the intervention is difficult to evaluate, and this is indeed obviously so with prelicensure interdisciplinary education. Problems in the evaluability of the effectiveness of prelicensure interdisciplinary education include: large scale changes necessary to encourage interdisciplinary education often are best implemented at the level of an entire school of health sciences, which switches philosophy towards educating students in different professions together, interactively. Such institutions are often led by charismatic individuals, so that the process of change cannot simply be packaged and delivered as an intervention at other schools. Secondly, if the evaluation is to go beyond subjective assessments by participants, or before-after uncontrolled assessments of knowledge or attitude, far deeper evaluations are required, over a period long enough to look at the sustainability of changes into the professional life of the graduates. A formidable logistical barrier to these studies exists: if a controlled study of pre-licensure interdisciplinary education was conducted, the intervention is at the level of the school of health sciences, as this is the ‘unit’ that undergoes change. The pre-licensure students are then exposed to interdisciplinary education by virtue of the change that takes place at the school they attend. A randomized or controlled trial would thus need to consist of an intervention group (comprising a large number of schools of health sciences) and a similar control group (also composed of large numbers of schools of health sciences). The task of organizing such an experiment is indeed formidable, as many schools of health sciences would need to be encouraged to undertake such a change, while other, randomly selected schools would have to be prevented from so doing. This is certainly more complex than any such study in any field, especially given the autonomy of schools of health sciences. A weaker study design, but much more reliable, and informative than any to date, would randomize a group of (would be students to schools), some of which are using an interdisciplinary approach, and others of which use the traditional approach. The problem with this design is that the outcome of the study will be due to characteristics of the schools beyond simply their commitment to interdisciplinary education. Post-licensure Collaboration In contrast to the lack of evidence for interdisciplinary education, our review of collaboration interventions involving two or more qualified health and/or social care professions provides more reliable evidence of positive impact on health care processes and outcomes. Indeed, as outlined above, this evidence reveals that collaboration interventions can have a positive effect on the delivery of care in a range of areas, including: geriatric evaluation and management, congestive heart failure; neonatal care and screening. The post-licensure collaboration intervention studies were a heterogeneous group, and so no formal meta-analysis was possible. The patient groups extended from young children to the elderly, the conditions of interest from fractured hip to sexually transmitted infections, and the
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settings from community based primary care to hospital based intensive care. The participating professionals from the different studies included physicians, pharmacists, nurses, laypersons and the patient themselves. Interventions to promote collaboration between different professionals were usually aimed at a localized health team, and were not theory based, being mostly empirical responses to perceived problems, driven and designed largely by clinicians. In most studies, no specific attempt was made to encourage or facilitate relations and collaboration between professionals; instead a structure, guideline or new way of working was implemented. The exception to this approach was a number of studies using an iterative Quality Improvement approach. Several studies did not test interventions to improve faceto face communication or collaboration between professionals from different disciplines; instead they ensured or increased the passage of information between professions, in the form of referrals, notes, or other written feedback. In general, post-licensure collaboration interventions appeared to achieve benefit (11/14). Five of these studies were able to demonstrate statistically significant and clinically important outcome differences in patient mortality rates, decline in healthy function, and other highly patient relevant outcomes. The remainder were effective in achieving process changes, also of importance, but not explicitly connected in the studies to patient health outcomes.
Conclusions Pre-licensure Interdisciplinary Education
The absence of evidence for positive effects from pre-licensure interdisciplinary education cautions against widespread intervention programs now, as no model exists with reliable evidence for effectiveness. Given the scarcity of empirical evidence of the effectiveness of interdisciplinary education approaches, more models of this type of education are required, and the feasibility of implementing them needs to be tested. In Chapter 10, D’Amour & Oandasan present just such a model, a conceptual framework describing how interdisciplinary education that is developed to enhance learner outcomes is linked to collaborative practice initiatives that are developed to enhance patient outcomes. In this chapter they suggest several sets of learner and learning outcomes that are intermediate process variables on the way to impact on patient care and thus on patient outcomes. Rigorous studies have not yet been conducted to evaluate the effect of interdisciplinary education on these ‘upstream’ attributes; such studies should be a part of any program of research in this area, as we outline below. Although profoundly theorized, the field of pre-licensure interdisciplinary education is relatively under researched in terms of empirical evaluation of alternative interventions to impact learner, learning, health care system or patient outcomes. A consensus should be reached on a number of approaches to interdisciplinary education that should be tested, selecting those which have advantages in terms of implementability, affordability and acceptability. A program of research should be considered to fund pilot implementation of a small number of these, in the context of contextual, qualitative studies and quantitative studies of their working.
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Once models have been developed and piloted, their effectiveness needs to be evaluated. At that point, substantial program evaluations including randomized trials need to be carried out to understand the impact of these new models of interdisciplinary education. In addition, qualitative data needs to be collected to help explain the effects of such interventions. The technical challenges of these studies are not to be underestimated given the long path from undergraduate education to improved patient care and health care outcomes, the difficulty of random allocation of units other than individuals (schools, classes) and the high probability of bias in less rigorous assessments. Post-licensure collaboration We consider that post-licensure collaboration interventions have the highest priority for research and implementation, given that there is evidence that some of these interventions offer substantial promise for impacting on health system problems. The fact that they are workplace based ensures that stakeholders other than the professions or their organizations have an interest in supporting these interventions. Individual professionals in their workplace may be more willing to depart from perceived professional norms if the advantages of so doing (solving local problems, improving patient care outcomes, building better relationships with known individuals from other professions in their teams) overcome the long held habit of poor collaboration. The work on post-licensure collaboration interventions has been fragmented – few groups (and even fewer in Canada) have built up substantial expertise. Even in successful intervention studies the determinants of collaboration have not been studied. We therefore recommend that a number of high priority health problems are chosen for study and a small number of skilled multidisciplinary research teams are commissioned to conduct comprehensive studies on postlicensure collaboration interventions for one or more of these problems. These studies need to cover development of interventions, and their comprehensive evaluation. The majority of rigorously evaluated, effective post-licensure collaboration interventions have been tested in the in patient hospital setting. As with our comments above on interdisciplinary education, the absence of evidence for the effectiveness of post-licensure collaboration interventions in the ambulatory and primary care settings does not mean that these interventions do not work in those settings; it means only that they are untested. Unlike the problems associated with evaluation of interdisciplinary education, where randomized trials would have to be on an extremely large scale, rigorous studies of the effectiveness of these interventions in primary and ambulatory care would not be so challenging. We therefore recommend that efforts to move towards widespread implementation of collaboration interventions focus on those for which there is reliable evidence, (many of which are hospital based), and we further recommend that substantial efforts be made to develop collaboration interventions in primary and ambulatory care, and that these are moved rapidly through pilot testing and rigorous large scale trials. We would not presume to specify in advance the theoretical framework that should be used for the development of interventions. The only framework commonly cited in our systematic review that of Quality Improvement was not consistently successful. Social science researchers may have most to contribute to formulation of a basis for collaboration interventions. 49
Methodologically, the groups conducting research in this area should be able to demonstrate active participation of practitioners from well-motivated practice sites, (hospital, or primary care). Researchers must be able to test effectiveness of their proposed interventions in a number of settings using well designed randomized controlled trials, and conduct parallel qualitative evaluative work to understand the reasons for success or failure in their post-licensure collaboration interventions. Based on the conclusions presented above, three recommendations for post licensure collaboration interventions are offered: Where there is evidence of effectiveness, collaboration intervention models could be implemented. Extrapolations of proven models should be implemented with integrated larger trials and qualitative research New models of collaboration could be developed, piloted and trailed.
Summary Governments and funders of health services are keen to improve collaboration between professionals, but our review has shown that there is no reliable evidence on the effectiveness of some of the more popular interventions which are thought likely to achieve this aim. Our scan and summary of the existing reliable empirical research evidence suggests that the effects of widespread implementation of pre-licensure interdisciplinary education will be more of an unknown than those of post-licensure collaboration interventions, for which there is a significant body of evidence suggesting positive effects. The coverage of this latter evidence is patchy, being especially weak in primary care. In a field where policy level interventions have been value driven for the last half century, we have identified a base of evidence for the effectiveness of certain post-licensure collaboration interventions; this evidence is lacking for pre-licensure interdisciplinary education. If interventions and policies on either of these interventions are implemented without accompanying rigorous evaluation research, we will remain mired in this same uncertainty into the future.
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References 1. West M and Slater J (1996) Teamworking in Primary Health Care: A Review of its Effectiveness. HEA, London. 2. Freeth D, Hammick M, Koppel I, Reeves S & Barr H (2002) A Critical Reviews of Evaluations of Education. LTSN, London. 3. Cooper H, Carlisle C, Gibbs T & Watkins C (2001) Developing an evidence base for interdisciplinary learning: a systematic review. Journal of Advanced Nursing; 35:228-237. 4. Reeves S (2001) A systematic review of the effects of education on staff involved in the care of adults with mental health problems. Journal of Psychiatric and Mental Health Nursing; 8:533-542 5. Schmitt M (2001) Collaboration improves the quality of care: methodological challenges and evidence from US health care research. Journal of Care; 15:47-66 6. Borrill CS, Carletta J, Carter AJ, Dawson JF, Garrod S, Rees A, Richards A, Shapiro D, West MA. (2001). The effectiveness of health care teams in the National Health Service. Report. 7. Zwarenstein M, Bryant W. Interventions to promote collaboration between nurses and doctors. Cochrane Database Syst Rev. 2000;(2): CD000072. 8. Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Atkins J. Education: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(1): CD002213 9. Shafer MA, Tebb KP, Pantell RH, Wibbelsman CJ, Neuhaus JM, Tipton AC et al. Effect of a clinical practice improvement intervention on Chlamydia screening among adolescent girls. JAMA 2002;288:2846-52. 10. Siriwardena AN, Rashid A, Johnson MR, Dewey ME. Cluster randomized controlled trial of an educational outreach visit to improve influenza and pneumococcal immunization rates in primary care. Br J Gen Pract 2002;52:735-40. 11. Naglie G, Tansey C, Kirkland JL, Ogilvie-Harris DJ, Detsky AS, Etchells E et al. Interdisciplinary inpatient care for elderly people with hip fracture: a randomized controlled trial. CMAJ 2002;167:25-32. 12. Saltvedt I, Mo ES, Fayers P, Kaasa S, Sletvold O. Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit. A prospective randomized trial. J Am Geriatr Soc 2002;50:792-8.
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13. Boult C, Boult LB, Morishita L, Dowd B, Kane RL, Urdangarin CF. A randomized clinical trial of outpatient geriatric evaluation and management. J Am Geriatr Soc 2001;49:351-9. 14. Campbell JC, Coben JH, McLoughlin E, Dearwater S, Nah G, Glass N et al. An evaluation of a system-change training model to improve emergency department response to battered women. Acad Emerg Med 2001;8:131-8. 15. Kasper EK, Gerstenblith G, Hefter G, Van Anden E, Brinker JA, Thiemann DR et al. A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. J Am Coll Cardiol 2002;39:471-80. 16. Rogowski JA, Horbar JD, Plsek PE, Baker LS, Deterding J, Edwards WH et al. Economic implications of neonatal intensive care unit collaborative quality improvement. Pediatrics 2001;107:23-9. 17. Solberg LI, Fischer LR, Wei F, Rush WA, Conboy KS, Davis TF et al. A CQI intervention to change the care of depression: a controlled study. Eff Clin Pract 2001;4:239-49. 18. Rost K, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming. J Gen Intern Med 2001;16:143-9. 19. Muir AJ, Sanders LL, Wilkinson WE, Schmader K. Reducing medication regimen complexity: a controlled trial. J Gen Intern Med 2001;16:77-82. 20. Grymonpre RE, Williamson DA, Montgomery PR. Impact of a pharmaceutical care model for non-institutionalized elderly: results of a randomized, controlled trial. International Journal of Pharmacy Practice 2001;9:235-41. 21. Chan, P. K., Fischer, S., Stewart, T. E., Hallett, D. C., Hynes-Gay, P., Lapinsky, S. E., MacDonald, R., and Mehta, S., Practicing evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol, Crit Care, 5( 6), 2001, p.349 - 354 22. Debehnke, D. and Decker, M. C., The effects of a physician-nurse patient care team on patient satisfaction in an academic ED, Am J Emerg Med, 20( 4), 2002, p.267 – 270 23. Elliott, T. E., Elliott, B. A., Regal, R. R., Renier, C. M., Crouse, B. J., Gangeness, D. E., Witrak, M. T., and Jensen, P. B., Lake Superior Rural Cancer Care Project, part I: an interventional trial, Cancer Pract, 9(1), 2001, p.27 – 36 24. Evans, A., Perez, I., Harraf, F., Melbourn, A., Steadman, J., Donaldson, N., and Kalra, L., Can differences in management processes explain different outcomes between stroke unit and stroke-team care?, Lancet, 358( 9293), 11-10-2001, p.1586 – 1592
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25. Homer, C. S., Davis, G. K., Brodie, P. M., Sheehan, A., Barclay, L. M., Wills, J., and Chapman, M. G., Collaboration in maternity care: a randomized controlled trial comparing community-based continuity of care with standard hospital care, BJOG, 108( 1), 2001, p.16 – 22 26. Jensen, J., Lundin-Olsson, L., Nyberg, L., and Gustafson, Y., Fall and injury prevention in older people living in residential care facilities. A cluster randomized trial, Ann Intern Med, 136( 10), 5-21-2002, p.733 –741 27. Kalra, L., Evans, A., Perez, I., Melbourn, A., Steadman, J., and Donaldson, N., A randomized comparison of processes of care between stroke unit and stroke team management, Cerebrovascular Diseases, 11( Suppl 4), 2002, p 122 28. Kendrick, D., Pritchard, A., Cloke, J., and Barley, M., Randomized controlled trial assessing the impact of increasing information to health visitors about children's injuries, Arch Dis Child, 85( 5), 2001, p.366 – 370 29. Margolis, P. A., Stevens, R., Bordley, W. C., Stuart, J., Harlan, C., Keyes-Elstein, L., and Wisseh, S., From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children, Pediatrics, 108( 3), 2001, p.E42 30. Midlov, P., Bondesson, A., Ericksson, T., Petersson, J., Minthon, L., and Hoglund, P., Descriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinson's disease at nursing homes in southern Sweden, Eur J Clin Pharmacol, 57( 12), 2002, p.903 – 910 31. Naughton, B. J., Mylotte, J. M., Ramadan, F., Karuza, J., and Priore, R. L., Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia, J Am Geriatr Soc, 49( 8), 2001, p.1020 – 1024 32. Horbar, J. D., Rogowski, J., Plsek, P. E., Delmore, P., Edwards, W. H., Hocker, J., Kantak, A. D., Lewallen, P., Lewis, W., Lewit, E., McCarroll, C. J., Mujsce, D., Payne, N. R., Shiono, P., Soll, R. F., Leahy, K., and Carpenter, J. H., Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network, Pediatrics, 107( 1), 2001, p.14 - 22 33. Samet, J. H., Larson, M. J., Horton, N. J., Doyle, K., Winter, M., and Saitz, R., Linking alcohol- and drug-dependent adults to primary medical care: a randomized controlled trial of a multi-disciplinary health intervention in a detoxification unit, Addiction, 98( 4), 2003, p.509 – 516 34. Skouen, J. S., Grasdal, A. L., Haldorsen, E. M., and Ursin, H., Relative cost-effectiveness of extensive and light multidisciplinary treatment programs versus treatment as usual for patients with chronic low back pain on long-term sick leave: randomized controlled study, Spine, 27( 9), 5-1-2002, p.901 – 909
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Appendices for Chapter Two: Effectiveness of Pre-licensure Interdisciplinary Education and Post-licensure Collaborative Interventions
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Appendix 2-1 Reviews of interdisciplinary education and interprofessional collaboration Borrill et al (2001) Parameters
Design details
Key findings
Conclusions
Overview
Focus: Postlicensure interprofessional collaboration intervention
Study design: Few controlled studies. Design not used as an inclusion criterion.
Number of included studies not specified.
Reduced hospital time & costs, and improved service provision showed measurable effectiveness.
Does not contribute information for assessment of effectiveness.
Search strategy not specified
Participants: all. Not used as an inclusion criterion.
Patient satisfaction, staff motivation, and team innovation appeared to improve based on self reports.
Summarizes descriptive studies
Semi-qualitative review of effects, no methodological critique offered.
Narrative review Report for UK National Health Service
Intervention: Mainly not intervention studies. Described existing teamwork.
No meta-analysis, no statistical methods used
Outcomes: not clear
Not systematic
Future work on this review: Extract reliable controlled studies and incorporate them directly into a systematic review.
Period: not specified
Cooper et al (2001) Parameters
Design details
Key findings
Conclusions
Overview
Focus: Prelicensure interdisciplinary education
Study design: Design not used as an inclusion criterion.
30 studies were included.
Does not contribute information for assessment of effectiveness.
Search strategy not specified
Participants: All undergraduate health sciences students.
Positive findings for self reported student satisfaction with the learning experience, self reported skill and knowledge acquisition, changes in behaviour and in professional practice.
Researcher initiated review, described as ‘systematic review’
Intervention: students of two or more health professions learning together. Outcomes: Mainly learner self-reports. Period: Not stated
Semi-qualitative review of effects. Methodological critique offered. Most studies were of poor quality, using invalidated survey instruments. No meta-analysis, no statistical methods.
Few studies with reliable methods. Summarizes low quality studies Future work on this review: Extract reliable controlled studies and incorporate them directly into a systematic review.
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Freeth et al (2002) Parameters
Design details
Key findings
Conclusions
Overview
Focus: ¼ prelicensure interdisciplinary education / ¾ post-licensure interprofessional collaboration intervention
Study design: Design used as an inclusion criterion: ‘higher quality’ studies.
53 studies were included of 220 retrieved.
Positive findings predominate.
Does not contribute information for assessment of effectiveness.
Search strategy specified: Medline, CINAHL, BEI Researcher initiated systematic review, UK.
Participants: All. Used as an inclusion criterion. Intervention: 2 or more disciplines learning together. Mainly intervention studies.
Semi-qualitative review of effects. Methodological critique offered.
Most outcomes were assessed on self-reports of learner perceptions and of attitudes.
Few studies with reliable methods. Systematic review Summarizes low quality studies
No meta-analysis, simple study count summary.
Cannot distinguish IPC from IDE Future work: Extract reliable controlled studies and incorporate into a systematic review.
Outcomes: Mainly learner self-reports. Period: 1966-2001
Reeves S (2001) Parameters
Design details
Key findings
Conclusions
Overview
Focus: Postlicensure interprofessional collaboration intervention
Study design: Design not used as an inclusion criterion.
18 studies were included of 1529 abstracts retrieved.
Does not contribute information for assessment of effectiveness.
Participants: Mental health professionals working with adult patients. Used as an inclusion criterion.
Semi-quantitative review of effects. Methodological critique offered. 13 studies were of good or moderate quality, but little information was available to make this judgement.
Positive findings for self-reported satisfaction with -The learning experience (5 studies), -Self-reported skill and knowledge acquisition (4 studies) -Changes in behaviour (3 studies) -Professional practice (6 studies).
Search strategy: Medline Psychlit Cinahl. Researcher initiated systematic review, UK.
Intervention: 2 or more disciplines learning together. Mainly intervention studies. Outcomes: Mainly learner self-reports.
Used study counts to summarize.
Narrow area of application- problem specific. Few studies described their methods adequately Future work on this review: Extract reliable controlled studies and incorporate them directly into a systematic review.
Period: 1966-98
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Schmitt M (2001) Parameters
Design details
Key findings
Conclusions
Overview
Focus: Postlicensure interprofessional collaboration intervention
Study design: Design not used as an inclusion criterion.
47 studies were included.
Does not contribute information for assessment of effectiveness.
Participants: Geriatric and chronic illness/rehabilitation health professionals. Used as an inclusion criterion.
Methodological critique offered. Mainly descriptive designs (even comparisons are descriptive case study type designs).
More effective in 14 studies, similar in 30, and less in one study. 2 were non contributory.
Search strategy: Not reported Researcher initiated systematic review, US.
Intervention: Team interprofessional collaboration. Mainly comparative studies, but not necessarily intervention studies.
-Narrow problem specific area of inclusion -Not systematic -Summarizes descriptive studies Future work on this review: Extract reliable controlled studies and incorporate them directly into a systematic review.
Used study counts to summarize findings.
Outcomes: Patient functional and health status, hospital use, costs, death and disease. Mainly objective simple outcomes. Period: 1955-95 West & Slater (1996) Parameters
Design details
Key findings
Conclusions
Overview
Focus: Postlicensure interprofessional collaboration intervention
Study design: Few controlled studies. Design not used as an inclusion criterion.
14 studies were examined.
Teamwork reduced curative health care utilization while increasing health promotion activities.
Does not contribute information for assessment of effectiveness.
Search strategy specified. Report for Health Education Authority, United Kingdom NHS
Participants: All team members Intervention: Mainly not intervention studies. Described existing teamwork. Outcomes: Not clear. Period: Not specified
Semi-qualitative review of effects, no methodological critique offered. No meta-analysis, no statistical methods used.
Improved quality of care, improved staff morale and job satisfaction.
-Not systematic -Summarizes descriptive studies Future work on this review: Extract reliable controlled studies and incorporate them directly into a systematic review.
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Zwarenstein & Bryant (2000) Parameters Focus: Postlicensure interprofessional collaboration intervention Search strategy: EPOC database, Medline, and hand searching of reference lists. Researcher initiated systematic review, South Africa
Design details Study design: Design used as an inclusion criterion. CBA, ITS and RCT, CCT. Participants: Nurses and Doctors only. Intervention: Interventions to encourage nurses and doctors to work together.
Key findings ‘Several hundred’ studies were retrieved on electronic search, 31 reviewed by hand, 2 met criteria. Methodological critique offered
Conclusions One study showed positive effects on shortening length of stay, and costs while the other showed no difference on length of stay.
No meta-analysis. Narrative description.
Overview Does not contribute information for assessment of effectiveness. -Two studies found of moderate quality. -Interventions poorly described -Narrow review in terms of definition of included professions Future research: include these studies in formal systematic review
Outcomes: Patient functional and health status, hospital use, costs, death and disease. Mainly objective simple outcomes. Period: 1968-98
Zwarenstein et al (2001) Parameters
Design details
Key findings
Conclusions
Overview
Focus: Prelicensure interdisciplinary education
Study design: Design used as an inclusion criterion. CBA, ITS and RCT, CCT.
1042 on electronic search, 89 reviewed by hand, and 0 met criteria.
No reliable evidence available.
Does not contribute information for assessment of effectiveness.
Search strategy: EPOC, Medline, Cinahl, handsearching.
Participants: All health professions.
Methodological critique offered.
Researcher initiated systematic review, international
No studies found
Intervention: 2 or more disciplines learning together. More rigorous controlled intervention studies only. Outcomes: Patient functional and health status, hospital use, costs, death and disease. Mainly objective simple outcomes. Period: 1968-98
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Appendix 2-2 Search Strategy (From: Freeth D, Hammick M, Koppel I, Reeves S & Barr H (2002) A Critical Reviews of Evaluations of Interprofessional Education. LTSN, London).
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.
INTER-PROFESSION* or INTERPROFESSION* INTER-DISCIPLIN* or INTERDISCIPLIN* INTER-OCCUPATION* or INTEROCCUPATION* INTER-INSTITUTION* or INTERINSTITUTION* INTER-AGEN* or INTERAGEN* INTER-SECTOR* or INTERSECTOR*. INTER-DEPARTMENT* or INTERDEPARTMENT* INTER-ORGANIZATION* or INTERORGANIZATION* INTERPROFESSIONAL RELATIONS TEAM* 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 MULTI-PROFESSION* or MULTIPROFESSION* MULTI-DISCIPLIN* or MULTIDISCIPLIN* MULTI-INSTITUTION* or MULTIINSTITUTION* MULTI-OCCUPATION* or MULTIOCCUPATION* MULTI-AGEN* or MULTIAGEN* MULTI-SECTOR* or MULTISECTOR* MULTI-ORGANIZATION* or MULTIORGANIZATION* PROFESSIONAL-PATIENT RELATION* 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 11 or 20 EDUCATION* or TRAIN* or LEARN* or TEACH* or COURSE* QUALITY ASSURANCE or TQM or CQI or GUIDELINE DEVELOPMENT 22 or 23 21 and 24 STUDENT PERFORMANCE APPRAISAL COURSE EVALUATION PROGRAM* EVALUATION EVALUATION RESEARCH EVALUATION METHODS HEALTH CARE OUTCOME* SOCIAL CARE OUTCOME* EDUCATION* OUTCOME* LEARNING OUTCOME* 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 25 and 35
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Appendix 2-3 Systematic Review - 26 recent studies Study
Intervention
Study included?
A randomized clinical trial of outpatient geriatric evaluation and management Author: Boult, C., Boult, L. B., Morishita, L., Dowd, B., et al
Comprehensive assessment followed by interdisciplinary primary care. No specific intervention to encourage collaboration of team.
Yes
An evaluation of a system-change training model to improve emergency department response to battered women Author: Campbell, J. C., Coben, J. H., McLoughlin, E., et al
Team participated in 2 day didactic training and team planning exercise.
Yes
Practicing evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol: Chan, P. K., Fischer, S., Stewart, T. E., Hallett, D. C., Hynes-Gay, P., Lapinsky, S. et al
Multidisciplinary construction of a protocol for extubation.
No
The effects of a physician-nurse patient care team on patient satisfaction in an academic ED: Debehnke, D. and Decker, M. C.
Nurses and physicians were organized into Nurse/physician teams. No specific intervention to encourage collaboration of team.
No
Lake Superior Rural Cancer Care Project, part I: an interventional trial: Elliott, T. E., Elliott, B. A., Regal, R. R., Renier, C. M., Crouse, B. J., et al
Multimodal, multidisciplinary intervention that involved rural healthcare providers and their healthcare system. No specific intervention to encourage collaboration of team.
No
Can differences in management processes explain different outcomes between stroke unit and stroke-team care?: Evans, A., Perez, I., Harraf, F., Melbourn, A., Steadman, J., et al
Stroke unit. No specific intervention to encourage collaboration of team.
Yes
Impact of a pharmaceutical care model for non-institutionalized elderly: results of a randomized, controlled trial: Grymonpre, R. E., Williamson, D. A., and Montgomery, P. R.
A pharmacist conducted a comprehensive drug therapy review on test clients, then addressed issues with the client and/or the client's physician, with a follow-up as required. No specific two way collaboration intended. Information transfer.
Yes
Collaboration in maternity care: a randomized controlled trial comparing community-based continuity of care with standard hospital care: Homer, C. S., Davis, G. K., Brodie, P. M., et al
Community based care provided by midwife and obstetrician. No specific intervention to encourage collaboration of team.
No
Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network: Horbar, J. D., Rogowski, J., Plsek, P. E., et al
Six hospital teams worked with a facilitator on issues of infection, four on issues of chronic lung disease
No
60
Study
Intervention
Study included?
Fall and injury prevention in older people living in residential care facilities. A cluster randomized trial: Jensen, J., Lundin-Olsson, L., Nyberg, L., and Gustafson, Y.
11-week multidisciplinary program that included both general and resident-specific, tailored strategies. The strategies comprised educating staff, modifying the environment, implementing exercise programs, supplying and repairing aids, reviewing drug regimen.
No
A randomized comparison of processes of care between stroke unit and stroke team management: Kalra, L., Evans, A., Perez, I., et al
Stroke units. No specific intervention to encourage collaboration of team.
No
A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission: Kasper, E. K., Gerstenblith, G., Hefter, G., et al
The intervention team consisted of a cardiologist, a CHF nurse, a telephone nurse coordinator and the patient's primary physician. Contact with the patient was on a pre-specified schedule. No specific intervention to encourage collaboration of team.
Yes
Randomized controlled trial assessing the impact of increasing information to health visitors about children's injuries: Kendrick, D., Pritchard, A., Cloke, J., and Barley, M.
Different information transfer patterns between hospital and community based public health nurse: full info versus selected info (diagnosis, circumstances surrounding injury, and disposal)
No
From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children: Margolis, P. A., Stevens, R., Bordley, W. C., et al
Multifaceted intervention, including clinical practice change, policy change, staff support, etc. No specific intervention to encourage collaboration of team.
No
Descriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinson's disease at nursing homes in southern Sweden: Midlov, P., Bondesson, A., Ericksson, T., et al
A multi-specialty group consisting of pharmacists, a primary care physician, a neurologist, a neuropsychiatrist and a clinical pharmacologist evaluated the patients' medication and, when appropriate, suggested changes. No specific intervention to encourage collaboration of team.
No
Reducing medication regimen complexity: a controlled trial: Muir, A. J., Sanders, L. L., Wilkinson, W. E., and Schmader, K.
For intervention patients, a medication grid was created that displayed all of the patients' medicines and the times of administration for 1 week. This grid was delivered to the admitting resident soon after admission. Information transfer intervention.
Yes
Interdisciplinary inpatient care for elderly people with hip fracture: a randomized controlled trial: Naglie, G., Tansey, C., Kirkland, J. L., Ogilvie-Harris, D. J., Detsky, A. S., Etchells, E., et al
Interdisciplinary rounds to discuss each patient twice weekly. No specific intervention to encourage collaboration of team.
Yes
Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia: Naughton, B. J., Mylotte, J. M., Ramadan, F., Karuza, J., and Priore, R. L.
Multifaceted educational intervention aimed at nurses and physicians in intervention group, aimed at physicians only in control period. No specific intervention to encourage collaboration of team.
Yes
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Study
Intervention
Study included?
Economic implications of neonatal intensive care unit collaborative quality improvement: Rogowski, J. A., Horbar, J. D., Plsek, P. E., et al
Multidisciplinary teams doing collaborative quality improvement, reviewing performance data, developing shared goals, designing improvements to their practices.
Yes
Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming: Rost, K., Nutting, P., Smith, J., Werner, J., and Duan, N.
Two primary care physicians, one nurse, and one administrative staff member in each intervention practice received brief training to improve the detection and management of major depression. No specific intervention to encourage collaboration of team.
Yes
Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit (GEMU). A prospective randomized trial: Saltvedt, I., Mo, E. S., Fayers, P., Kaasa, S., and Sletvold, O.
GEMU, the treatment strategy emphasized interdisciplinary assessment of all relevant disorders, prevention of complications and iatrogenic conditions, early mobilization/rehabilitation, and comprehensive discharge planning. No specific intervention to encourage collaboration of team members.
Yes
Linking alcohol- and drug-dependent adults to primary medical care: a randomized controlled trial of a multidisciplinary health intervention in a detoxification unit: Samet, J. H., Larson, M. J., Horton, N. J., Doyle, K., Winter, M., and Saitz, R.
Multidisciplinary clinic in which patients were explicitly referred to ongoing primary care provider. No contact between referring and receiving care providers.
No
Effect of a clinical practice improvement intervention on Chlamydia screening among adolescent girls: Shafer, M. A., Tebb, K. P., Pantell, R. H., Wibbelsman, C. J., et al
Audit and feedback, barrier identification, team building and meetings, iterative approach.
Yes
Cluster randomized controlled trial of an educational outreach visit to improve influenza and pneumococcal immunization rates in primary care: Siriwardena, A. N., Rashid, A., Johnson, M. R., et al.
Academic detailing to team in each practice to promote immunization, combined with audit and feedback. Control group received audit and feedback only. No specific intervention to encourage collaboration of team members.
Yes
Relative cost-effectiveness of extensive and light multidisciplinary treatment programs versus treatment as usual for patients with chronic low back pain on long-term sick leave: randomized controlled study: Skouen, J. S., Grasdal, A. L., Haldorsen,
Light multidisciplinary versus intensive multidisciplinary rehabilitation versus general practitioner care with referral as needed. No specific intervention to encourage collaboration of team members.
No
A CQI intervention to change the care of depression: a controlled study: Solberg, L. I., Fischer, L. R., Wei, et al
CQI intervention in which participants from intervention clinics developed an approach to depression care.
Yes
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Chapter Three Key Elements of Collaborative Practive & Frameworks: Conceptual Basis for Interdisciplinary Practice By Danielle D’Amour, Marie-Dominique Beaulieu, Leticia San Martin Rodriguez & Marcela Ferrada-Videla
Introduction This chapter aims at reviewing the state-of-the-art knowledge on the concept of interprofessional collaboration and on collaborative practices described in the literature. To that end, four elements have been brought out to be taken into consideration: the various definitions proposed in the literature and the various concepts associated with collaboration are first reviewed; the various theoretical frameworks surrounding the concept of collaboration; the determinants that foster collaborative practices and strengthen them are then discussed; and the policy levers needed to support collaborative practices. As shown in Figure 1, the environment in which collaborative practice takes place is influenced by education, research and macrostructural determinants. In a professional practice setting, two levels of determinants are at work: the organization (meso-structural) and the team (microstructural). The collaboration dynamics is influenced by all the above determinants. The combined influence of multi-level factors makes collaboration a most complex phenomenon. A collaboration model must therefore take into account structural, professional and personal components but also the processes of collaboration. This chapter is divided into five sections describing respectively: 1. 2. 3. 4. 5.
literature review strategy definitions and concepts surrounding collaboration theoretical models collaboration determinants policy levers in collaboration projects
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Figure 1 - Framework of Interdisciplinary Education for Collaborative Patient-Centred Practice (IECPCP) EDUCATIONAL ENVIRONNEMENT
WORKPLACE PRACTICE
ORGANIZATIONAL FACTORS (MESO)
ORGANIZATIONAL FACTORS (MESO)
PROGRAMME / FACULTY FACTORS (MICRO)
FORMALIZATION
Disciplinary Factors
TEAM FACTORS (MICRO)
FINALIZATION • Ends
• Existence agreements
• Allegiances
• Inf. infrastructure
OUTCOMES
Academicians • • • •
IECPCP
Students Academicians Organization System
• Leadership
• Trust
• Connectivity/ discussion
Personal Factors
• Mutual acquaintance
GOVERNANCE
Research - Development of appropriate research strategies - Knowledge dissemination
INTERNALIZATION
HEALTH CARE INTERVENTIONS
OUTCOMES • • • •
Patient Professional Organization System
ENVIRONMENTAL FACTORS (MACRO) cultural system, social system (politic and economic), professional system, educational system
D’Amour, SanMartín-Rodríguez, Ferrada-Videla, Beaulieu, 2003
The literature review focussed on research and experiments related to collaborative care in various care settings including acute, rehabilitation and primary care services. It must however be stressed that the organizational structures are different in each of these sectors and, furthermore, that they vary between provinces and territories. For instance, in acute care, program-driven management is widespread in some provinces whereas traditional professiondriven management remains the rule in others. The same is true in primary care, some provinces having merged different professional groups under a common management while others still recognize traditional professional management. Thus, collaborative care experiments in Canada have been found to nest in a wide spectrum of structural settings depending on the type of care and the geographic location. More will be said below about literature findings about the impact of such structures on collaborative care. Yet, one element clearly stands out beyond any variation in the type of health care or geographical location: finding better ways to work together is a major challenge for every institution and every health care professional.
1. Literature review strategy The following databases were searched for the 1990-2003 period: Medline, CINHAL, Sociological Abstracts, PsycINFO and ProQuest. The search keywords are listed in Appendix 1. A total of 588 papers were pre-selected as a result of that first screening (Table 1). Table 1: Count of relevant papers in the searched databases Database
Papers
Medline & CINHAL
511
Sociological Abstracts
10
PsycINFO
37
ProQuest
30
TOTAL
588
The abstracts of these 588 papers were then analysed by three independent readers. For a paper to be selected, collaborative practice had to be its main topic. This resulted in eighty (80) papers being retained for further screening. A screening grid was applied to each of the 80 articles by two independent reviewers. The screening criteria helped identify the overall setting in which collaborative care took place (type of team, number of professionals involved, type of professions represented, and field of practice), the methodology, the conceptual framework and its importance, and explanatory variables. That second screening resulted in 27 papers being selected for the quality of the methodology they followed, 17 of which dealt with collaborative care definitions and determinants and 10 with collaborative care models. To these 17 papers, 26 more were added that dealt with randomized trials to assess the outcome of collaborative care. In general, these 26 extra papers did not improve our understanding of collaborative care models or of explanatory variables 65
because collaborative care was poorly, if at all, conceptualized, and no data was given about the implementation of collaborative practice. In order to identify the policy levers used to support collaborative care, three review reports on the projects of the Health Transition Fund (HTF) and the taxonomy of primary care models published by Lamarche, Beaulieu, Pineault, et al. (2003) were reviewed.
2. Collaboration – Definitions and Concepts Collaboration deals with the type of relations and interactions taking place between coworkers. The concept of “team” describes the human context in which collaboration takes place. Thus, these two concepts are explored below. 2.1 Definitions of collaboration A first level of definition of collaboration focuses on related concepts, among which the most commonly used are: sharing, partnership, interdependency and power. Collaboration definitions have thus been sorted according to these keywords in order to outline the complexity of that concept. Collaboration is also defined as a dynamic process. Sharing is a concept used by most authors. Some speak of shared responsibilities (Arcangelo, 1994; Arslanian-Engoren, 1995; Baggs & Schmitt, 1988; Cowan & Tviet, 1994; Henneman et al., 1995; Henneman, 1995; Liedtka & Whitten, 1998; Lindeke & Block, 1998; Pike et al., 1993), others of shared decision-making (Baggs & Schmitt, 1988; D’Amour, 1997; Liedtka & Whitten, 1998), others of shared health care philosophy (King 1990), values (Clark, 1997; Henneman, 1995), data (D’Amour, 1997; Ivey, Brown, Teske & Silverman, 1987), planning and intervention (Baggs & Schmitt, 1988; Lindeke & Block, 1998) and, finally, some authors focus on the sharing of different professional perspectives (Walsh, Bradeck & Howard, 1999). All these facets of sharing can be at work in a collaborative undertaking. Second to sharing, the notion of partnership implies that two or more actors join in a collaborative undertaking (Wylie, 1994; Sullivan, 1998) characterized by a collegial-like relationship (Arslanian-Engoren, 1995; Henneman, 1995, King, 1990; Pike et al., 1993), authentic and constructive (Hanson et al., 2000). Such a relationship demands an open and honest communication (Stichler 1995), mutual trust and respect (Alpert et al., 1992; Pike et al., 1993; Siegler & Whitney, 1994). Each partner must also be aware of and value the work and perspectives of the other professionals (Coluccio & Maguire, 1983; Stichler, 1995; Walsh, Bradeck & Howard, 1999). Finally, partnership implies that the partners pursue a common goal (Baggs & Schmitt, 1988; Cowan & Tviet, 1994; Henneman, 1995; Lindeke & Block, 1998; Pike et al., 1993; Stichler, 1995), a set of shared goals (American Nurses Association 1989) or specific outcomes (Hanson et al., 2000). Interdependency, our third concept, implies a mutual dependency (Le Nouveau Petit Robert, 2000). In this context, professionals are like actors depending on one another (D’Amour, 1997; Fagin, 1992; Liedtka & Whitten; 1998). Thus, collaboration requires that professionals be
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interdependent rather than autonomous (Evans, 1994; Pike et al., 1993) and their interdependency arises from a common desire to fulfill the patient's needs. When the team members become aware of such interdependency, synergy takes place (Morin 1997) and their individual contribution is maximized; the output of the whole becomes much larger than the sum of the inputs of the parts (Alpert et al., 1992; Evans, 1994; Henry et al., 1992; Pike et al., 1993). Such interdependency should eventually lead to collective action (D’Amour 1997). The fourth concept is that of power, considered as shared between team members. Several authors see collaboration as a true partnership characterized by a simultaneous empowerment of each participant whose power is recognized by all (Cowan & Tviet, 1994; Stichler, 1995; Sullivan; 1998). Furthermore, such power is based on knowledge and experience rather than on functions or titles (Henneman, 1995; Henneman et al., 1995; Mundinger, 1994; Stichler, 1995). Besides such concepts, collaboration is also recognized as a process in motion. Various authors see collaboration as a dynamic or interactive process (Hanson et al., 2000; Stichler, 1995; Sullivan, 1998), a transforming process (Sullivan, 1998), an interpersonal process (Hanson et al., 2000; Henneman, 1995) or as the structuring of a collective intervention (D’Amour et al., 1999). The collaborative process may undergo very concrete steps such as: negotiation and compromise in decision-making (Liedtka et Whitten, 1998), or shared planning and intervention (Lindeke & Block, 1998). For that reason, the collaborative process requires that professional boundaries be transcended to allow each participant to contribute to improving client care while still taking in due consideration the qualities and skills of each professional (Henry, Schmitz, Reif & Rudie, 1992; Liedtka, 1998). 2.2 The concept of team Teamwork has become a sine qua non condition for effective practice in health care related institutions. Indeed, collaboration is a must to ensure quality health care and teamwork is the main setting in which patient-centred care can be provided (King, 1990; Warner, Ford-Gilboe, Laforet-Fliesser, Olson, & Ward-Griffin, 1994). One of the first observations made during the literature review was that the various definitions found in published papers use a variety of terms to qualify teams and the interactions that take place in team environments. The most frequent qualifiers used for a team are: multidisciplinary, interdisciplinary, and transdisciplinary (Ducanis & Golin, 1979; Golin & Ducanis, 1981; Guyonnet & Adam, 1992; Klein, 1990; Mariano, 1989; Ivey et al., 1987). Furthermore, some authors use "professional" as a suffix like in multiprofessional, interprofessional, transprofessional, when they refer to the practice instead of using the suffix "discipline" that would imply the acquisition of a body of knowledge based on theory and research (Golin & Ducanis, 1981; D’Amour, 1997; Satin, 1994). One cannot but conclude that such terms are rarely defined with clarity by those who use them and that they are interchangeable in practice (Faulkner & Amodeo, 1999; Ivey et al., 1987; Satin, 1994). On the other hand, most of the time, these various terms convey different degrees of collaboration within a team. According to Brill (1976), Ivey et al, (1987) and Satin (1994), collaboration within a team can be described on a continuum of professional autonomy. At one
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end of the spectrum, professionals intervene on an autonomous or parallel basis, thus creating de facto a parallel practice (Satin, 1994). At the other end of the spectrum, professionals have a narrower margin of autonomy but the team as a whole is more autonomous and its members are better integrated (Yvey et al., 1987; Satin, 1994). The concept of transdisciplinarity is more recent (Paul & Peterson, 2001; Stephan, Thompson & Buchanan, 2002). These different varieties of teamwork are examined in more detail below. Multidisciplinarity refers to situations where several participants representing several disciplines (Siegler & Whitnay, 1994) work on the same project but independently or in parallel (Faulkner & Amodeo, 1999; Paul & Peterson, 2001; Satin, 1994). In essence, multidisciplinarity evokes the juxtaposition of various disciplines and competencies (Klein, 1990; Guyonnet & Adam, 1992; Satin, 1994) interacting on a limited and transient basis (Guyonnet & Adam, 1992; Klein, 1990). Although they do not necessarily meet, the members of a multidisciplinary team manage to work in a coordinated fashion (Ivey et al., 1987; Satin, 1994). Interdisciplinarity implies a deeper degree of collaboration between team members (Baggs & Schmitt, 1988; Ducanis & Golin, 1979; Golin & Ducanis, 1981; Klein, 1990; Lindeke & Block, 1998; Satin, 1994; Siegler & Whitnay, 1994). According to Berthelot (1999) and Satin (1994), interdisciplinarity involves an effort to integrate and translate, at least to some degree, themes and schemes shared by several disciplines. To that extent, the prefix "inter" does not only refer to a plurality or juxtaposition, but to a common space, an element of cohesion, a shared ownership (Gusdorf, 1990). The interdisciplinary team is a structured entity with a common goal and a common decision-making process (Ludwig, 1988; Mariano, 1989; Wells et al., 1998). Thus, interdisciplinarity is based on the integration of the knowledge and expertise of each professional in order to propose solutions to complex problems (Ducanis & Golin, 1979; Ivey et al., 1987; Klein, 1990; Paul & Peterson, 2001) in a flexible and open-minded way (Satin, 1994). One of the major challenges facing interprofessional practice is the carving of professional territories distributed in a complex system and with boundaries as tightly sealed as possible. Lead into interdependency to fulfill the clients' needs, members of interdisciplinary teams open these territorial boundaries to provide more flexibility in the sharing of professional responsibilities (D’Amour et al., 1999; Paicheler, 1995). Lastly, transdisciplinarity refers to a type of professional practice in which consensus-seeking and the opening of professional territories play a major role. As a result, boundaries become more blurry and vanish (Paul & Peterson, 2001; Stepans, Thompson & Buchanan, 2002). Transdisciplinarity is characterized by a deliberate exchange of information, knowledge, skills and expertise that transcend traditional discipline boundaries (Stepans, Thompson & Buchanan, 2002). 2.3 Focus on the client Golin & Ducanis (1981) stresses that the client is one of the main components of a professional team. The opinion that clients who participate in the decision-making process have more positive outcomes is held by several authors (Hinojosa, Bedell, Buchholz, Charles, Shigaki & Bicchieri, 2001; Morrison, 1996; McLeod & Nelson 2000; Walker & Dewar, 2001). Also, associating the client with the interprofessional health care team minimizes professional
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paternalism (Clark, 1995; 1997; Lindeke & Block, 1997) and tends to replace traditional methods of intervention (Walsh et al., 1999). D’Amour (1997) observes that clients can act as external entities or as third-party guarantors to whom the responsibility of coordinating interprofessional work is delegated. Drinka and Clark (2000) state that it is unrealistic to expect that clients could fully participate in the various aspects of health care on the same footing as the other members of the team. The question of finding an optimal way to involve the patient to achieve a collaborative patientcentred practice is not theoretical. As a matter of fact, although all teams and all collaborative undertakings have, in principle, the patient at the centre of their concerns, some data suggests that patients may remain unaware of the collaborative practice and see the team as a source of division and a barrier between them and a specific professional. As a matter of fact, in a recent literature survey on the impact of various primary care organization models, Lamarche et al. (2003) have observed that community models, which, among other specific features, rely on multidisciplinary professional teams operating in well-structured health institutions, have poorer outcomes than professional models in terms of accessibility and responsiveness. They offer as a possible explanation that “community models may favour a patient-institution relationship whereas professional models favour a more personal relationship between patient and physician” (Lamarche et al., op cit, p14). Safran (2003) comes to the same conclusion in a survey of the evolution of patients’ perception of primary care accessibility, continuity and coordination in the U.S. She suggests that American patients are accustomed to “invisible team care” and that one of the main challenges in the primary care sector will be to switch to “visible team care”.
3. Theoretical Frameworks of Collaboration In this review paper, a theoretical framework is defined as a set of relationships between various concepts. A theoretical framework must rely on a proven body of knowledge. Beside the theoretical frameworks, some theoretical propositions have also been analysed for their potential to help renewing the way collaboration is perceived, by asking, in particular, whether such propositions create extra value and could therefore foster changes or progress in our current reflection about collaboration and collaborative practices. That way of thinking has guided the literature review and made us decide to exclude all papers dealing with disease management such as the systematic follow-up of clients with diabetes and to eliminate all the articles in which a mere identification of the collaborating partners was provided. Such articles offer no theoretical concept of collaboration. 3.1 The selected models 3.1.1 Model evaluation criteria Three criteria were used to assess the collaboration models proposed in the literature: 1) their relying on empirical data collected by researchers; 2) their explicit strategy of reviewing literature; and 3) their reliance on an explicit theory.
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Using these criteria, the reviewed papers were sorted in three groups: ++ : mpirical data or explicit strategy of reviewing literature and explicit theory. + : empirical data or explicit strategy of reviewing literature or explicit theory. 0 : no empirical data, no explicit strategy of reviewing literature, no explicit theory. Seven models were selected using the above grid. They are listed in Table 2 along with their estimated robustness and their taking into account the collaboration structures and processes. Table 2: Selected models AUTHORS
MODEL TYPE
STRENGTH
West, Borrill, Unsworth, 1998
Structure & process ++
Sicotte, D’Amour & Moreault, 2003
Structure & process ++
D’Amour, 1997 D’Amour et al, 1999 D’Amour et al, 2003
Structure & process ++ Structure & process
Gitlin, Lyons & Kolodner, 1994
Process
+
Hayward, DeMarco & Lynch, 2000
Process
+
Corser, 1998 Miller, 1997
Structure & process + Process +
Three models are based on empirical data and on an explicit theory, two of them on an explicit theory and two on empirical data. The models are presented according to their theoretical origin. Two of them come from organizational theory: West, Borrill & Unsworth (1998) and Sicotte, D’Amour & Moreault (2003). One is based on the sociology of organizations (D’Amour, 1997; D’Amour et al. 1999; 2003) and another on social exchange theory (Gitlin, Lyons & Kolodner, 1994). Some authors have added the concept of alliance to the latter to create a new model (Hayward, DeMarco & Lynch, 2000). Two empirical models are also presented: Corser (1998) and Miller (1997). 3.1.2 Collaboration models and organizational theory Several studies in organizational theory have developed working group and team efficiency models. Two research teams have used such models to develop interprofessional collaboration models in health care. They are West, Borrill & Unsworth (1998) and Sicotte, D’Amour & Moreault, (2003). West, Borrill & Unsworth (1998) have reviewed the literature on group effectiveness and proposed a model, which takes into account the inputs related to the task, the group composition, the cultural context and the organizational context. The model also includes variables related to the processes in relation to effectiveness for example leadership, communication, and decisionmaking. Lastly the outputs are stated as performance, innovation, well-being and viability (Figure 2). This model has been used by the Aston Centre for Health Organization Research 70
(2002) to study many NHS organizations. The objectives were to identify conditions conducive to efficient team work and to assess the impact on the quality of health care and welfare. This model has also been used to evaluate the effectiveness of cancer teams (Haward, Amir, Borrill et al. (2003). Figure 2: Input, process and output model of team effectiveness (West, Borrill & Unsworth, 1998)
A second research team, Sicotte, D’Amour and Moreault (2003), has also used group effectiveness models, more precisely the model proposed by Gladstein (1984), and conducted a surveyed of the 146 CLSC’s in Quebec. In their model, the inputs are the contextual variables more specifically the characteristics of the managers and the structural characteristics of the program. The intragroup processes are particularly taken into consideration such as the beliefs in collaboration, the social integration, the level of conflicts, and the conflicting logics. The nature of the task is acting as an important mediating variable. The results are analysed in terms of the intensity of collaboration through the degree of interdisciplinary coordination and the degree of sharing of activities. The main results show that interprofessional collaboration depends on conflicting factors, thus underlining the complexity of professional allegiances. Conflicting beliefs and values are at work that foster collaboration and constrain it at the same time. Another key result is the demonstration of the importance of formalization for collaboration. The benefits of formalization appear to be related to its capacity to offer an articulated frame of interprofessional work.
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Figure 3: Analytical framework of interdisciplinary collaboration (Sicotte, D’Amour & Moreault, (2003)
3.1.3 Collaboration and sociology of organizations The research conducted by D’Amour (1997), D’Amour, Sicotte & Lévy (1999) and D’Amour, Goulet, Pineault et al. (2003) stems from the strategic analysis of Crozier & Friedberg (1977) and the organizational analysis of Friedberg (1993). D’Amour (1997) uses Friedberg’s approach to develop a model of interprofessional collaboration. Friedberg considers the organization as a local system of action resulting from the inter-structuring of a set of rules (formalization) and with the world of human relationships (actors’ strategy). The model developed by D’Amour (1997) has been verified with data from several case studies to understand interprofessional and interorganizational collaboration (Daigle, 2000; D’Amour et al. 2000, Echaquan, 2003; Ferrada, 2002) (Figure 4). D’Amour’s model divides the process of collaboration into four components: 1) finalization refers to the existence of common goals and their appropriation by the team; the recognition of divergent motives and of multiple allegiances; and the diversity of definitions and expectations regarding collaboration; 2) interiorization refers to the awareness by professionals of their interdependency and of the importance of managing it; it translates into a mutual knowledge of the values and disciplinary framework; in a trusting relationship, and in a consensus on responsibilities sharing; 3) formalization is analysed in terms of rules meant to regulate the action by strengthening structures; and
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4) delegation deals with governance, and more specifically with centrality, leadership, expertise and connectivity. Figure 4: Structuration model of interprofessional collaboration (D’Amour, 1997; D’Amour, Sicotte & Lévy, 1999.
Delegation of authority Centrality Leadership Expertise Connectivity/discussion
Formalization Existence of an agreement Information infrastructure
Finalization Ends Allegiances
Internalization of IC Mutual acquaintanceship Trust
Drawing from the model and from numerous case studies, a typology was developed that recognizes three types of collaboration: collaboration in action, collaboration in construction and collaboration in inertia (D’Amour et al., 2003). Ten variables were selected to perform an analysis of the above three types. This work can be applied to diagnose the type of collaboration in a given group and to investigate departures from expectations. D’Amour et al. (2003) insert this model into a larger model of interorganizational collaboration (Figure 5) to analyse collaboration between professionals from different organizations in perinatal care.
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Figure 5 : D’Amour, Goulet, Pineault et al. (2003)
Organizational model for the analysis of professional collaboration Satisfaction of professionals Feeling of solidarity Network characteristics Structuration processes of collaboration
- History - Size - Centrality - Complexity - Connectivity
Formalization
Finalization
Délégation
Intériorization
Organization characteristics - Number of clients - Quantity of resources - Modes of delivery of care - On-the-job training
Professionals practices
Quality of services - Continuity - Accessibility - Appropriateness
Political and economic environment
3.1.4
Collaboration and social exchange theory
Gitlin, Lyons & Kolodner (1994) use social exchange theory to analyse collaboration. The basic assumption of that theory is that social structures can be understood by analysing the interpersonal transactions that take place. Understanding interactions is therefore the key to understanding complex social behaviours between groups. The two basic concepts of that theory are exchange and negotiation. The underlying principle is that people join a group because it provides them a specific benefit and that, in return, individuals within a group must help the group reach its objectives: this is where the exchange takes place. The negotiation process stems from the proposal of expertise to the group by an individual who, in return, expects some benefits. Individuals and groups are thus constantly engaged in a negotiation to try to optimize the benefits, to reduce the costs, and to move forward under conditions of fairness to all. Gitlin et al. (1994) expand that theory into a four parameter model: exchange, negotiation, trustworthiness and differentiation of contributions. Their model suggests an intervention in 5 steps: 1) assessment and research of a consensus regarding common objectives that take into account personal as well as institutional goals for all the team members and assessment
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of the pertinence of a collaboration; 2) assessment of the correlation between the above elements and negotiation of a possible collaborative effort once mutual trust is established; 3) resource identification and reflection; individuals go back to their group to assess the resources needed for the collaborative effort and the benefits of participating; 4) refinement and implementation, this is the stage where suggestions are put forward and the individual contributions differentiated; 5) evaluation and feedback (Figure 6). This model explains the how and the why behind any step toward a culture that is supportive of collaboration Figure 6: Five-stage model of collaboration (Gitlin et al. 1994)
Hayward, DeMarco & Lynch (2000) started from the work of Gitlin and the work of DeMarco, Horowitz & McLeod (2000) to propose a framework entitled Interprofessional Alliance Model ( Figure 7). Their model achieves a theoretical merge of two models, that of Gitlin and another by DeMarco on the concept of alliance. The former deals with iterative processes in a collaborative setting and the latter with interpersonal factors at play during an interaction. However, this model has not been field tested.
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Figure 7: Interprofessional Alliance Model (Hayward, De Marco, Lynch, 2000)
3.1.5 Two other bi-disciplinary models Two bi-disciplinary models have been developed, both based on empirical data. Corser (1998) proposes a collaboration framework between physicians and nurses based on a literature review on collaboration between nurses and physicians (Figure 8). The framework developed by Corser takes into consideration the personal and organizational influences on collaboration. According to Corser, such collaboration requires an even distribution of power between physicians and nurses. Collaboration has an impact on the patients’ outcomes and on the professionals. This empirical framework has not been validated.
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Figure 8: Conceptual Model of Collaborative Nurse-Physician Interactions (Corser, 1998)
Miller (1997) conducted a qualitative research through interviews with 17 midwives and 5 physicians. The author describes the collaboration cycle between the midwives, the physicians and the clients. She stresses the importance of developing a trust-based relationship and of conducting trust incentive activities that should be part of professional education. “Developing mission statements for philosophical congruence, educating each profession on the capabilities and roles of the other, and fostering an understanding of their own and each other’s expectations can become as necessary as a part of practice formation as obtaining a license” (p. 307). (Figure 8)
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Figure 9: Miller, 1997
3.2 Other theoretical assumptions Beside the above models, a few theoretical assumptions have been selected because of their potential contribution to a reflection on collaboration and teamwork. 3.2.1 The work of Koff, DeFriese & Witzke (1994) and the Loosely Coupled Systems Theory of Weick (1976) Koff, DeFriese & Witzke (1994) apply loosely coupled systems theory to interdisciplinary education. They state that loosely coupled systems theory is suitable because each discipline has its own philosophy, methodology, rules and values, and that the blending of various professional perspectives is difficult. That observation leads to the assumption that the various professional groups within a given institution are loosely coupled. In 1976, Weick did propose a theory of loosely coupled systems, defined as structures in which the links between various components are relatively “soft”. On that basis, one can assess the strength of the bonds between the various components of an organization as well as analyse and understand each organization on the basis of the cohesion between its components. According to Koff, DeFriese & Witzke (1994), loosely coupled system theory explains how systems that seem to be in opposition and conflictual can survive and even bloom. According to these researchers, loosely coupled systems theory is useful to understand interprofessional collaboration as well as education leading to it, and reassures us on the viability of such systems not only despite the loose linkage between professionals but because of it. Planners and managers should understand that interprofessional collaboration is not the outcome of easily integrated activities.
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3.2.2 The work of Clark based on Schön’s reflective practitioner (1983) According to Clark (1994), the capacity of professionals to practice in a multidisciplinary environment depends primarily upon their ability to understand and to respect cognitive patterns i.e. the way in which others conceptualize problems and interventions as well as the values of every profession. Building upon research in sociology of professions, and especially on studies of the socialization process during professional education, Clark shows that professionals develop different cognitive patterns and values that can hinder their capacity to collaborate. He stresses the importance of explicit training to allow professionals to understand what he call the “cognitive maps” and “value maps” of others. To succeed, practitioners must master the skills that allow them to become “reflective practitioners”, according to a concept developed by Schön (1983). The reflective practitioner is not only able to integrate his own personal experience to his theoretical knowledge in order to build professional knowledge, but he can also relate to another professional and contribute to a continuum of clinical investigation in full recognition of the specific expertise of his partners. He is also able to integrate his knowledge to that of other professionals. The adoption of such a framework requires important changes in professional’s values, attitudes and practice. The author also raises the issue of choosing the proper timing to expose students to interprofessional practice: students must first develop a professional identity strong enough to represent their discipline but flexible enough not to resist collaborative practice. What about already established professionals, may one ask? Clark also addresses the issue of resocialization at the workplace and stresses the importance of providing a work environment that fosters collaborative practice. 3.2.3 Drinka’s research on group developmental stages Drinka (1994) extends literature findings on team developmental stages, where groups are understood as transitory entities, and applies them to the developmental stages of health care teams. Drinka’s research is based on conflict and problem resolution models and explores 5 stages: 1) team development (forming); 2) norms and pattern development (norming); 3) confrontation of team members (confronting); 4) team performance (performing) and 5) team dissolution (leaving). Confrontation and conflict are two important components of this model of team evolution through conflict resolution.
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3.3 Pros and cons of the models The proposed models are based on a body of knowledge that helps us grasp the described phenomena. In summary, the most thorough models have the following characteristics: • • • • •
The most complete models seem to be those which are based on a strong theoretical background either in organizational theory or in organizational sociology; Such models take into account both the structural and process dimensions of collaboration and their correlation; They recognize several structural levels (i.e. macro and meso); They lead to a process theory that sheds light on behaviours in collaborative practice; They rely on empirical data;
However, the above models were not sufficiently tested. They assume that collaborative practice has an impact on patient outcomes, a yet unproven assumption. The strengths of the relations between the various model components have also not been proven. We believe that other theoretical frameworks like on policy-making and other organizational and sociological theories could be explored to support a broadened conceptualization of such a complex phenomenon.
4. Collaboration Determinants Collaboration determinants can be defined as key elements in the development and subsequent strengthening of collaboration within health care teams. As shown in the framework that guides this literature review, such determinants are macro-factors arising from conditions outside the organization as well as factors resulting from conditions in the midst of the organization “mesofactors” and micro-factors that depend on the interpersonal relationships between team members. A literature review on collaboration determinants has shown that a vast majority of the published work relies on a conceptual approach rather than on empirical data. To our knowledge, very few researches have investigated the influence of macrostructural, organizational or interactional determinants on interprofessional collaboration. In the following sections, the main characteristics of interprofessional collaboration determinants are explored. For each of the categories, macrostructural, organizational and interactional, we propose: 1) a tabulated compilation of the determinants identified by empirical research and 2) the main characteristics of these determinants as found in conceptual work.
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4.1 Macrostructural determinants Macrostructural determinants are elements outside the organization, such as components of the social, cultural, educational and professional systems. Table 3 presents the research that has explored the links between macrostructural determinants and collaboration or its outcomes. Table 3: Results of empirical studies: macrostructural determinants of interprofessional collaboration Social System Arslanian-Engoren, 1995 (Phenomenology) Baggs & Schmitt, 1997 (Grounded theory) D’Amour, 1997 (Case study, Grounded theory) Hojat et al.,2001 (Comparative study) Silén-Lipponen et al., 2002 (Phenomenological study) Sicotte et al., 2002 (Correlational study)
Cultural System
Professional System
Educational System
collegiality (+) power differences (-)
awareness and valorization of other professionals’ contribution (+) Fragmentation of care along professional jurisdictions (-) Different perspectives on collaboration (-) Awareness of other professionals contribution (+) Adhesion to professional logics (-) Adhesion to collaboration logics (+)
(+) : fosters interprofessional collaboration (-) : hinders interprofessional collaboration
4.1.1 The social system The authors believe that the power differences between professionals within a given team that hamper collaborative practice have their origin in social factors. Indeed, equality between professionals, one of the conditions that foster collaboration (Evans, 1994; Henneman et al., 1995; King, 1990; Pike at al., 1993), is hindered by power differences arising from stereotypes like those surrounding gender, and by differences in the social background of the various professionals. Power differences constitute an important barrier to interprofessional collaboration (Bradford, 1989; Krebs, Myers, Decker, Kinzler, Asfahani & Jackson, 1996; Fagin, 1992; Hanson et al., 2000; Henneman et al., 1995; Lindeke & Block, 1998; Lockhart-Wood, 2000; Mariano, 1989; Pike et al., 1993; Reese & Sontang, 2001; Sweet & Norman, 1995; Walsh et al., 1999). 4.1.2 The cultural system Specific cultural values may also have an impact on the development of collaboration between professionals. According to Gage (1998) and Mariano (1989), some cultures may harbour deep cultural values which run directly against the spirit of collaboration. For instance, a strong cultural affinity for autonomy will foster and support individualism and specialization within health care teams rather than collaborative practice (Mariano, 1989).
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4.1.3
The professional system
The professional system has a strong influence on the development of collaborative practice because it promotes a perspective that is the opposite of the rationale for collaboration (D’Amour, 1997; D’Amour et al., 1999). As a matter of fact, the process of professionalization is characterized by domination, autonomy and control, rather than by collegiality and trust (Freidson, 1986). Therefore, whereas the development of collaborative practice depends on the mutual recognition by professionals of their interdependence as well as the acceptation of “grey zones” where their respective contributions may overlap, (D’Amour, 2001; Henneman et al., 1995; Hanson et al., 2000; Mariano, 1989; Stichler, 1995), the professionalization dynamics lead to the differentiation of professionals and to territorial behaviours within the team (D’Amour, 1997; D’Amour et al., 1999). Furthermore, health professionals are immersed, during their entire professional socialization phase, in philosophies, values and basic theoretical perspectives inherent to each profession (Clark, 1995; 1997). Such differences between the various professionals are potential sources of conflict and hinder the development of a true collaborative practice (Clark, 1995; 1997; Fagin, 1992; Hanson et al., 2000; Lindeke & Block, 1998; Mariano, 1998; Reese & Sontag, 2001; Walsh et al., 1999). On that front, Clark (1995; 1997) proposes new conceptual models of clinical practice that are client-centred and based of the concept of “reflective practitioner”. The development of a reflective practice among professionals fosters the understanding of the differences between the team professionals (Clark, 1995; 1997; McKee, 2003). 4.1.4
The educational system
The literature presents the educational system as one of the main determinants of interprofessional collaborative practice, because it is the main lever of collaborative values promotion among future health care professionals. Traditionally, candidates to health related professions are being socialized with strong professional identification within the boundaries of their respective professions (Ivey et al, 1987; Walsh et al., 1999; Reese & Sontag, 2001). Such socialization maintains a very limited knowledge of other professionals in the team. Members of each discipline know very little of the practices, expertise, responsibilities, skills, values and theoretical perspectives of professionals in other disciplines. This is considered as one of the main obstacles to collaborative practice in health care teams (Alpert et al., 1992; Bradford, 1989; Fagin, 1992; Hanson et al., 2000; Mariano, 1998; Reese & Sontag, 2001; Stanley & Peterson, 2001). According to Glen (1999), there is a need for an educational system that helps students to recognize the values and responsibilities of their own profession while teaching them professional plurality. To that effect, several authors stress the need for interdisciplinary education curricula (Fagin, 1992; Johnson, 1992; Lindeke & Block, 1998; MacIntosh & McCormack, 2001; Mariano, 1989; Satin, 1994; Walsh et al., 1999). Such educational programs will help students value professional pluralism, awareness, sharing and integration of their knowledge and practices.
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4.2 Organizational determinants Interprofessional collaboration requires a favourable organizational setting. Therefore, the organizational determinants combine attributes of the organization that define the work environment of the team, such as its structure and philosophy, the team resources and administrative support, as well as communication and coordination mechanisms. Table 4 shows the organizational determinants studied six researches on determinants. Some determinants like the structure and the philosophy have been discussed but not studied through formal research. Table 4: Results of empirical studies: organizational determinants of interprofessional collaboration Organization Structure
Organization’s Philosophy
Administrative Support
Arslanian-Engoren, 1995 (Phennomenology) Baggs & Schmitt, 1997 (Grounded theory) Borrill et al. (2002) (Correlation study) D’Amour, 1997 (Case study, Grounded theory) Liedtka & Whitten, 1998 (Case study) Sicotte et al. 2002 (Correlational study)
Resource
Coordination Mechanisms Common rules (+)
Space and time (+) Leadership (+) lack of administrators (-) Leadership (+)
Clear objectives (+) Group discussions (+) Formalization (rules and protocols) (+)
Realistic objectives (+) Leadership
Formalization (+)
(+) : fosters interprofessional collaboration (-) : hinders interprofessional collaboration
4.2.1
Organizational structure
The organizational structure has a strong influence on the development of collaborative practice in health care teams (Walsh, Brabeck & Howard, 1999). According to some authors, successful collaboration between health care professionals requires a shift from hierarchical traditional structures toward more horizontal structures (Henneman et al., 1995; King, 1990). As a matter of fact, traditional structures do not facilitate the key conditions for collaboration, such as shared decision-making or open and direct communication (Evans, 1994). On the contrary, decentralized and flexible structures stress the importance of team work and support shared decision-making, thus fostering collaborative practice (Feifer, Nocella, DeArtola, Rowden & Morrison, 2003; Evans, 1994). 4.2.2
Organization’s philosophy
According to the surveyed literature, the organization’s philosophy and its inherent values have also an impact on the degree of collaboration. The organization’s philosophy must support collaborative practice among professionals. For instance, a philosophy that values participation, fairness, freedom of expression and interdependence, is essential for the development of 83
collaboration within heath care teams (Evans, 1994; Henneman et al., 1995). According to Stichler (1995), collaborative attitudes between professionals are fostered by a climate of openness, risk-taking, integrity and trust. 4.2.3
Administrative support
The implementation of interprofessional collaboration requires administrative support (Johnson, 1992; Koerner, Cohen & Armstrong, 1986; Stichler, 1995). Indeed, the development of collaboration between team members is facilitated by the availability of leaders who know how to convey the new vision of collaborative practice (Stichler, 1995), who motivate professionals into collaborative practice (Stichler, 1995; Swanson, 1997) and are able to create an organizational setting that fosters collaboration (Evans, 1994; Henneman et al., 1995; Johnson, 1992). 4.2.4
Team resources
One of the key conditions for a successful collaborative practice is the availability of time to interact and of space to meet. First of all, a strong collaborative relationship demands that enough time be available for the team professionals to share information, develop interpersonal relationships and address team issues (Mariano, 1998; Warren et al., 1998). Furthermore, space sharing and physical proximity reduce professional territoriality and atavistic behaviours (Mariano, 1998) and facilitate collaboration, especially when conflicts arise (Lindeke & Block, 1998). It is therefore essential that the organization consider time and space sharing opportunities for professionals working in the same team (Koerner et al., 1986; Lindeke & Block, 1998; Siegler & Whitney, 1994). Several authors emphasize the need for adequate financial investments to promote the development of a collaborative practice (MacIntosh & McCormack, 2001; Mariano, 1989; Siegler & Whitney, 1994; Walsh et al., 1999). 4.2.5
Coordination and communication mechanisms
The development of a collaborative practice requires appropriate coordination and communication mechanisms (Cabello, 2002; Evans, 1994; Koerner et al., 1986; Stichler, 1995; Way, Jones & Busing, 2000). Interprofessional collaboration can benefit, in particular, from the availability of standards, policies, and interdisciplinary protocols, unified and standardized documentation and of sessions, forums or formal meetings of all team professionals (Cabello, 2002; Hanson et al., 2000; Henneman et al., 1995; Johnson, 1992; Koerner et al., 1986; Warren et al., 1998; Way & Jones, 1994).
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4.3 Interactional determinants Interactional determinants are components of the interpersonal relationships of team members such as their willingness to collaborate, mutual trust, respect and communication. Table 5 shows that this category of determinants has been the object of more research. Table 5: Results of empirical studies: interactional determinants of interprofessional collaboration Willingness to Collaborate Arslanian-Engoren, 1995 (Phenomenology)
Trust
Communication
Presence (+)
Mutual Respect Presence (+)
Baggs & Schmitt, 1997 (Grounded theory)
Openness to collaboration (+)
Presence (+)
Active listening open communication (+)
Presence (+)
D’Amour, 1997 (Case study. Grounded theory)
Common goals (+) Expectations from collaboration (+)
Firm trust (+)
Mutual knowledge (+)
Presence (+)
Liedtka & Whitten, 1998 (Case study)
Commitment (+)
High degree (+)
Sicotte et al., 2002 (Corelational study)
Convictions about collaboration benefits (+)
Silén-Lipponen et al., 2002 (Phenomenology)
Presence (+)
Insufficient (-)
(+): fosters interprofessional collaboration (-): hinders interprofessional collaboration
4.3.1
Willingness to collaborate
Although health care systems tend to make interprofessional collaboration mandatory by implementing structures and standards conducive to collaborative practice, collaboration is, by nature, voluntary (D’Amour et al., 1999). Therefore, in order to implement a collaborative practice, the professionals must be willing to commit to a collaborative process (Henneman et al., 1995; Stichler, 1995). According to some researchers, group cohesion is one of the key indicators of the willingness of individuals to be part of a team (Cohen & Bailey, 1997; Evans & Dion, 1991; Stahelski & Tsukuda, 1990). For instance, according to Stahelski and Tsukuda (1990), the key indicator of cohesion is professional constancy in the group. The willingness of the team professionals to work in collaboration depends on factors such as professional education, previous experience of similar situations and personal maturity (Henneman et al., 1995).
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4.3.2
Trust
Most researchers agree to classify trust as one of the key elements of collaborative practice development (Alpert et al., 1992; D’Amour, 2002; Evans, 1994; Gage, 1998; Henneman et al., 1995; King, 1990; Pike et al., 1993; Siegler & Whitney, 1994; Stichler, 1995; Warren et al., 1998; Way, Jones & Busing, 2000). Building trust requires time, effort, patience and previous positive experiences (Henneman et al., 1995). According to Henneman (1995) self-confidence as a professional is necessary as well as displays of trust towards other professionals. At both levels of trust (trusting oneself and others), researchers conclude that trust depends on competence – skills and knowledge—and on experience (Henneman et al., 1995; Johnson, 1992; Pike et al., 1993; Warren et al., 1998). 4.3.3
Communication
According to the reviewed literature, communication is another interactional element that influences the degree of collaboration. For instance, communication skills among professionals is a primordial aptitude that leads to collaborative relationships between team members (Burd, Cheung, Wong, Ying & Cheng, 2002; Evans, 1994; Fagin, 1992; Henneman et al., 1995; Koerner et al., 1986; Mariano, 1989; Siegler & Whitney, 1994; Way et al., 2000). The literature suggests three main reasons why communication can be considered as a key determinant of collaboration in health care teams. First, the development of collaborative practices demands those professionals are able to understand how their work contributes to the outcomes and to the team objectives (Evans, 1994; Mariano 1989; Lindeke & Block, 1998) and how to convey to others the extent of that contribution (Johnson, 1992; Mariano, 1989). Secondly, efficient communication is essential since it allows constructive negotiations with other professionals (Henneman, 1995; Mariano, 1989). Finally, communication is a vehicle for other collaboration determinants such as mutual respect, sharing or mutual trust (Henneman et al., 1995). 4.3.4
Mutual respect
Mutual respect is considered by researchers as a determinant of collaboration. It implies knowledge and recognition of the complementarity of the contributions of the various professionals within the team and of their interdependence (Bushnell & Dean, 1993; Evans, 1994; Gage, 1998; Mariano, 1989; Pike et al., 1993; Satin, 1994; Siegler & Whitney, 1994; Stichler, 1995; Way & Jones, 1994; Way, et al., 2000). Thus, lack of understanding, respect or appreciation of the contribution of other professionals constitutes a true barrier to collaboration between health care professionals (Bradford, 1989; Stichler, 1995). We can conclude that we do not possess much evidence of the influence of the determinants on collaboration. Only a few researches have studied the determinants in relation to collaboration and the interactional determinants have received more attention. There is a need for a better understanding of the relation between the macro, meso and micro factors affecting collaboration and especially at the organizational level, we need to understand the components of the organization that will favour collaboration. 86
5. Policy Levers Towards Collaborative Practice Projects No policy implementation analysis could be found that specifically aimed at interprofessional collaboration enhancement. However, the Canadian Health Transition Fund (HTF) initiative, held between 1997 and 2001, can be considered as a broad undertaking to implement various health services restructuring policies at the local, regional and provincial/territorial levels. Several projects dealing with integrated care and primary care had an interprofessional collaboration dimension. Thus, three summary reports related to these projects were analysed (Mable & Marriott, 2002; Leatt, 2002; Desbiens & Dagenais, 2002). The review paper on primary care restructuring by Lamarche et al (2003) was also taken into consideration. These papers were screened for any data related to interprofessional collaboration and to the most promising levers of intervention. In these reports, primary care is the main focus of that analysis, but we believe our conclusions are applicable to other health care settings as well. It is important to stress that all the above projects explored a combination of factors believed to be essential to the success of the primary care restructuring (client registration, information systems, compensation, education, training, etc.) Consequently, and the implications of that conclusion regarding health policies are profound, the estimated impact of interdisciplinary practice and the implementation levers deemed to be “successful” should not be taken in isolation. Other factors are also at work and a systemic approach to restructuring is a must. Among the primary care related projects sponsored by HTF, 26 projects featured structural innovations related to multidisciplinary practice or interprofessional collaboration in an intra or inter organizational context. Several of these projects also established links between primary and secondary care professionals. Most of them also dealt with broadening the mandate of nurses (especially nurse practitioners) and of other professionals such as social workers and pharmacists, among others. Of the 41 projects dealing with integrated services, 14 dealt with models of clinical service integration for specific patient populations. It is the opinion of the authors of the three HTF project reviews that when collaboration relies only on partnership between service providers, its success is limited. Local, regional and provincial/territorial stakeholders have also important roles to play. Concerning local and regional administrations, one should stress the importance of: Managerial leadership and expertise; Human resource management (availability of qualified managers) Training of service providers (the “actors”) Access to key structural levers: in particular seed funding and funding of projects As far as health care teams are concerned, the following factors were identified as favourable: Collegial development of health care protocol/practice manuals by concerned professionals selected at the onset (experience, knowledge, shared unique skills); Clear definition of team member roles in order to minimize duplication and to facilitate delegation; Education to collective decision-making and team work;
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Joint education of the concerned professionals during the entire restructuring phase has proven to be an important element of success in terms of collaborative attitudes. Some projects required changes to provincial legislation to fully implement the model. Lawmakers are the only people mandated to allocate budgets, legislate on professional compensation and to regulate professional practices. For instance, in Nova-Scotia, the provincial government agreed to modify the “Pharmacy Act” to allow prescriptions by nurse practitioners. In other projects, existing laws had to be accommodated and the implementation of new models was, for that reason, limited. Such considerations were especially important in several projects dealing with collaborative practice. The following barriers were identified: Professional jurisdictional factors: some regulations must be reviewed to allow more flexible professional roles; Traditional resource-driven funding instead of objective-driven; Professional compensation, especially for physicians, fee-for-service is a two-fold hindrance to collaboration since time must be allocated to the team process and it creates a potential for competition in some areas and with some clientele; The non existence of clear policies governing professional practice in physician and nurse associations or licensing bodies; Medico-legal considerations may hinder true collaborative practice among professionals. The three project reviews come to the conclusion that governments must work with individuals and institutions involved in health care restructuring by: Jointly developing practice manuals for the implementation of new models (planning, management of change, evaluation) Providing the necessary education in health care organization and administration; Allocating specific bridge-funding, including physician compensation; Accepting to change the traditional method of funding and of physician compensation; Giving a clear signal to professionals, in particular to physician and nurses, about the importance of patient-centred services, by providing both career and financial incentives. Professional associations and colleges must show leadership by: Giving priority to interdisciplinary development of clinical guides and protocols; Promoting reflection and regulatory work regarding specific professional roles and practices. Lamarche and collaborators came to similar conclusions. Although multidisciplinary practice is one of the ingredients of positive outcomes, it is not the only one. The multidisciplinary team is part of a constellation of characteristics that includes service funding modalities, professional compensation, information systems and type of governance.
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Conclusions In essence, collaboration is an interpersonal process that requires both willingness and skills to be successful. To successfully collaborate, individuals must be able to acquire a vision and to explicitly develop common goals. Yet, although the above conditions are necessary, they are not sufficient because in complex health care systems, professionals cannot, by themselves, create all the necessary conditions for success. Organizational determinants play a crucial role, especially by providing human resource management capabilities and strong leadership. Collaborative assessment of professional interventions has, according to several studies, proven to be an effective way to structure interprofessional collaboration, probably because it provides an opportunity to develop a common knowledge and to focus on the common goal of all professionals, i.e. health care quality. The complexity of the task at hand and the degree of collaboration sought (multi vs. inter) has a modulating effect. Although several levers are available to most organizations, it may happen that higher considerations hinder successful collaborations. This is likely to occur when the new mode of operation alters the traditional allocation of responsibilities or requires new funding mechanisms or a new method of professional compensation. Changing the regulatory or budgetary framework, for instance, requires systemic leverage. The education system is also a key player since collaborative practice requires the mastery of new skills. It goes without saying that every intervention lever contributes to developing favourable conditions for collaborative practice.
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Siegler, E. L. & Whitney, F. W. (1994). Nurse-Physician collaboration. Care of adults and the elderly. New York: Stringer Publishing Company. Silén-Lipponen, M., Turunen, H., & Tossavainen, K. (2002). Collaboration in the operating room: the nurses' perspective. Journal of Nursing Administration, 32(1), 16-19. Stahelski, A.J. & Tsukuda, R. (1990). Predictors of cooperation in health teams. Small Group Research, 21(5) 220-233. Stepans, M. B., Thompson, C. L., & Buchanan, M. L. (2002). The role of the nurse on a transdisciplinary early intervention assessment team. Public Health Nursing, 19(4), 238245. Stichler, J. F. (1995). Professional interdependence: the art of collaboration. Advanced Practice Nursing Quarterly, 1(1), 53-61. Sullivan, T. J. (1998). Collaboration. A health care imperative. New York: McGraw-Hill. Swanson, J. W. (1997). Building a successful tam through collaboration. Nursing Management, 28(5), 71-73. Sweet, S. J. & Norman, I. J. (1995). The nurse-doctor relationship: a selective literature review. Journal of Advanced Nursing, 22 165-170. Walker, E. & Dewar, B.J. (2001). How do we facilitate careers’ involvement in decision making? Journal of Advanced Nursing, 34, (3), 329-337. Walsh, M. E., Brabeck, M. M., & Howard, K. A. (1999). Interprofessional collaboration in children's services: toward a theoretical framework. Children's Services: Social Policy, Research, & Practice, 2(4), 183-208. Warner, M., Ford-Gilboe, M., Laforet-Fliesser, Y., Olson, J., & Ward-Griffin, C. (1994). The teamwork project: a collaborative approach to learning to nurse families. Journal of Nursing Education, 33(1), 5-12. Warren, M. L., Houston, S., & Luquire, R. (1998). Collaborative practice teams: from multidisciplinary to interdisciplinary. Outcomes Management for Nursing Practice, 2(3), 95-98. Way, D. O., Busing, N., & Jones, L. (2000). Implementation strategies: “Collaboration in primary care-family doctors & nurse practitioners delivering shared care”. The Ontario College of Family Physicians. Way, D. O. & Jones, L. (1994). The family physician-nurse practitioner dyad: indications and guidelines. Canadian Medical Association, 151(1), 29-34.
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Weich, K. E. (1976). Educational organizations as loosely coupled systems. Administrative Science Quarterly, 21 1-19. Wells, N., Johnson, R., & Salyer, S. (1998). Interdisciplinary collaboration. Clinical Nurse Specialist, 12(4), 161-168. West, M. A., Borril, C. S., & Unsworth, K. L. (1998). Team effectiveness in organizations. International Review of Industrial and Organizational Psychology, 13, 1-48. Wylie, D. M. (1994). Interdisciplinary teams and group process. In J.M.Hibber & M. E. Kyle (Eds.), Nursing management in Canada (pp. 501-515). Toronto: W.A. Saunders.
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Appendices for Chapter Three: Key Elements of Collaborative Practice and Frameworks: Conceptual Basis for Interdiscplinary Practice
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Appendix 3-1 LITERATURE SEARCH STRATEGY COLLABORATIVE PRACTICE (framework) 1) exp interprofessional relations/ 2) cooperative behavior/ 3) (interdisciplinary team? or inter-disciplinary team?).tw 4) (multidisciplinary team? or multi-disciplinary team?).tw 5) (interprofessional team? or inter-professional team?).tw 6) (multiprofessional team? or multi-professional team?).tw 7) (interoccupation? or inter-occupation?).tw 8) (multioccupation? or multi-occupation?).tw 9) 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 10) (interinstitution? or inter-institution?).tw 11) (multiinstitution? or multi-institution?).tw 12) (interagen$ or inter-agen$).tw 13) (multiagen$ or multi-agen$).tw 14) (interorganization$ or inter-organization$ or interorganization$ or inter-organization$).tw 15) (multiorganization$ or multi-organization$ or multiorganization$ or multi-organization$).tw 16) (intersector? or inter-sector?).tw 17) (multisector? or multi-sector?).tw 18) (professional patient relation$ or professional client relation$).tw 19) 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 20) 9 or 19 21) exp delivery of health care/ 22) practice?.tw 23) 21 or 22 24) Models, Theoretical/ 25) (framework? or theoretical model? or conceptual model?).tw 26) 24 or 25 27) 20 and 23 and 26 28) limit 27 to yr=1990-2004
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Appendix 3-2 Literature Screening Grid Reviewer: _________________________ Author:___________________________ Title: _________________________________________________________ 1. Composition of the studied team or collaboration unit Duo, identify___________________________ Trio, identify___________________________ More than three, identify__________________ 2. Client is included as partner:
___Yes ___ No
3. Type of organization: Hospitals ____________________________ Primary/ambulatory care ______________ Interorganizational ____________________ Other _____________________________ 4. Specific clientele: ___Yes ___ No If yes, identify _________________________ 5. Collaboration model or theoretical framework: ___Yes ___ No If yes, based on: Empirical data / research ______________________ Literature review ______________________ Proven explicit theoretical frame _______________ Without theoretical frame ______________________ 6. If literature-based, was the research strategy explicit? ___Yes ___ No 7. If based on explicit theoretical frame, which? ______________________________________________________________________________ ______________________________________________________________________________ 8. If empirical data based, are they Quantitative_____________ Qualitative_______________
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9. If quantitative design: Randomized trial/ time series / cohort study with comparison group __________ Other quasi-experimental designs with comparison groups ________________ Non-experimental designs, cross-sectional, case-control ________________ 10. If quantitative design, sample size: Large (with adequate statistical power) __________ Medium (with reduced, acknowledged statistical power) __________ Small (low statistical power) __________ 11. If qualitative design: Case study __________ Phenomenology __________ Grounded theory __________ Ethnography __________ 12. Qualitative design rigor: Explicit rigor criteria __________ Triangulation __________ Saturation __________ Representatives of key informants __________ Explicit analysis strategy__________ Others ____________________________________________________________ __________________________________________________________________ 13. Number of studied sites Several (>5) __________ Few (2-5) __________ One __________ 14. Outcome assessment ___Yes ___ No If yes, Among clients __________ Among professionals __________ In organizations __________ In health care system __________ 15. Explanatory variables: determinants, barriers, incentives. Of what type ? Professional ______________________ Personal ______________________ Organizational ______________________ Macrostructural ______________________ Draw or copy model if needed
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Chapter Four Key Elements of Interdisciplinary Education By Ivy Oandasan and Scott Reeves
Introduction This chapter discusses key elements that may be needed for planning and implementing interdisciplinary educational interventions at both the pre-licensure and post-licensure training. We build upon the information in the previous chapters related to collaborative practice and the mounting evidence that collaborative practice can improve patient outcomes for specific population groups. However, the link between interdisciplinary education and improved patient outcomes is yet to be determined. There is still much to be learned about the pedagogical constructs related to the content and methods of teaching interdisciplinary education. By gaining a better understanding of the educational constructs related to interdisciplinary education, the chances of obtaining informed results related to the true outcomes of interdisciplinary education are anticipated. This chapter will highlight: • • •
a description of competencies related to interdisciplinary education; discuss the timing of interdisciplinary education into the training of health professionals; and consider methods of implementation informed by pedagogical theory.
Factors that influence the learner, the teaching environment and the institutional environment will be discussed as key determinants for the success of interdisciplinary education. The chapter’s conclusion addresses what components are necessary for curriculum reform and the tools required for educators and practitioners as they develop initiatives with pedagogical constructs.
Methodology A search was conducted to obtain literature on competencies, attitudes, values, teaching methods, learning conditions, and faculty development and training related to interprofessional education. Due to the time constraints for this project, references from the ‘Jet Review’{Freeth, et al. 2002}(See Chapter 2) was decided as a starting point. However, because the Jet Review included only evaluation studies, a broad literature review in this field was necessary to capture both descriptive and evaluative references. A search was conducted in Medline and CINAHL from 1990-2003 using the following search terms: interprofessional, multiprofessional, interdisciplinary, multidisciplinary and team. This core part of the search was combined with the following key words and phrases: education, teaching methods, faculty development, attitudes, and competency. As well, a search was conducted in ERIC (Educational Resources Information Center) for the last 5 years and included the following search terms in combination: values,
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teaching methods, educational environment, and competency based education, attitudes, combined with interprofessional, multidisciplinary, interdisciplinary approach, and health, medicine, allied health occupations. Appropriate wildcards were used in the searching in order to account for plurals and variations in wording. The articles were then subdivided manually according to the following interdisciplinary education themes: - attitudes, values & philosophies - attitude tools - enablers/ barriers - continuing medical education examples - competencies - educational content
- educational theoretical constructs - educational teaching methods/ strategies - history - policies - reviews - terminology
In addition, a manual search was conducted of these articles and references from key articles were retrieved for review. It should be noted that on-line survey participants described in Chapter 5 sent references they felt were important for the researcher team to review. These references included grey literature, published references and articles yet to be published. These contributions were of great value to the research team.
Defining Interdisciplinary Education in Context As alluded from the second chapter, there is a need for consensus and understanding of the terminologies used in the literature for both interdisciplinary practice and interdisciplinary education. There appears to be a movement towards using the term interprofessional versus interdisciplinary. However, both are still being used interchangeably. As this report was commissioned using the term “interdisciplinary education” (IDE) we have decided to use this term within this chapter. However, as there has been no consensus reached, within the references cited in the chapter the term interprofessional has often been used. Thus, the term interdisciplinary and interprofessional are used interchangeably in this chapter and are defined the same. For clarification, we will use the following terms and define them in this manner: 1. Uniprofessional learning occurs where trainees learn within their own specific health professional programs with minimal contact with other health professional trainees. This form of training “isolates” trainees from one another 2. Multiprofessional learning occurs when trainees are brought together, learning in parallel. They may work on a particular problem or try to solve a specific problem but they do so working within their own profession-specific paradigm. They “learn together for whatever reason” (Barr, 1996) 3. Interprofessional/interdisciplinary learning occurs when trainees are brought together from two or more professions to work synergistically with each other with the purpose of integrating their professional perspectives. (Harden 1998; Parsell and Bligh 1998) It is
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“learning together to promote collaboration and the quality of care”. (CAIPE, 1997 revised) 4. Transprofessional learning opportunities reflect an extension of interprofessional learning where trainees begin to see their professional roles blurred. 5. Pre-Licensure Learners – Individuals who are in training and not yet licensed to practice. This would be the equivalent to the United Kingdom’s Pre-registration designation. 6. Post-Licensure - Individuals who are licensed to practice and therefore are not engaged in any formalized learning program. This would be the equivalent to the United Kingdom’s Post-registration designation. Harden introduced the notion that there exists a spectrum of learning within a health professional trainees’ educational programming. (Harden 1998) On the one hand, there are professionspecific competencies that must be learned and therefore a uni-professional educational strategy would be the best method of choice. Alternatively, learning how to become a collaborative practitioner cannot be learned in isolation and hence using interprofessional learning strategies is ideal. There may be times, however, when it may be more appropriate to use a multiprofessional approach to learning. In choosing whether to use a uni-, multi- or inter-professional learning strategy, educators must consider both the goals of the curriculum and the context of learning including: the phases/stages of education, the setting, the participants, the learning approach, and the topics or subjects to be taught. (Harden 1998; Johnston and Banks 2000) For this chapter, we will consider the factors that relate to utilizing an interprofessional learning approach for health professional training but acknowledge that there is a role for the other learning strategies (multior trans- disciplinary) given the specific goals and/or context of the educational intervention. IDE Curriculum Goals: What are we trying to teach? If the goal of IDE “is to teach collaborative practice [then] the content must be on interdisciplinary knowledge, skills and attitudes. Do not confuse teaching medical content foci with the primary goals of collaborative practice.” (Reeves and Freeth 2002) (Johnston and Banks 2000) This narrative helps to clarify when IDE strategies should be used. In essence, health professional trainees may be brought together to study about HIV management, but unless they are learning ‘how to work together’ in the management of HIV they will be learning in parallel. This is a classic example of multi-professional learning. When trainees use a topic, like HIV management, as a vector to learn how to work in synergy with one another, they are engaged in interprofessional learning. The primary goal of IDE is developing competent trainees who have the knowledge, skills and attitudes to become collaborative practitioners.
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Interdisciplinary Education Competencies Defining Competencies In the second chapter, we discussed a definition of collaboration as “an interprofessional process of communication and decision making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client/patient care provided” (Way, Jones et al. 2001) Using this definition, it is interesting to reflect upon whether the definitions of collaborator competencies from health professional programs fits with the literature. The College of Family Physicians of Canada in its Accreditation Standards for Residency Programs (College of Family Physicians of Canada 2002) describes competencies related to collaboration as family medicine residents must be able to “have a knowledge of and be willing to draw upon the community’s resources including medical consultants, health professionals and community agencies (page 21). One other section related to care of the elderly, states that residents “should learn to be effective team members by participating in multidisciplinary geriatric teams.” (page 19). The Royal College of Physicians and Surgeons of Canada have identified that all of their trainees must demonstrate that they are competent in carrying out the role of the “Physician as Collaborator” before they complete their residency programs. (The Royal College of Physicians and Surgeons of Canada 2000) The role of the Physician as Collaborator is one of seven roles for which specialists must demonstrate competency. To be competent as a “Collaborator”, the specialist is able to: “Effectively consult with other physicians & health care professionals” – implying the development of management plans “in partnership with the patient and care providers”. The specialists “recognizes the roles and expertise of the other individuals involved and “explicitly integrates the opinions of the patient and caregivers into management plans.” (page 6). This definition which is only an excerpt from the Royal College Accreditation guidelines provides a more explicit definition of collaborator competencies. The definitions and descriptions of competencies related to the notion of collaboration by educational accrediting bodies are important as they drive the educational objectives and curriculum development. In our review of the literature, other than medicine, it was difficult to find specifically defined competencies related to collaboration amongst other health professional educational accreditation bodies in Canada. Whether or not collaborator competencies exist amongst them and whether or not those who do list collaborator competencies define them appropriately is questioned. Only with good definitions and a true understanding of the types of “collaborator” competencies we expect our health professional trainees to demonstrate, will we be able to teach and evaluate this construct more successfully. The literature provides a good source of information to define the types of competencies that may be required of health professionals to increase their likelihood to work collaboratively. For
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example, Way & Jones in their work with physicians and nurse practitioners found that there were seven essential elements which are required for successful collaborative practice: cooperation, assertiveness, responsibility/accountability, autonomy, communication, coordination, mutual trust and respect (Way, Jones et al. 2001), D’Amour et al, in Chapter 3 report similar key elements that collaborative practitioners share from their systematic review of the literature. These elements include: • • • •
Willingness to work together Trust related to self-competence and competence in other’s abilities Good communication including negotiation skills Mutual respect implying knowing other health professionals and their contributions to patient care.
Hall & Weaver effectively discuss content specific issues for IDE in their review stating that trainees should learn issues related to professional role demarcation vs. role blurring, group skills (forming, storming norming and performing), communication skills, conflict resolution skills and leadership skills. (Hall and Weaver 2001) In Figure 1, Barr described interdisciplinary education competencies highlighting specific knowledge, skills and attitudes (Barr 1998) Many of the content specific areas relate to the elements described above. Of knowledge, most were related to an understanding of one’s own professional role and the professional roles of others. Skills were related to methods of working with other health professionals, resolving conflict and providing patient care. Respect, tolerance and the willingness to work with others were attitudinal competencies that were described. It is incumbent upon health professional educators to determine whether interprofessional education competencies are profession-specific or whether these are competencies that all health professional trainees must share. If developing interprofessional initiatives across health professional programs, one might argue that the discussion of competencies for trainees should be shared amongst all health professional faculties, licensing, certification and accreditation bodies involved. This approach has been taken by the Institute of Medicine (IOM) in the United States, when health professionals, educators, consumers, policy makers, regulators and students were organized to meet at a Health Professions Summit in June of 2002. During this Summit meeting participants developed a core set of competency requirements in interdisciplinary teamwork for health professionals in training and for the design and development of innovative educational programs to teach health professional students the knowledge and skills required to work together more effectively.(Greiner 2003) In addition to the competency requirements for working within interdisciplinary teams, the participants in the Summit identified the following four other competencies that should be mastered by all health professional trainees: patient centred care, evidence-based practice, quality improvement, and informatics The call for competency-based inter-professional education is loud. What comes of it is determined by the context and the educational leaders who bring forth an interpretation of the competencies for which they want their trainees to adopt into practice. How these competencies are taught depends upon a number of factors embedded within the context of learning for health
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professional trainees. It is through careful consideration of all of these factors that the best pedagogical approach to teaching IDE can be developed. Figure 1: Collaborative Competencies – Summarized (Barr, 1998: 181)
1. Describe one’s roles and responsibilities clearly to other professions 2. Recognize and observe the constraints of one’s role, responsibilities and competence, yet perceive needs in a wider framework 3. Recognize and respect the roles, responsibilities and competence of other professions in relation to one’s own 4. Work with other professions to effect change and resolve conflict in the provision of care and treatment 5. Work with others to assess, plan, provide and review care for individual patients 6. Tolerate differences, misunderstandings and shortcomings in other professions 7. Facilitate interprofessional case conferences, team meetings, etc. 8. Enter into interdependent relationships with other professions
Learning Context In considering the context of learning, educators are faced with a number of key questions: • • • • •
When should IDE be introduced into health professional training? How can educational theories inform the development of teaching strategies? What types of settings can be used? Who should be the learners? What methods of facilitation of learning can be used?
1. Timing of IDE Within the literature there has been much debate about when to introduce IDE into the training of health professionals. One recommendation has been that IDE should take place in the early phases or stages of education. Some say it should take place specifically within the first two years (Horak, O'Leary et al. 1998; Leaviss 2000), as experiences of shared learning may better facilitate interdisciplinary collaboration. Others state that by introducing interprofessional education early in training then negative stereotypes and attitudes related to other health professionals that are difficult to revert, never develop in the first place. Many trainees do come into their health professional programs with stereotypes of their own health profession and of others.(Tunstall-Pedoe, Rink et al. 2003) Despite this, encouragingly, it has been found that learners early in their health professional training programs are ready and willing to engage in interprofessional learning activities. (Hind, Norman et al. 2003) Literature findings support that attitudinal changes can be altered. (Carpenter and Hewstone 1996) One of the main arguments for introducing IDE early in training is to effect how health professionals come to know each other and relate to one another through the development of positive attitudes and behaviours. If there is a willingness to learn together early in their professional training years, then perhaps this too is a reason to capitalize on initiating IDE early on.
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Counter-arguments have been made for IDE to take place later in people’s training. Proponents of this approach feel that that individuals must first be secure in their professional roles before they can function effectively as team members (Petrie 1976; Parsell and Bligh 1998). In thinking about an educational session where senior trainees may be involved, one can see that if a particular professional trainee is unable to contribute to the problem for which the group of learners has been tasked, it could potentially negatively reinforce stereotypes of the health profession the trainee represents. Consequently, being confident in sharing the knowledge and skills of one’s profession may be important for the success of IDE initiatives. The notion of involving senior level trainees may not be as clear cut as it seems. In a recent study with senior trainees from six health disciplines, nursing, pharmacy, social work, chiropody, family medicine and advanced nurse practitioners, a variation was noted between trainees who have had significant clinical exposure in their training versus those with less exposure. Despite being similar in their years of training, there are differences that seem to emerging related to the types of training they have had which may have implications related to the introduction of IDE beyond number of years in training. (Oandasan, Kwan et al. 2003) Harden’s notion (Harden, 1998) of a spectrum of learning during a health professional’s training is being adopted by movements such as the New Generation Project in the United Kingdom where trainees from 19 health professions have begun sharing learning experiences from their first years of undergraduate training. (University of Southhampton: New Generation Project 2003) In this Project, trainees are exposed to the traditional uni-professional models of learning to gain specific health profession competencies. However, they are also given opportunities for shared learning using multiprofessional learning strategies in the early years with gradual introduction of interprofessional/interdisciplinary learning strategies based in clinical or service settings in the latter years of training. Course content and goals reflect the need to reduce stereotype inculturation early in training while ensuring role identification and confidence has developed before introducing educational initiatives to trainees later in their professional programs. The notion of a continuum of learning, with the introduction of different types of shared learning opportunities using uni-multi-or interprofessional models may be one way of considering the age-old question, “When should IDE be introduced?” Let us move beyond this question refining it to ask: • • •
What are the goals we are trying to achieve in having trainees learn together? Based upon these goals, when should we introduce the learning to trainees? What strategy of shared learning (uni-multi-inter-trans-professional learning strategies) should be used to accomplish these goals?
2. Strategies for teaching IDE informed by Theory There is a strong call for educators to ground their IDE initiatives with educational theoretical constructs (Hall & Weaver, 2001) Educational theory can influence the types of teaching strategies that can be used and influence the success of initiatives. Classic theories of adult education,(Figure 2) (Knowles 1980) reflection on practice (Schon 1987), problem based
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learning (Barrows and Tamblin 1980), and experiential learning (Kolb 1984) are examples of theories that should be considered. In addition, the use of teamwork models can also contribute to considerations related to teaching methodology.(Gilbert, Camp et al. 2000) An articulation with theory/models and their relationship to educational strategies can add to the type of rigor that is required at this time for the development, implementation and evaluation of IDE. Although, all of these theories are important a few will be highlighted to illustrate ways in which competencies such as those described by Barr in Figure 1 and teaching methodologies can be blended to create pedagogically informed curricula. Figure 2: Malcolm Knowles Tenets of Androgogy – Seven Principles of Adult Learning • • • • • • •
Adults respond best to a non-threatening learning environment where there is good teacher-learner relationship They want to assess themselves against a relevant standard to determine their educational needs They want to select their own learning experiences – to be self-directing. They prefer a problem-oriented approach to learning. They want to apply their new knowledge and skills immediately. They want to know how they are progressing. They want to contribute from their own reservoir of knowledge and skills to help others to learn
2.1 Creating a Non-Threatening Learning environment In order to master competencies like “respecting roles” and “tolerating differences, misunderstandings and shortcomings in other professions”, we must consider aspects related to developing positive attitudes amongst health professional trainees. (Barr 1996) Knowles’ first principle related to creating a non-threatening learning environment should be considered. Social psychologists have recognized that contact between opposing groups can modify attitudes in a positive manner. The “Contact Hypothesis” theory (Tajfel 1981), as it is now called, was reviewed by Hewstone and Brown (1986) and they found that there are certain conditions that need to be established to increase the success of encounters between opposing groups. These conditions include: institutional support, equal status of participants, positive expectations, cooperative atmosphere, successful joint work, a concern for and understanding of differences and similarities, a perception that members of the other group are typical and not exceptions. These conditions have been shown to be associated with improved attitudes between final year medical students and social work students engaged in an IDE project. (Carpenter and Hewstone 1996) Carpenter notes that students need to be able to express themselves openly, share their attitudes in a safe environment and be given time to reflect on their role in a team of equals.(Carpenter 1995c) 2.2. Developing Reflective Collaborative Practitioners Reflection is a key component of IDE teaching strategies. It has been found that time for reflection has been a useful exercise for students to engage in. (Reeves and Freeth 2002) Methods incorporating reflection include writing in journals and small group discussions. (Clark 1994) In the previous chapter by D’Amour et. al., an important determinant for being able to
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work in a collaborative practice is to be a reflective practitioner. Schon’s theory of reflective practice calls for health care practitioners to address the “swampy zones of practice” where “confusing problems which defy technical solutions” often lie. (Schon, 1987:3) When thinking about interprofessional education it is a “swampy zone”. Trainees must grapple with issues related to hierarchy, role blurring, leadership, decision-making, communication, respect … there are no easy answers to these concepts. These concepts cannot be taught didactically. Schon recommends that trainees need to be immersed in a practicum experience where they can engage in “reflection-in-action”, serving to reshape what one is doing while one is doing it, and have opportunities to engage in “reflection-on-action” to look back on experiences and come to an understanding of how outcomes have come to pass. Through self and group reflective exercises, within safe learning environments, learners may begin to develop the reflective skills necessary for developing an appreciation and understanding of each other’s roles, their unique backgrounds and training and the professional perspectives impacting clinical decision making that makes each profession distinctive. (Drinka and Clark 2000) Reflection can only occur if opportunities are provided for trainees to engage in activities that expose them to issues that they must grapple with. These opportunities should be based on subject matter that relates to learners’ immediate interests and concerns as this has been shown to increase learner motivation. (Schwenk and Whitman 1987) 2.3 Creating Relevant Learning Experiences Within the IDE literature learners’ reactions to IDE are more favorable when they see a direct relevance between the educational experiences they are exposed to and their current or future practices. (Parsell and Bligh 1998; Pirrie, Wilson et al. 1998a) It is therefore not surprising to find that the bulk of interdisciplinary education initiatives employ learning approaches that are based in, or have a substantial part of the course based in, clinical practice (e.g. Van der Horst, Turpie et al. 1995, Wealthall, Graham et al 1998). Where interdisciplinary courses are based within higher education institutions for trainees at the pre-licensure level, one finds that these courses incorporate some form of clinical input, whether it is a clinical placement, (Wahlstrom and Sanden 1998; Kipp and Pimlott 2003) , the use of a simulated clinical environment (Freeth and Nicol 1998) or going to meet and talk to service users about their health needs. (Reeves 2000) (Turner, Sheldon et al, 2000) Hence the type of setting can influence the motivation of learners to engage in IDE activities. Three other factors related to relevance of IDE need mention as well: perceived status, elective status and course credit. First, the perceived status of IDE amongst health professional practitioners and trainees may be an important consideration. Studies have shown that students have felt that collaborative learning was not as important as their profession-specific learning experiences. (Dienst and Byl 1981; Wahlstrom and Sanden 1998; Fallsberg and Wijma 1999) Eliciting public support from professional leaders (Funnell, Gill et al. 1992) and recruiting high quality tutors to deliver the education (Loxley 1997) have been suggested as ways to improve the status of IDE. The second factor for consideration is whether the IDE initiative is to be mandatory or elective. As an elective course, it gives the message that the material to be covered is not essential for health professionals to learn. Some authors would say however, that choice should be given to engage in IDE initiatives as it will ensure that those participating will be more "interested and committed." ((Lary, Lavigne et al. 1997):68) The third factor relates to course credit. If the experiences are not evaluated in a way that gives equal weight to other uini110
professional courses, relevance again is questioned for why health professionals should participate in IDE and motivation to learn may dwindle.(Reeves 2000) In the clinical practice setting, with post-licensure practitioners, introducing IDE initiatives can often be regarded with suspicion by practitioners. (Falconer, Roth et al. 1993) This is unsurprising, when one realizes that IDE is generally introduced into these environments attempt to change and enhance present practice, unlike pre-licensure IDE which aims to improve collaborative practice in the future. Thus, the introduction of this form of education could be perceived as a possible indication that their current practices are not adequate. Resistance may be higher particularly for those already in practice as participation is purely elective and there may be no incentives for post-licensure practitioners to participate as opposed to pre-licensure trainees who require course credits to graduate. 2.4 Using Small group learning methodologies In his “Evaluation of Interprofessional Education”, (Barr 2001) Barr found that the best teaching strategies for IDE, other than working with real/simulated patients included those that were interactive such as case-based learning (Woodhouse and Pengally 1992); Observation-based learning (Likierman 1997) and problem based learning (Barrows and Tamblin 1980). These strategies are optimized when using small group learning formats. Whenever a small group convenes, a learning environment develops which has the potential to have participants share tasks, enabling them to learn, not merely with, but also from, one another (another principle of adult learning) and to help raise self awareness. (Tiberius 1990) In devising IDE initiatives, whether utilizing a case-based, problem-based, simulated patient or real patient, the clinical problem that arises from the learning exercise is the vector for which learners come to an understanding of how to work together. Regardless of whether using a theoretical case or a real life case there are some specific learned lessons related to the use of small group learning which has been shown to be more helpful in IDE initiatives. The factors which need to be considered include: group balance, group mix and group stability. a) Group Balance: For interactive learning to take place there is a need to attain and maintain a ‘balance’ within learning groups. By doing so, it is argued that one can promote good interprofessional interaction. A crucial element in achieving group balance is to ensure that there should be an equal mix of professionals in the group (e.g. Funnell et al 1992, Gill & ling 1995). It is argued by these authors that if the group make-up is skewed too heavily in favour of one profession, it will inhibit interaction, as the larger professional group can dominate. In post-licensure educational initiatives, it is not so easy to ensure that equal numbers of health professionals are represented in small groups particularly in the practice setting where there is often a disproportionate number of health professionals working on health care teams, e.g. on the hospital ward there may be more nurses and physicians versus pharmacists and social workers. b) Group Size: Good quality interprofessional interaction can only be obtained if learners work together in small groups. (Gill and Ling 1995; Hughes and Lucas 1997) It is noted that in this time of fiscal restraints, opposition may be high to create small group
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learning formats. (Barr 1994; Miller, Ross et al. 1999) For effective learning to occur, a learning group should consist of around 8-10 members. (Gill and Ling 1995) Where groups are over 10 members, problems related to less than optimal interactions can be encountered.(Hughes and Lucas 1997) Looking more widely at the literature, one can see that interdisciplinary education initiatives generally report group sizes of between 5-10 learners. (DePoy, Wood et al.1997). Indeed, it is quite common to find initiatives where interdisciplinary dyads of learners work together. (Nash and Hoy 1993; Way and Jones 1994; Green, Cavell et al. 1996) c) Group Stability - The final facet connected to group balance is stability or the need to maintain stable group membership. Interaction is enhanced if learners work together within a group where there is stable membership with little ‘turnover’ in terms of established members leaving and new ones joining the group (Loxley, 1980; Forbes & Fitzsimons 1993). From the literature this issue can be especially difficult to achieve for post-licensure IDE activities. For example, where an IDE course is run over a number of weeks, heavy workloads can mean that group stability is interrupted, as practitioners are not able to attend complete courses (e.g. Hart & Fletcher 1999, Freeth et al 2000). Strategies can be offered to help overcome these pressures and thus enhance group stability. For example, offering lunch for physicians and nurses for a series of IDE education sessions related to quality improvement can help attendance and this positively affect group stability (Freeth et al 2000). For learners undertaking full-time pre-licensure education, such pressures on group stability may not be as problematic if timetabling can be coordinated. Although the literature offers some helpful accounts of the affects of group balance on collaboration, one needs to remember that these accounts provide only a limited picture of this area. In addition, discussions related to small group learning assume that this format of learning can be established, particularly in the pre-licensure years. However, as we will see in the section related to barriers, logistics related to timetabling students and faculty time is one of the most difficult barriers in implementing IDE.
3. Patient/Client Conditions for IDE Do all patients/clients require an interprofessional approach to care? Certainly, the individual with a finger laceration would likely not need to see a number of health professionals working synergistically together to treat his/her clinical problem. However, the question of what types of patient/client conditions or health care settings are more suited to an interprofessional approach to care arises. If we know where to find effective collaborative practices then perhaps we can provide opportunities for our learners to be involved in those settings. From the information gained in the chapter by Zwarenstein & Reeves there is good evidence to show that collaborative practice improves patient outcomes in the following areas: substance abuse, sexually transmitted infection screening, adult immunization, geriatric evaluation and management, and acute care for abused women in the emergency room. The Jet Review found that the majority of the studies they utilized for their reviews described interprofessional education in clinical service delivery settings. (Freeth, Hammick et al. 2002)This is not
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surprising given the discussion earlier on educational theory and how it informs teaching strategies. What is important to note is the need or the dependence IDE has for clinical service settings which demonstrate interprofessional practice. Finding best models of collaborative practices in both hospital and community health settings will be important as we launch IDE opportunities in the future. Indeed D’Amour et al in Chapter 3 provide modelswhich can be transformed into tools. This would allow us to evaluate collaborative practices that can be used for IDE settings. The tools can also help foster improvements in the clinical settings where collaborative practice can be enhanced. There is a need to know where collaborative practices can improve patient outcomes as it is assumed that it is here where collaborative practitioners who can act as role models for learners may exist. The issue of role models and facilitators is an important factor for enhancing IDE. 4. Learning Settings & IDE A broad overview of the literature reviewed for this chapter revealed that, the most common clinical settings that have incorporated information about IDE initiatives fell within the fields of geriatrics (eg.(Drinka and Clark 2000; Hyer, Fairchild et al. 2000)), primary health care (Way, Jones et al. 2001), rural medicine (McNair, Brown et al. 2001) and rehabilitation medicine (Wahlstrom and Sanden 1998).2 From the Jet Review (Freeth, Hammick et al. 2002), they found that 76% of the articles they reviewed (n=217 eligible articles) came from the post-licensure setting or clinical practice settings, where health professionals involved were part of the workforce. (See Chapter 1 for further information on search strategy) The IDE initiatives were categorized under quality improvement activities including guideline development/improvement and staff development activities such as workshops, short-courses or problem-solving groups. It is interesting to note that of the remaining articles reviewed, 24% came from the pre-licensure setting or within formal institutions of learning. Hence, either a significantly decreased number of initiatives are being developed at the pre-licensure training period or, the evaluations of the initiatives are not being written with sufficient rigor to allow for inclusion within systematic reviews. The latter is the more likely conclusion as was noted by Hammick and will be discussed further in this chapter under evaluation considerations. (Hammick, 2000) Much more needs to be learned about the prelicensure setting and its impact on IDE to provide sound information about what is needed for pedagogically informed IDE. It has already been discussed that both pre-licensure and post-licensure IDE initiatives have used clinical settings as their most common locations for implementation of learning activities. Beyond the clinical setting, however, there are two other learning settings that are worth mentioning as they hold opportunities for IDE and may impact planning of IDE initiatives.
2
The citations mentioned are meant to provide examples of references from the settings listed but are no means representative of all the articles that have been written within each of these settings. The authors recognize that there are other settings where IPE has been situated as well.
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4.1 Using Community Service Settings for IDE Emerging from the literature are initiatives where health professional learners, particularly in the early years of training, are exposed to service-learning activities using a community-service model. Service-learning is described as a structured learning experience where students provide direct community service but also learn about the context in which the service is provided and understand the connection between the service and their academic coursework. (Seifer 1998) Service-learning has been able to meet the needs of the community and the needs of the trainees through structured educational components promoting uni-professional and inter-professional learning objectives. (Lough, Schmidt et al.1996; Russell and Hymans 1999) The notions of community health and health promotion are topics that seem to cross health professional training programs. As a result, this presents an opportunity to introduce ways of having trainees learn together while meeting social accountability responsibilities for higher education institutions. (Health Canada 2001) 4.2 Informal Settings as Learning Opportunities A number of papers have stressed the importance of informal learning in creating more collaborative teams of learners (Green, Cavell et al. 1996; Howkins and Allison 1997; Freeth and Nicol 1998) Indeed, from the literature, this factor appears to have relevance for interdisciplinary education particularly at the pre-licensure levels of training. (Erkel 1995, Nivens et al, 1995) (Salvatori and Berry 2003) It may have an impact on changing professional students’ socialization processes as will be discussed later in this chapter. Pryce & Reeves (Pryce and Reeves 1997) found that medical, nursing and dental students continued to discuss aspects of their learning whilst socializing together after their formal learning was completed. Time in the local cafeteria or time together car-pooling can be useful settings for sharing informal experiences among pre-licensure students. (Casto 1994; LaSala, Hopper et al. 1997) It may be important to set aside time in the structured learning environment in order to create informal learning opportunities. However, although the IDE literature offers some 'clues' about the processes of informal learning, more research is needed to examine more fully, if indeed, informal learning is important to the success of IDE initiatives and why. 5. Facilitation & Its Impact on IDE The role of the interdisciplinary facilitator is regarded as pivotal in the IDE literature (Barr 1994; Casto 1994; Parsell and Bligh 1998; Cleghorn and Baker 2000). As Barr (1996:244) argues: "[The interprofessional facilitator needs to be] attuned to the dynamics of interprofessional learning, skilled in optimizing learning opportunities, valuing the distinctive experience and expertise which each of the participating professions brings."
In interprofessional education, the traditional notion of the 'expert teacher' needs to be replaced by that of a 'facilitator' (Fox 1994) or “coach” (Schon 1987). Instead of 'teaching' to learners, facilitators need to 'work with' learners. This approach was initially advocated in adult learning literature (Knowles, 1980). Two issues related to facilitation are worthy of discussion: facilitation strategies and facilitator preparation. 114
It is argued that in order to positively affect collaboration between learners, facilitators need to pay attention to facets of facilitation that involve both team formation and team maintenance. In doing so, it is argued that the opportunities for enhancing the knowledge and skills for collaboration can be maximized.(Headrick, Wilcock et al. 1998; Parsell and Bligh 1998) Facilitators must be ready to encounter interprofessional friction between learners when they are working together. (Hammick 1998) It is felt that problems can arise between learners particularly over ‘sensitive’ areas such as misunderstanding over professional roles. Offering more autonomy to groups during their learning can help to optimize good interaction between learners versus interaction between learners and the facilitator. This allows for the development of self-directed learning opportunities (one of Knowles’ principles of adult learning) particularly if the group of learners has a mature system of facilitating their own discussions. (Thomas 1995) This method of facilitation works particularly well for post-licensure practitioners. (Howkins and Allison 1997) The literature offers little in the way of empirical accounts of the effectiveness of these facilitator approaches. As a result, there is a need to learn more about what facilitation methodology methods work best. In considering the type of preparation for facilitators, the interprofessional education literature falls short. Although a number of authors stress the need for good interprofessional facilitation, little is offered in terms of suggestions which could actually inform potential facilitators. Much of the literature written in this area, although sparse states that facilitators should have knowledge of interprofessional learning and has experience working in an interprofessional approach them. (Lary, Lavigne et al. 1997) (Perkins and Tryssenaar 1994) (Funnell 1995) Some also state that it is important that facilitators need to understand issues of power and hierarchy which are connected to the everyday practice of the health care teams. (Thomas 1995; Miller, Ross et al. 1999) Therefore it seems that good preparation is central to the success of an interprofessional initiative but it is not yet known what type of preparation is needed and whether preparation indeed improves IDE success. This is a gapwhich needs to be addressed. 6. Factors Influencing IDE Success There are a number of factors that can act as either barriers or enablers for the success of IDE initiatives. At the pre-licensure level, there are a number of factors that need to be specifically addressed. The factors can be subdivided into issues directly related to the learner, the teaching environment and the institutional environment. Parsell & Bligh (1998) listed a number of these barriers that must be overcome if IDE is to be advanced in Figure 3. The main issues that will be discussed for the purpose of this review will be: the socialization process which naturally occurs amongst health professional learners in training; logistical issues for both learners and faculty that affect the teaching environment; and support from decision-makers in higher education institutions. By gaining a better understanding of some of the barriers that IDE faces, we may be able to find ways to overcome them and advance IDE forward. Particular challenges are faced within the pre-licensure levels of training that is highlighted in the figure below.
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Figure 3: Barriers to interprofessional learning in pre-licensure courses (Parsell & Bligh, 1998:94) Single subject approach to teaching Curriculum structures and design Timetabling difficulties Time eg. For course planners to meet Lack of senior management support Practical difficulties e.g. Separate buildings Lack of commitment Lack of knowledge and understanding of other professions Redrawing of professional boundaries Need for new forms of teaching and learning Training teachers for a different teaching role Unwillingness to change attitudes Requirements of professional bodies Separate professional ‘languages’ and concepts Financial constraints
________________________________________________________________________ 6.1. Socialization & Its Effect on IDE In thinking about where some of the resistance may reside in IDE implementation we must consider the issues related to the learner. Individuals embarking on interprofessional educational initiatives are those who have chosen to enter a particular health professional field because of their own attitudes, beliefs and understandings of what their chosen profession means to them and how they see themselves in that role in the future. Through the transfer of professionspecific attitudes, knowledge and behaviours, a professional culture is developed often beginning in pre-licensure education continuing well into the post-licensure workforce years. We outline the notions of how the socialization practices impact attitudes, values and beliefs of learners which often have a negative effect on IDE initiatives. In most higher education institutions, health professionals are trained separately with minimal interaction with other health professional trainees. This undoubtedly affects the socialization processes of identify formation. As Drinka and Taylor write “the new “inductees” in health professions training programs are usually protectively housed in different buildings on campus – where they can be free from the potentially contaminating and threatening influences of students and faculty from other fields.” (Drinka & Clark, 2000:66). The professional socialization process is regularly acknowledged within the literature as an important factor affecting collaboration within IDE initiatives (Tryssenaar 1994; Zungalo 1994) While there are many cultural similarities between professions (for example, the language of medicine), there are differences in the way health professionals view themselves vis-a-vis patients and other members of the health care team. (Austin and Beales 2004) For example, for medical students, it has been written that part of their socialization process is the development of a “cloak of competence” where they feel they must learn how to be authoritative in professional situations. (Haas and Shaffir 1991; Headrick, Wilcock et al. 1998) Differing types of professional knowledge and value systems that each profession places on either the natural
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sciences or social sciences can also create distinctly different professional cultures. This can isolate professionals from one another and impede their collaborative learning and practice opportunities. (Freeth & Nicol 1998) In addition, professional or 'turf' protectionism is another cultural factor which has negatively impacted students and practitioners in participating in interprofessional education initiatives. (Itano, Williams et al. 1991; Skovholt, Lia-Hoagberg et al. 1994) (Connolly 1995; Pirrie, Wilson et al. 1998b) Learners enter their health professional programs with stereotypes of their own professional identities and stereotypes of others. (Tunstall-Pedoe, Rink et al. 2003) Professional hierarchy, as a learned stereotypical construct, may be a challenge for interprofessional education. For example, research by Reeves (2000) with pre-licensure medical, nursing and dental students found that, based on pre-course interviews, nursing students generally felt they had lower academic status and their intended profession was less ‘prestigious’ than medicine. For them, medical knowledge was regarded as ‘higher’ status. Based on these views, the differing students had constructed a range of stereotypical notions of how the 'other' students would behave towards them during their interdisciplinary education learning. Encouragingly, these views were observed not to have any profound affect on the interaction of these students over the duration of the interdisciplinary education course. However, it stresses the notion of stereotypical attitudes and beliefs that may impact an interdisciplinary education initiative. As this study was a small scale qualitative project one must be cautious on how generalizable these findings are to other pre-licensure courses. However, it does give insight into the learners’ belief systems. In considering our learners, we know that they will be embarking upon gaining competence in the knowledge, skills and attitudes for their own uni-professional specific programs. However, there may be an opportunity to influence the types of attitudes that they develop through a different form of socialization process. This process would increase opportunities for trainees to learn together, tearing down the buildings that isolate them from each other and perhaps, diminish the already formed stereotypes they enter their health professional programs with. 6.2. Logistics & Its Impact on IDE It is generally agreed that organizing interprofessional education is a difficult task to achieve as there are numerous logistical obstacles which all need to be overcome. (Collier 1981; Lough, Schmidt et al. 1996; Pryce and Reeves 1997; Miller, Ross et al. 1999) In particular, organizing pre-licensure courses across health professional training programs involves overcoming a number of what Pirrie et al (1998) refer to as 'internal inhibitors' (such as: inequalities in the number of students, geographical isolation from one another, differences in curricula which cause timetable clashes) and 'external inhibitors' (like: securing joint validation and accreditation, agreeing on joint financial arrangements). This complex range of factors all need to be negotiated and ultimately resolved between course organizers even before course can usually take place.
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The way interprofessional education is planned may be a major determinant of the success of the initiative. It is important to identify who the key partners are in the initiative and involve them in the planning and implementation from the very beginning. (Parsell and Bligh 1998) (Parsell and Bligh 1998; Nasmith, Oandasan et al. 2003) Creating a collaborative initiative requires collaborative planning by all representatives of the health professions involved. As one can see the planning of interprofessional education involves a number of complex issueswhich require a significant amount of timewhich may cause further logistical difficulties amongst staff involved in organizing interprofessional education. (Chapman, Hugman et al. 1995; Freeth, Myer et al. 1998) Often collaborative projects are initiatives that are usually undertaken on top of a normal workload by a committed few. (Sommer, Silagy et al, 1992) It is generally agreed that staff who are committed to interprofessional education should be recruited to undertake this work (Boyer, Lee et al. 1977; Collier 1981; Lough, Schmidt et al. 1996) It is argued that such staff will be prepared to devote their time, energy and enthusiasm overcoming the various educational, professional and logistical difficulties associated with IDE activity. However, as (Freeth 2001) points out, where interprofessional education is dependent upon the input of a few key enthusiasts, it can encounter problems of continuity when these individuals move on. When this happens, an initiative may wither away. 6.3 Faculty Support and its impact on IDE The faculty plays a key role in creating an environment that is supportive of the goals for IDE and indeed can act as role models for trainees (Gill and Ling 1995) (Waugaman 1994; Parsell & Bligh 1998). The perceived status or importance of IDE can be negatively affected if faculty does not “walk the talk”. (Falconer, Roth et al. 1993; Mathias and Thompson 1997; Graham and Wealthall 1999) Lingard noted that for surgical resident trainees who are developing their sense of professional roles, echoing “the surgical community’s prominent discourse patterns serves as a way of advertising community membership: ‘I walk and talk like you, therefore I am worthy of belonging’. (Lingard, Reznick et al. 2002) The implications for this professional socialization through discourse role modeling needs to be reflected upon by health educators, particularly as many of the discussions may relate to negative opinions about other health professionals which may be overheard by trainees in non-formal learning settings (e.g. cafeteria, hallways etc.) Thus, just as the socialization process for learners has an effect on IDE, its effect is heightened for faculty, as many may be unwilling to change their attitudes and or be unwilling to learn different ways of practicing and/or teaching that may be more conducive to IDE. (Parsell and Bligh 1998) 6.4 Support from Decision-Makers Within the literature, there is consensus that the success of any interprofessional initiative depends on attracting commitment from two important sources: political and institutional. Indeed, it is argued that political support for interprofessional education can create the necessary 'incentive' for educational institutions to begin operationalizing this activity (Parsell & Bligh 1998; Freeth 2001). Indeed this is what has happened in the United Kingdom when the National Health Service (NHS), called for a partnership amongst all 118
health care workers to ensure seamless service for patient-centred care and announced the development of a “new core curriculum” to give everyone working in the NHS the skills and knowledge to respond effectively to the individual needs of patients. (Barr 2000) Universities and higher education colleges were given the mandate henceforth to provide interprofessional training. The government endorsement created the impetus for change. At the level of the academic institutions it is noted that support is needed from senior administrators who have the power to decide on educational policies and control resources. (Shaw 1994), (Goble 1994) (Carpenter 1995c) (Edwards, Stanton et al 1997, (Pirrie, Wilson et al. 1998b)They can implement changes in course structures, conjure up faculty support through academic incentives, provide funding to operate IDE budgets and have a major role to play in the long-term sustainability of initiatives. Getting support from key senior administrators can be a challenge but with political backing it is possible for interprofessional education to become a priority issue. Institutions are also influenced by decisions made by accreditation, certification and licensure bodies. As mentioned earlier, the IOM has decided to utilize this lever to try to encourage health professional programs in the United States to adopt the five competencies which they feel health professionals need to master to provide the best care to the American population. (Greiner 2003) In the United Kingdom, the Quality Assurance Agency has agreed upon benchmarks or statements to describe the “nature and standards of study” for nursing, midwifery and the professions allied to medicine in the pre-licensure years of training. (Barr 2001) In both the United Kingdom and the United, extensive consultations were required amongst the various stakeholders in order for agreement to be reached. However, once consensus is made, the levers become very powerful movers for institutions to enact change. Despite offering some helpful 'clues' into what types of support are required to develop interprofessional education in the pre-licensure years using a micro (learner/educator), meso (teaching environment) and macro level (institution/government), the literature does not provide a deep understanding of what processes of interaction and negotiation are involved in securing support? One of the main reasons for this shortfall is that the literature does not contain any research in explaining the nature of securing 'support' for interprofessional education. A gap needs to be filled in this area.
Post-Licensure Educational Interventions Although most of the discussion to this point in this chapter has related to the academic institutional environment with trainees from the pre-licensure level of training, there is a need to discuss educational interventions that can be implemented for post-licensure health professionals. Currently there is a lack of formalized educational methods used to enhance the post-licensure health professionals’ opportunities to gain specific competencies related to collaboration. Suffice it to say there are potentially different types of educational initiatives that can be used with post-licensure health professionals in practice. The types one can foresee providing include “Professional Development” initiatives and “Continuing Education (CE) initiatives”. Currently, there is confusion related to the differences of these types of educational interventions even beyond IECPCP. 119
Similar to our earlier discussion on goals, if the goal of post-licensure interdisciplinary educational initiatives is to teach collaborative competencies then the content must be on interdisciplinary knowledge, skills and attitudes that can affect ways of heath professionals practicing with each other. In essence, different types of health professionals may be brought together to learn how to improve their management of congestive heart failure using the latest pharmaceutical guideline and this may be classified as continuing education. However, when different health professionals come together to learn how each health professional can contribute and work with each other in the management of congestive heart failure and develop new ways of working together in improving patient care, therein lies the difference between continuing education and professional (team) development. In the latter, there is a requirement of an implied understanding of different roles, a willingness to incorporate new health professionals in the management of patient care and mutual respect and trust that has been established to ensure that collaborative working relationships can be developed. These interactional determinants were described by D’Amour in the previous chapter. If these determinants are not in place, then there is a role for an educational intervention to help provide the knowledge, skills and attitudes (competencies) to get the health professionals to a place where they can begin to find methods to change their uni-professional ways of practice to inter-professional collaborative practices. Chapter 3 on the Conceptual Framework helps to provide further understanding of the nuances of education for post-licensure practitioners. The notion of Faculty Development should also be addressed at this time, as the educators who are the health professionals who are working at the post-licensure level require skills to teach curricula developed for IECPCP. Not all health professionals are expected to be educators, hence those who do choose to teach this area must be given “Faculty Development” to specifically address teaching skills for IECPCP. These “would –be IECPCP health professional educators”, must be collaborators themselves who have developed collaborative competencies in some way, practicing in a patient-centred collaborative manner. Currently, very little faculty development initiatives have been described in the literature.
Evaluation of IDE: Issues Related to Outcome Measurements of IDE Initiatives &Assessment of Learners There are two forms of evaluation that are required of any educational initiative. The first is an evaluation of the program itself and the other an evaluation or assessment of the learner and the particular knowledge, skills and/or attitudes gained from the educational program. These two types of evaluation processes are described below. 1. Evaluation of IDE Programs In considering the impact of IDE initiatives, many would say that the strongest evidence to show that IDE has true impact would be to measure improvements in patient/client outcomes. Indeed that is what Zwarenstein et al. set out to find when they conducted a systematic review of the literature on IDE in 1999.(Zwarenstein, Atkins et al. 1999) The final conclusion from the
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Cochrane report was: “there is no published evidence that interdisciplinary education promotes interprofessional collaboration or improves client relevant outcomes.” The same author of this paper conducted a similar systematic review of the literature five years later for this report and again, in Chapter 2 found the same findings. Although this may sound discouraging for some and even evidence for others that there is no need to encourage the development of IDE, one must still remember that: “No evidence of effectiveness is not evidence of ineffectiveness”. (Hammick, 2000) The Centre for Advancement of Interprofessional Education (CAIPE) in the United Kingdom recognized that there may be other studies in the literature that were excluded from the Cochrane Review as they did meet its rigid evaluation standards but could still provide useful information. They launched their own systematic review entitled the “Jet Review” (Freeth, Hammick et al. 2002) Three questions were asked of the literature: • • •
What are the interprofessional learning experiences and processes of learning? What are the outcomes of interprofessional education? How can the impact of interprofessional education be measured?
In reviewing the literature, they determined that there are various forms of outcomes that are being measured beyond patient outcomes that are of importance in understanding issues related to interprofessional learning. These outcomes are listed in Figure 4. The Jet reviewers acknowledge that the educational outcomes listed are a modification of Kirkpatrick’s Model of Educational Outcomes. (Kirkpatrick 1976), In the Jet Review, only 53 articles out of an eligible 217 articles (using a search strategy including Medline 1996-2000, CINAHL 1982-2001, and British Education Index 1964-June 2001) were found to be of good quality for consideration of reliability/validity or trustworthiness/authenticity. In the last few years since the Jet Review, not much has changed in the literature related to rigid evaluations to determine effectiveness of interdisciplinary education in terms of collaborative practice and quality of care. (Barr, Koppel et al. forthcoming) However, in the last few years we are learning more about the components related to teaching interdisciplinary education. Effectiveness measurements through rigorous evaluation methods need to be developed and tested as noted by Reeves and Zwarenstein in Chapter 2 and others who write within this field of study.(Mattick and Bligh 2003) The learning curve is still steep in forming better pedagogical constructs of the “how” to teach interdisciplinary education. The use of qualitative research methods has been proposed by Zwarenstein and Reeves in Chapter 2 in order to help inform us better about these constructs. Not only is there a need to develop these educational methods, educators and researchers must find ways to rigorously evaluate the methods used to show the true impact of IDE. Currently, most studies have measured changes in attitudes as the method of outcome measurement. But as we can see from Figure 4, the modified Kirkpatrick Model of Educational Outcomes, there are other methods beyond attitudinal shifts that can measure impact of IDE. Ultimately, improvement of patient outcomes is one of the key strategies for advancing IDE and we need to strive for ways in which evaluations of IDE can be conducted which meet the methodological criteria of systematic reviews. (Hammick 2000)
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Figure 4:
Modified Kirkpatrick’s Model of Educational Outcomes for IDE By the Jet Review (Freeth et al. 2002:14) 1/ Reaction Learners’ views on the learning experience and its interprofessional nature 2a/ Modification of attitudes/perceptions
Changes in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude towards the value and/or use of team approaches to caring for a specific client group.
2b/ Acquisition of knowledge/skills
Including knowledge and skills linked to interprofessional collaboration
3/ Behavioural change
Identifies individuals’ transfer of interprofessional learning to their practice setting and changed professional practice
4a/ Change in organizational practice
Wider changes in the organization and delivery of care.
4b/ Benefits to patients/clients
Improvements in health or well-being of patients/clients.
2. Assessment of Learners The literature is sparse related to “how we can assess competencies related to collaborative practice”. Most of the assessment conducted after IDE initiatives have been in the realm of measuring shifts of attitudes. (Luecht, Madsen et al. 1990; Baggs 1994; Parsell and Bligh 1999; Hyer, Fairchild et al. 2000) However, there needs to be ways to measure not only attitudes but knowledge and skills related to collaborative practice as well. There have been a number of definitions of competence in the educational literature. Mast and Davis described competence as what one can do and performance as what one actually does. (Mast and Davis 1994) In describing how to measure competence, Norman uses the concept of “KNOW – CAN -DO”. (Norman 1991) He describes “KNOW” as the ability to know something in theory which is most often measured in a written format. “CAN” is the ability to do something in an observed setting like a standardized patient examination. Finally “DO” is what one does when no one is looking, which is the basis for quality assurance techniques like practice audits. The University of Alberta has contributed to the area of assessment by measuring what trainees’ “CAN” do in an observed setting, using a Team Oral Structured Clinical Examination or (TOSCE) to measure their acquired knowledge and skills from participation in a mandatory interdisciplinary team course at the undergraduate level. (King, Boman et al. 2003) Few other assessment models were found in the literature to date and hence there is an urgent need to foster the development, implementation and evaluation of competency assessment tools in the area of IDE.
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Summary The recipe for interdisciplinary education is interesting at this juncture of time. We know many of the ingredients that are needed but may not be sure how best to mix them together to create the best outcome. There may be particular environmental factors that may positively or negatively impact the recipe. The final product may vary according to who the chefs may be and where the recipe is being created. Ultimately, many wait in anticipation for the product that they believe is worthwhile. This chapter provided an overview of some of the ingredients or elements that are required for IDE. There is much more to learn. In terms of future directions in this field, particularly for Canada to consider, the following questions below highlight some of the issues that remain contentious and require further answers. Some of the questions are concurrent with the other chapters in this report. The questions are meant to provoke further discussion to advance IECPCP and its understanding in Canada? •
What terminology should we in Canada adopt when discussing interdisciplinary initiatives? • Do we expect all health professional trainees to share the same collaborative competencies? Is there a common definition amongst all health professional training programs about the competencies related to collaboration? • Is it feasible to introduce a spectrum of learning opportunities for health professional trainees during their health professional programs to include uni-, multi- and inter professional educational strategies? • How strong are the linkages between higher education institutions for health professional training and community practice settings that practice in collaborative ways? Are we optimizing our opportunities to find and utilize these collaborative practice ideal settings for learners? Are we aware of best practices that are in existence for collaborative practices within our own health care communities? • What opportunities exist for using service-learning as a way to teach interprofessional education? • How can we develop ways to improve our understanding of methods of facilitation and facilitation preparation through faculty development? • Do we have a good understanding of the types of levers that can be used to overcome macro-, meso-, and micro- level barriers that have been identified influencing the success of IDE advancement? • How can we improve the type of rigor used in evaluating IDE initiatives and promote dissemination of findings related to initiatives developed particularly in Canada? • Are there ways to develop and implement competency assessment tools to measure collaborator competencies for health professional trainees? • Are quality improvement and staff development initiatives which are conducted at the practice level with practitioners (post-licensure) considered educational interventions? How are they similar or dissimilar to higher education institutionally led IDE programs? Should distinctions be made between post-licensure and prelicensure educational initiatives and why?
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Chapter Five Examples of Interprofessional Education and Collaborative Practice: Findings from On-Line Survey By Keegan Barker
Introduction An environmental scan was completed to investigate the different initiatives and programs in IECPCP across Canada. The environmental scan consisted of an online survey, as well as several in-depth interviews. The current chapter will discuss the results of the online survey. The chapter begins with the background of the online survey, followed by the methodology used. Next, results will be presented, in the order of broad findings, then findings regarding interdisciplinary education and finally results on collaborative patient centred care. Lastly, a summary of these findings as well as a discussion and recommendations will conclude the chapter. For clarity throughout this chapter, use of the term “program” will refer to interprofessional education efforts, while “initiative” will refer to collaborative practice efforts.
Background: On-Line Survey An online survey was developed in order to document efforts in interprofessional education and collaborative patient centred care. (See Appendix 5-1 on page 159) The survey provides a portrait of interprofessional education and collaborative patient centred care in Canada, as well as some international examples. The goal was to capture initiatives and programs in Canada and abroad in order to also create a database of key players (individual informants, institutions and programs). The research team determined that an online survey would provide an economical, efficient method of reaching a large audience within a short amount of time.
Methodology As cited above, the environmental scan’s goals were to: (1) describe the initiatives and programs in Canada in the area of interdisciplinary education and collaborative practice, and (2) develop a database to document names of individuals involved in the area, as well as names/locations of initiatives.
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Because the goals were twofold, the methodology described below will outline the development of both of these processes. 1. Database – A master database of individuals (n=821) was generated that includes all the names of actual, and potential survey respondents (this database is housed with Health Canada). Surveys were sent to approximately 67% of those in the database. The remaining database entries were not sent surveys because of incorrect or absent email addresses. A second database (this database is housed with Health Canada) was developed which includes the programs and initiatives in IECPCP of which we became aware through the environmental scan. The database also contains the names of the individuals who were informants about the programs, regardless if they informed us via their survey response or by another mean. It should be noted that not all respondents provided such detailed information, and thus not all respondents (n= 316) are included in this database. As previously mentioned, respondents may have anecdotally reported upon initiatives with which they were familiar, not necessarily those with which they were involved. The information on the programs/initiatives contained in Appendix 5-2 on page 169 was obtained from: i)
qualitative analysis of segments of the open ended survey responses, including answers to the question "what opportunities are you aware of that support interdisciplinary education and collaborative patient centred care?" ii) the in-depth interviews that were conducted in Chapter 6 iii) informal communication with the research team iv) a survey that was sent to the Canadian Deans of Medicine regarding interprofessional education initiatives, in order to supplement the online survey information (See Appendix 5-3 on page 172) v) the results of a presentation on the in-depth interviews (conducted by Brandcue) with the members of the National Expert Committee on IECPCP (November 2003). Some column headings in this database have explanations, as indicated by a red triangle in the upper right corner of the cell. Readers can access these explanations by placing their cursor over the cell. 2. On-Line Survey—The survey was created with consensus from the research team members. Their collective expertise in interdisciplinary education and collaborative practice was used to construct the survey tool. The survey was posted online (via an online survey company) in early December 2003. A French version of the survey was posted in midDecember 2003. The potential survey participants were identified via a purposeful sample1. Each member of the research team generated a list of “key players” in the areas of interprofessional education and collaborative patient centred care. In addition, health associations, deans of medicine, and ministers of health were added to the list.
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The initial request for completion of the English survey was sent to 170 people. The initial French survey was sent to 12 people. Electronic mail-outs continued on a daily basis from December 8, 2003 until the survey closing date of January 16, 2004. To generate further names of people to whom the survey should be sent, a snowball sampling technique2 was utilized. Each participant who completed the survey was asked to provide the names of 3 other individuals (each) in the areas of: (a) interprofessional education and (b) collaborative patient centred care. Reminder emails were sent as the closing date of the survey approached, in accordance with reminder recommendations outlined in the Dillman survey technique3.
Findings of the On-line Survey The number of surveys sent including responses is noted in the following table.
English survey
Table 1 – Survey Response Rate Survey sent to Respondents Response Rate (N) (N) 497 287 57.7%
Declined (N) 14
French survey
53
4
29
54.7%
In examining the response rates, it is important to note that the response rate is affected by nonresponders. Non-responders included those who received notification of the survey and chose not to respond, and those who may have not have received the notice due to email errors, SPAM filtering devices and absence from office/sabbatical. Data from the online survey participants (n = 316) provided an understanding of : (1) a broad sense of all the initiatives reported, (2) more detailed understanding of the results according to the areas of interprofessional education and collaborative patient centred care. The results provided examples of interprofessional education and collaborative practice that currently exist in Canada, and abroad. When the program/initiative locations that were clearly reported were analyzed, it revealed that 84.9% of interdisciplinary education programs and 95.7 % of collaborative practice initiatives were Canadian. Broad Description of Programs Reported One hundred and seventy-seven (177) respondents reported that they knew of an interprofessional education program, and 91 respondents reported that they knew of a collaborative practice initiative. However, of these 162 went on to actually described an interprofessional education program, and 86 went on to describe a collaborative practice initiative.
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Missing Values Before going on to describe the findings of the online survey, readers should be cognizant of the missing data for the survey. In Table 2, readers will see the questions that were asked of respondents, and the number of people that answered those questions. Table 2:
Number of responses to key questions in the survey Question
First question in Interdisciplinary Education segment of survey: (a) I know of an interdisciplinary educational program which I can report via this survey (b) I do not know of an interdisciplinary educational program which I can report via this survey.
N 234 answered this question: (a) N=177 (b) N=57
People who did not answer this first question
N=82
People who stated they knew of an interdisciplinary educational program, but did not go on to describe it in the survey
N=15
People who stated they knew of an interdisciplinary educational program and went on to describe it in the survey
N=162
Will you be describing a successful or unsuccessful program?
Successful N=157 Unsuccessful N=5
First question #1 in Collaborative Practice segment of survey: (a) I know of a collaborative practice initiative which I can report via this survey (b) I do not know of collaborative practice initiative which I can report via this survey.
N= 195 answered this question: (a) N=91 (b) N=104
People who did not answer this first question
N=121
People who stated they knew of a collaborative practice initiative, but did not go on to describe it in the survey
N=5
People who stated they knew of a collaborative practice initiative and went on to describe it in the survey
N=86
Will you be describing a successful or unsuccessful initiative?
Successful N=81 Unsuccessful N=5
Findings: Interprofessional Education Because many people have different understandings of interdisciplinary education, it was important to define what we meant by the term interdisciplinary education. In the online survey it was defined as “learning together with the specific goal of promoting collaboration"4. Of the 162 respondents who went on to describe the interprofessional education program of which they knew, successful programs were reported in 96.9% of cases.
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Respondents were asked why they considered the program as “successful”. Their answers reflected an array of definitions of success: • • • • • • •
positive learner involvement (good attendance, positive learner feedback) learners obtained increased knowledge, attitude shifts and enhanced skills for collaboration and interprofessional interaction. attitude shifts in faculty patients communicated positive experiences, and patient outcomes improved program itself was affected in that it experienced increased activity (either by receiving more referrals or via growth of the program). program met its goals and objectives success in the human resource area, in that the program was cost efficient and/or it helped with health professional recruitment.
By contrast, those programs that were described as unsuccessful provided reasons why this was so: • lack of time • lack of structural support for changes, some curriculum leaders failed to include the learning material Interprofessional Education: Location, Learners & Length of Programs Respondents were asked to classify where the program took place: 50% specified higher education institution, 10% service setting, and 40% mixed setting (a higher education with service setting links or vice versa). In those settings that were service or mixed, they were asked to further provide details regarding the type of setting. This information is provided in Table 3. Table 3:
Percent of Service or Mixed Setting Programs across Primary, Tertiary, Rehabilitative Care and Other Primary Care
Tertiary Care
Rehabilitation
Other
40.9 %
8.5%
7%
43.7% -a mix of: hospital & community care; acute & tertiary care; primary care & rehab -rural setting, Northern setting -community setting, community practice, private practice -a focus on disease group instead of care setting, e.g. cardiovascular, service for distressed children & families, geriatrics, mental health -long term care, palliative care -health sciences centre
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The composition of discipline of learners and educators for each setting type are presented graphically, in Figure 1. This figure outlines the disciplines of learners and educators in higher education programs (n= 77). Readers will note that both Figures 1 and 2 suggest a high concentration of students from nursing, medicine, and physiotherapy. In addition, there is consistent lack of involvement from psychology and chiropody. Fig. 1 - Percentage of higher education programs with at least one learner/educator from this discipline
Learners
T Ph ar So m cW or k N ut rit io n Ps yc ho l C hi ro p
Educators
O
M ed ic in e N ur si ng Ph ys io O th er
80 70 60 50 40 30 20 10 0
Figure 2 outlines the disciplines of learners and educators in either service setting or mixed setting programs (n= 77). Fig.2- Percentage of service/mixed setting programs with at least one learner/educator in this discipline 70 60 50 40
Learners
30
Educators
20 10
O
T N ut rit io n Ps yc ho l C hi ro p
M
ed ic in e N ur si ng Ph ys So io cW or k O th er Ph ar m
0
In order to gain a clear perspective of the programs in existence, the category of “other” in the above two figures was important to analyze so that there could be an understanding of all the different disciplines involved. Those disciplines unique to interprofessional education (i.e. not cited in collaborative practice) are highlighted with underlining. The disciplines involved are included in Table 4.
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Table 4: “Other” disciplines involved in interdisciplinary education programs Health Disciplines • Therapists & Mental Health - counseling/mental health/clinical psychology/social work - music/art therapy - biofeedback therapist - health promotion/support worker - radiation oncology therapist - physical therapy • Communicative specialists - audiology - speech language pathology - communication disease specialist • Muscle/skeletal health - chiropractic care - massage therapy • Oral Health - dental hygiene, dentistry • Health Technology/Engineering/Science - biomedical engineering - medical lab technology/science - radiology technician - respiratory therapy/technician - diagnostic cytology - pharmacy technologist - nuclear medicine technician •
•
•
•
Non-health Disciplines anthropology bioethicist business chaplaincy pastoral/spiritual care criminology economist law physical education/kinesiology/recreation/health education physics psychology sociology mental health service users
Health Administration/policy/research - health administration -medical records clerk - public health policy - epidemiology/demography Nursing - nursing/nurse educator, - nursing attendant, - nurse practitioner Complimentary/alternative medicine - midwifery - naturopathic/homeopathic medicine - traditional Chinese medicine/acupuncturist Other - clinical vision specialist - physician assistant
Respondents were asked to designate the education levels of the interdisciplinary education program participants. These are depicted in Figure 3. For the purposes of the survey, “undergraduate” referred to those in professional training, “postgraduate” referred to programs like medical residency, “graduate” meant programs like Masters of Social Work, Doctor of Pharmacy or fellowships. These three designations will be referred to collectively as “prelicensure”. The label “in clinical practice” was used in the survey to designate those in professional development, or in-service training. This label will be referred to as “postlicensure”.
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Fig.3- Percent of learners at various levels, by setting type
Mixed Setting Undergrad Postrgrad
Service Setting
Graduate Clin Pract
Higher Ed Setting 0%
20%
40%
60%
80%
100%
Respondents were asked for how many years the programs they described were administered, and this information is presented in Figure 4, below. Realizing that the number of years may not accurately capture the influence of a program, respondents were also asked to determine the number of times a program had been implemented. This description may more accurately capture those programs that initiate activity more than once per year. These results are presented in Figure 5. This description may more accurately capture those programs that initiated activity more once per year. These results are presented in Figure 5. Fig.4- Number of years programs have run
Fig.5- Number of times programs have run Ran once 6%
1 year 13% 4+ years 47%
2 years 16%
3 years 24%
Ran twice 22% Ran 4+ times 56%
Ran 3 times 16%
Funding Influence on Educational Programs Due to the low number of “unsuccessful programs” that were reported, the use of Fisher’s Exact Test was utilized to determine if funding had an impact on success of programs. Caution should be noted here, as low frequencies of unsuccessful cases make it difficult to interpret this result. Regarding funding, 71% of respondents stated the educational programs received funding (See Appendix 5-2 on page 168 for a list of those funding bodies). In general, funding was not found to have an impact on the success of the program (p = .07). However, of those programs that ran 3 or more times, it appears that funding may have had somewhat of an effect, as the analysis showed near significance (p = .058). More specifically, 73% that ran 3 or more times received funding versus 33% of those programs that ran once or twice. Once again, due to the low frequency of unsuccessful programs this result is difficult to interpret.
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Impetus for Educational Programs Curriculum development was indicated as an impetus for the educational programs 47.5%, 31% indicated ‘other’, 27.7% indicated “other”, 27.7% continuous quality improvement, 20.9% staff development, 15.8% research project, , 12.9% service/organization restructuring. Teaching Methods Used The respondents were asked to describe the programs, in terms of what teaching methods were utilized. Over half (51.98%) utilized workshops, followed by ‘other’ (36.16%), patient centred case conference (33.9%), patient interactions (30.51%), and development of clinical tools (16.95%). In order to determine whether a significant relationship existed between the teaching methods of the program and whether it was successful, Fisher’s Exact tests were run, with no significant findings between the methods and success: lecture (p=1.00), full course (p=0.58), workshop (p=0.65), patient conference (p=0.15), tool development (p=0.58), patient interaction (p=0.17), other (p=0.64). Once again, due to the low frequency of unsuccessful programs these results are unclear, due to statistical power. Patient Populations Involved in Educational Programs Respondents indicated which patient populations were involved in the various programs. Patient populations unique to interprofessional education programs (i.e. not included in collaborative practice initiatives) are highlighted with underlining. The array of patient populations involved is presented in Table 5. Table 5:
Patient populations involved in educational programs
Patient populations defined by health status -HIV/AIDS (patients and families) -Alzheimer patients -cancer survivors/patients, women with metastasis breast cancer -motor vehicle collision car accident victims -chronic/rehabilitation patients -chronic pain patients -families with infants with early behavior problems -orthopedic patients -psychiatry/mental health patients and those with post traumatic stress disorder -palliative care patients -pregnant women -patients with spinal cord injury -accident and emergency patients -ward patients -women going through menopause
Patient populations defined by socio-demographics -First Nations communities -adolescents -community-based populations in foreign countries (India, Niger, Mozambique) -rural people in developing countries -disadvantaged populations ([single] moms and infants, people in inner city, medically uninsured population) -elderly people and their families -geriatrics -pediatrics -persons with disabilities -rural patients and remote hospital in/out patients
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Patient Involvement in Program Patients were involved in 54.8% of programs described, however, patient involvement was not significantly related to the success of a program (p=0.08). Exactly how patients were involved was also queried, and respondents noted that patients were involved in various ways: as presenters/panelists who spoke about their experience from their own perspective (video or live); they interacted with learners in small group sessions, they were receivers/partners of care in clinics; as attendees to rounds and patient conference activities; as participants/students in the learning modules/courses; as standardized/surrogate patients; on program committees, members of boards, evaluation teams, and by assisting in the planning/delivery of sessions; some patients were observed by learners while receiving care from providers; as teachers and participants in courses; as consultants on the role they wanted to play in the interdisciplinary team and in the interdisciplinary action plan; and as interviewees. Evaluations of Educational Programs Respondents indicated that 89.3% of programs were evaluated. Of those that were evaluated, the majority were evaluated with a questionnaire (88%) while others were evaluated with an interview (44.4%) and other means (36.8%), while 39.3% of the programs utilized both a questionnaire and interview for evaluation. The timing of the evaluations varied, as depicted in Figure 8. Fig.8- Timing of evaluation by evaluation type (%)
other after
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Respondents were asked to indicate the specifics of what learners were asked about in the evaluations as presented in Table 6. Table 6:
Elements learners were asked about interdisciplinary education program evaluations Element Learners’ views on the learning experience and its interprofessional nature Knowledge and skills linked to interprofessional collaboration Changes in reciprocal attitudes or perceptions between participants Changes in perception or attitude towards the value and/or use of team approaches to caring for a specific client group Changes in interpersonal relationships and trust among team professionals Changes in professional practice in terms of sharing responsibilities Program logistics, administration (schedules etc) Transfer of interprofessional learning to their practice setting and changes in professional practice Improvements in health or well being of patients / clients Wider changes in the organization and delivery of care (organizational practice) Other Improvement in accessibility and /or continuity of care
Frequency indicated 79.5% 62.3% 55.5% 53.8% 52.1% 50.4% 42.7% 42.7% 33.3% 27.3% 23.9% 23.3%
Of those that evaluated their programs, only 7.3% (n=8) compared the evaluation results to a group that did not receive the program, and only 2 programs (1.8%) reported randomly assigning participants to either receive the program or not. Dissemination of Findings Regarding dissemination of findings, 31.6% reported the program results were published, while 60.8% reported presentation of results. Only 22.6% reported the results were both presented and published. Educational Materials Developed Lastly, respondents were asked to indicate what educational materials were developed from the program, and these results are presented in Figure 9. Fig.9- Percentage of programs that developed educational materials none workbooks manuals other curricula design workshops teaching methods 0
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Enablers & Barriers When respondents reported why they labeled the programs/initiatives as “successful” or not, some respondents highlighted various enablers and barriers to the programs, or what features either encouraged or discouraged the success of the programs. The data that respondents who described the “unsuccessful” initiatives is included under the barriers section of the table (specifically, points 3-5). The barrier of “timing” was cited both as a barrier to successful programs and a reason cited for unsuccessful programs. These determinants are presented in Table 7.
Table 7:
Enablers and Barriers to interdisciplinary education programs • • • • • • •
Enablers Sound program logistics & administration Balanced participation from different professional/discipline groups Programmatic and financial sponsorship Organizational support Critical mass of learners Participant compensation Quality improvement paradigm
• • • • •
Barriers Regarded as non-typical experience Lack of one’s own role understanding Timing (lack of time, scheduling) Lack of organizational-culture support Curriculum leaders failed to introduce course material
Findings: Collaborative Practice Once again, realizing that there exist many different understandings of IECPCP, for the purposed of the survey, it was important to state that by collaborative practice we meant “the structuring of collective action through information sharing and decision making in clinical processes”5. Ninety-one (91) people stated they knew of a collaborative practice initiative, but only 86 of those went on to actually describe it. These respondents reported that 94 % of the initiatives in collaborative practice initiative were successful. Similar to the education program question, respondents were asked why the considered the program as “successful”. To clarify, those “success” indicators that were also cited in interdisciplinary education programs are highlighted in italics as follows: • • •
•
increased activity or growth of the initiative positive participant outcomes regarding attitudes, skills, knowledge and increased/widened perspectives team members embodied collaboration skills: teams were flexible, respectful, professional and energized with good morale (a successful education program was one that increased the skills of learners in collaboration and interprofessional relations, while a practice initiative’s success was a team that embodied those skills) patient/community outcomes (increased access to care, appropriate use of services, 141
• •
satisfaction with services and improved coordination to care) positive human resource implications ( e.g. attracting qualified and skilled professionals to the community) attitude shifts (in education those shifts happened with faculty, and in collaborative practice, they occurred in the organization).
Collaborative Practice: Location Respondents were asked to classify where the initiative took place: 7.8 % specified higher education institution, 50.7 % service setting, and 41.5% mixed setting (higher education with service setting links or vice versa). In those settings that were service or mixed, respondents further provided details regarding the type of setting. This information is provided in Table 8. As readers can see, there are similar distributions across the different care settings, with slightly more involvement in tertiary care in the collaborative practice initiatives than those educational programs previously described 8.5% Table 8:
Percent of Service or Mixed Setting Programs across Primary, Tertiary, Rehabilitative Care and Other
Primary Care 41.9 %
Tertiary Care 14.5%
Rehabilitation 6.5%
Other 37.1% -various combinations of settings: primary & secondary acute, primary care with hospital-based components, community hospital & outreach -continuing medical education event -focus on disease/patient group instead of practice setting: teenagers in crisis, patients of various surgical procedures, urban Aboriginal health centre -home care -palliative & long term care
Disciplines of Professionals Involved The composition of discipline (nursing, medicine, physiotherapy, occupational therapy, pharmacy, social work, nutrition, psychology, chiropody, other) of personnel (both initiative participants, and initiative leaders) for each setting type is presented graphically, below. Figure 10 outlines the disciplines of participants and leaders in those initiatives situated in a higher education setting. It is important to note here that the number of initiatives categorized under this higher education label who answered these questions was n= 6. Fig. 10 - Percentage of collaborative practice intiatives in a higher education setting with at least one learner/educator from this discipline 60 50 40 30 20 10 0 O T Ps yc ho l C hi ro p
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Figure 11 outlines the disciplines of participants and leaders in either service setting or mixed setting initiatives. Respondents to these questions were n= 71. Similar to education programs, nursing and medicine had high involvement, and little involvement from psychology and chiropody. Fig.11- Percentage of service/mixed setting programs with at least participant/leader in this discipline
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Once again, because the survey research was focused on obtaining a broad sense of the initiatives that exist in Canada and abroad, it was determined that the category of “other” was important to distill in order to gain a clear perspective of the participants involved in these initiatives. Those disciplines unique to the collaboration practice initiative are highlighted with underlining. This information is depicted in Table 9. Table 9:
“Other” disciplines involved in collaborative practice initiatives Health Disciplines • Therapists & Mental Health - counseling/mental health/clinical psychology/social work - health promotion/support worker - music/art therapy • Communicative specialists - speech language pathology • Muscle/skeletal health - chiropractic care - massage therapy - physiotherapy • Oral Health - dentistry • Health Technology/Engineering/Science - medical lab tech/science - radiology technician - respiratory therapy/technology • Health Administration/policy/research - administrative database operator - health administration - program manager • Nursing
Non-health Disciplines - chaplaincy pastoral/spiritual care - physical education/kinesiology/recreation/health education - computer scientist - First Nation elders - language teacher
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Health Disciplines - nursing/clinical nurse specialist • Complimentary/alternative medicine - First Nation traditional healer - midwifery - naturopathic/homeopathic medicine - traditional medicine/acupuncturist • Other - ambulance attendant - community organizer - medicine (specialty) - psychiatry
Non-health Disciplines
Length of Initiatives Respondents indicated the number of years the initiatives they were describing were implemented. This information is presented in Figure 12. It was realized that the number of times an initiative was implemented may more accurately capture those initiatives that initiated activity more than once per year. These results are presented in Figure13. Fig.12- Number of years programs have run
Fig.13- Number of times initiatives have run Ran once 11%
1 year 11%
Ran twice 9%
2 years 11% 4+ years 58%
3 years 20%
Ran 3 times 9% Ran 4+ times 71%
Funding influence on Collaborative Practice Initiatives Regarding funding, 61.9% of respondents stated the initiatives they described had received funding. Please see the second half of Appendix 5-3 on page 168 for a list of those funding bodies. As was the case of the educational initiatives, there was a low frequency of ‘unsuccessful’ initiatives, reported in collaborative practice. Thus, in order to determine if funding had an impact on an initiatives’ success, Fisher’s Exact test was initiated. Once again (as in the case of educational programs) funding did not have an impact on the success of an initiative. (p = .64). In addition, contrary to the finding that long running education programs appeared to be related to funding status (though not statistically significant), long running collaborative practice initiatives were not related to funding (p = 1.00). However, there were only 5 initiatives that ran once or twice and this low number presents significant challenges to a meaningful analysis.
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Impetus for Collaborative Practice Initiatives The most frequently cited impetus of collaborative practice initiatives was “other” at 39.6%, followed closely by 34.1% continuous quality improvement (CQI). This is in contrast to the education program strong impetus of curriculum development, while collaborative practice initiatives tallied only 17.58% in this category. In addition, other collaborative practice initiatives included 16.48% staff development, 18.7% research project, 25.3% service/organization restructuring. Elements included in Collaborative Practice Initiatives Respondents were asked to describe the collaborative practice initiatives, in terms of what programmatic components (elements) they included: the development of clinical practice tools and/or guideline development a patient centred case conference a workshop/ interactive seminar a lecture implementation of changes in organization and delivery of care (organizational practice) o implementation of changes to program logistics and program administration o changes to improve accessibility and/or continuity of care for patients o other o o o o o
The distribution of those respondents’ answers is depicted in Figure 15. Fig.15- Percentage of initiatives that included element
or
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In order to determine whether a significant relationship existed between the elements of the initiative and whether it was successful, Fisher’s Exact tests were run, with no significant findings between the elements and success: development of clinical practice tools and/or guideline development (p= 1.00), patient centred case conference (p= 0.36), workshop/ interactive seminar (p= 1.00), changes in organization and delivery of care [organizational practice] (p=1.00), changes to program logistics and administration (p= 1.00), changes to improve accessibility and/or continuity of care for patients (p= 0.36), a lecture (p= 1.00), other (p= 0.58). Lack of “unsuccessful” cases render this finding difficult to interpret.
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Patient Populations Involved in Collaborative Practice Initiatives Respondents indicated which patient populations were involved in the various initiatives. Again, patient populations unique to collaborative practice initiatives are highlighted with underlining. This information is included in Table 10. Table 10: Patient populations involved in collaborative practice initiatives Patient populations defined by health status - patients who may require a do not resuscitate plan of care - recipients of total hip/knee joints - patients with tracheotomy tubes - patients with asthma -palliative care patients (home, institution) -individuals in long term care -patients at risk for medication adverse effects - psychiatry/mental health care (posttraumatic stress disorder, depression, aggression, sleep disorders) - individuals with cardiovascular illnesses -chronic pain patients -clients and family members of those in recovery from addiction -women who had a hysterectomy -people with diabetes
Patient populations defined by sociodemographics -First Nations people -Inuit people - the (young) disabled -childbearing women and their babies -elderly (frail, homebound) - rural community population - general community - young people/adolescents( and their parents) -inner city population (and urban underserved - community health centre patients/clients
Patient Involvement in Initiatives Patients were involved in 70% of initiatives described. Patient involvement was not significantly related to the success of an initiative (p=1.00). Exactly how patients were involved was also queried, and respondents noted that patients were involved in various ways: as clients/receivers of care; as a partner on the therapeutic team (as a participant in personal case conferences, in decision taking regarding care or service, talking circles, written suggestion forms, input into problem identification goals and action plans); as panelists; as board/committee members, founders of the program, advisors (representatives of the community involved in planning); as focus group and interview participants (for needs identification); and as providers of feedback to the care providers. Evaluation of Collaborative Practice Initiatives Respondents indicated that 70% of the initiatives described were evaluated. Of those that were evaluated, the majority were evaluated with a questionnaire (75%) while others were evaluated with an interview (56.3%) and other means (45.8%). Initiatives that utilized both a questionnaire and interview for evaluation tallied 52 %. The timing of the evaluations varied, as depicted in Figure 16.
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Fig.16- Timing of evaluation by evaluation type (%)
other after
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before & after
interview
during & after before, during & after
quest. 0%
50%
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Respondents were asked to indicate the specifics of what participants were asked about in the evaluations. They indicated the following answers, represented in Table 11. Table 11: The factors initiative participants were asked about in evaluation Element Changes in professional practice in terms of sharing responsibilities Improvements in health or well being of patients / clients Their views on the learning experience and its collaborative practice nature Changes in reciprocal attitudes or perceptions between participants Improvement in accessibility and /or continuity of care Changes in interpersonal relationships and trust among team professionals Changes in perception or attitude towards the value and/or use of team approaches to caring for a specific client group. Program logistics, administration (scheduling etc) Wider changes in the organization and delivery of care (organizational practice) Knowledge and skills linked to collaborative practice Transfer of collaborative practice learning to their practice setting and changes in professional Other
Frequency 62.5% 58.3% 52% 52% 52% 50% 50% 50% 43.75% 41.7% 31.25% 18.75%
Of those that reported the initiative was evaluated, only 10.9% (n=5) respondents reported the initiative compared the evaluation results to a group that did not receive the initiative, and only 3 respondents (6.82 %) reported the initiative randomly assigned participants to either receive the initiative or not. Dissemination of Findings Regarding dissemination of findings, 30.2% reported the initiative results were published, while 56.5% reported presentation of results. Of these, only 27.7% reported the results were both presented and published. These frequencies are similar to those reported for education initiatives (60.8%, 31.6%, and 22.6% respectively).
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Materials & Opportunities developed from the initiative Respondents were asked to indicate the materials that were developed as a result of the initiative: a training program in collaborative practice, clinical tools designed to share information and/or promote collective decision making, clinical/administrative protocols, workshops, workbooks, none, or other. These results are presented in Figure 17. Fig.17- Percent of initiatives that developed materials from program, by type of material none other workbooks TrainProg Workshop Tools Protocols 0
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Lastly, respondents were asked to indicate what (if any) interprofessional opportunities were created from the initiative. Respondents indicated that group discussions were the strong favourite at 52.75%, followed by interprofessional on-the-job training (41.76%), development of an interprofessional committee (38.46%), other (19.78%) and no opportunities (5.49%). Collaborative Practice Enablers & Barriers While discussing “success” some respondents highlighted various enablers and barriers of the initiatives, or what features either encouraged or discouraged the success of the initiatives. The data that respondents who described the “unsuccessful” initiatives provide is included under the barriers section of the table (specifically, points 2-5). This material is presented in Table12. Table 12: Enablers and Barriers to collaborative patient centred care initiatives Enablers • Inter-institutional commitment, sharing of resources • Common orientation/grounding in patient centred care • Faculty links and buy-in (for student-run initiatives) • Sound program logistics, administration • Time (participants freed up from regular activities to participate) • Policy & planning support from government
Barriers • participation in initiative not formally evaluated/graded • funding removed/lost • model not financially viable • lack of buy-in from some disciplines • structural barriers: limits of fee for service remuneration
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Policies to support interdisciplinary education and collaborative practice All respondents were asked, “What policies/initiatives are you aware of that may be utilized to bring health care students together to learn more about interdisciplinary education and collaborative patient centred care?” Respondents identified the following policy issues presented in Table 13. Some answers provided detailed policies, while other respondents gave more general ideas as to what policies could be utilized to support IECPCP. Table 13: Policies that support IECPCP Policies/Policy issues linked to supporting IECPCP • Universities: common approaches for health care students: timetabling, assessment, common course listing a general health sciences facility/faculty (e.g. Academic Health Sciences facility at the University of Saskatchewan) educational programs/recommendations to promote interdisciplinary, collaborative competencies diversification of University populations means that Universities of different levels must collaborate to provide health care to the regions interdisciplinary continuing education (e.g. NPs in CME courses) • Funding (grants awarded only to those who demonstrate collaboration and those that submit proposals in partnerships, e.g. Alberta Health Innovation Funding) • Interprofessional committees & councils in education & practice settings • Government: -Provincial care plans (frameworks & targets) which include health care that is dependent on regional partnerships & collaborative practice (e.g. Saskatchewan Action Plan for Health, 2001) - provincial Acts to support interdisciplinary/collaborative decision making (also legal & insurance system change re: decision making) • Professional organizations: allowing teaching and supervision of health professional students by other disciplines Formal statements in licensing, accreditation documents re: IECPCP • Practice settings: utilize job descriptions that include skills in IECPCP physical layout of the workplace to incorporate different disciplines situated together
On-line Survey Limitations There are several limitations to the data presented here, as well as the methodology employed. The methods fall short in that the snowball sampling technique could potentially be a closed system, or a self-affirming sampling method. That is, members of the interprofessional education and collaborative patient centred care community could be circular, with a possible decreased likelihood of naming previously unnamed individuals as experts in the field of IECPCP. However, the fact that the initial survey was sent to 170 people and the final database numbers 821 would suggest otherwise. More specifically, there exist some concerns related to specific survey questions. The data based on the number of years programs/initiatives were implemented, as well as the frequency with which they were executed, may not accurately capture the possible sustainability of programs 149
that have run for some length of time. For example, programs that may have run for 8 or more years would have been indicated under the “4 years or more” category. Second, it is important to note that the number of respondents does not accurately reflect the number of different initiatives in Canada. For example, several respondents could have described the same interdisciplinary education and/or collaborative practice initiatives. The fact that respondents were asked to name the initiative and its location attempted to guard against this, but because not all respondents provided this information, we are limited in any firm conclusions that can be drawn regarding this issue. Third, the survey question that asked respondents to indicate if the program was successful is imprecise. The term “success” was not operationalized, and it was left up to the discretion of respondents to determine if the program they described was successful. While the lack of operationalization presents some interpretation difficulties, the data that was gathered is interesting in that it sheds some light into both how key informants define successful programs/initiatives, and how the programs themselves may have defined success. Once again, we cannot be sure if respondents gave their own personal descriptions of success or if they relayed the program’s determined success indicators. In addition, the fact that a very small percentage of respondents described unsuccessful programs suggests that participants may have been cautious about reporting “unsuccessful” programs via the survey. Respondents were informed at the outset that the data they provided would not be anonymous, and they were also informed that Health Canada was involved in this initiative. Thus, some may have hesitated in reporting unsuccessful programs for fear of possible future negative ramifications on funding opportunities. More specifically, there were a number of respondents who did not complete all the information, as illustrated in Table 2. The issue of missing values is one that is potentially informative. For example, we do not accurately know how many “successful” and “unsuccessful” programs exist. That is, respondents indicated “I know of an interdisciplinary educational program which I can report via this survey” (177 people indicated this answer), and then, 15 people did not go any further to describe the program. From there, 162 went on to indicate the “success” status of the program, and 157 of them stated it was successful. We need to consider the missing values: did the 82 people who did not answer the first question not do so because they knew only of an unsuccessful program and perhaps determined that it was either not worthwhile (or perhaps risky, as described above) to report on such a program? The research team tried to alleviate this risk by stating in the survey instructions that we were interested in hearing about both successful and unsuccessful programs. The publication/presentation data present another example of the potentially informative nature of missing data. Here, there were 23 missing values. Does this mean that people have no knowledge about whether or not the results were published? Or does the missing value indicate that the initiative was not published or presented so participants did not deem it necessary to answer this question. Lastly, it is possible they simply skipped the question.
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The lack of “unsuccessful” programs also posed challenges in the statistical analyses employed involving this variable. Key questions whether various factors (e.g. funding) had a relationship to the success of a program were asked but because there were so few unsuccessful initiatives reported, Fisher’s Exact Test was utilized in lieu of a Chi-square analysis. Even so, the lack of unsuccessful cases presents inconclusiveness as to whether the findings are accurate, because there does not exist adequate statistical power to perform the tests. Lastly, the sampling technique utilized did not produce a random or representative sample. Statistical analysis (i.e. Fisher’s Exact Test) requires there is an assumption of independence, or that the scores were independently sampled. The snowball sampling technique does not meet this requirement. In addition, making generalizations from a sample of people to the rest of the population requires that the sample is representative of the population of interest. Once again, the snowball sampling technique runs contrary to this, for the sample may not be representative of “key players” in the field of IECPCP, not all health care professionals. Based on the sample obtained in the method described above, we did not achieve significant results for any of the other tests.
Discussion of Results Similarities and Differences The data outlined above details the key similarities and differences in the initiatives identified from the online survey. Briefly, the highlights are: • • • • • • • • •
Interdisciplinary education programs took place almost equally in higher education settings (50%) as in service or mixed settings (49%) Collaborative practice initiatives took place most often in service or mixed settings (92%) and rarely in higher education settings (7%) Seventeen disciplines were common amongst programs and initiatives, 27 disciplines were unique to interdisciplinary education, and 11 unique to collaborative practice. in both education and practice initiatives, the majority of the programs ran for more than 3 years, and more than 3 times funding had a slight effect on the length an interdisciplinary education program ran curriculum development was the impetus that drove interdisciplinary education, while CQI was a driver more for collaborative practice initiatives a large variety of patient populations were involved in programs/initiatives, with slightly more practice initiatives involving patients than education programs there was virtually no comparison to non-participants nor was there random assignment in evaluations programs and initiatives were more often presented at conferences than they were published
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What can we learn from the current examples of interprofessional education and collaborative best practice? A striking and unique finding to the online survey was the range of different populations involved in various initiatives. In Chapter 2, Zwarenstein outlines which patient populations are best utilized in these initiatives, according to effectiveness studies. However, because of the limitations of the “successful” categorization in the online survey, we cannot conclude from these results which patient populations described in the online survey is best suited to IECPCP. Thus, the online survey results are supplemental to Zwarenstein’s findings in that they document the variety of populations that have been involved in such initiatives, providing a richer picture and better sense of the “lay of the land” in IECPCP. For all the problems cited with the “success” categorization, it is illuminating data nonetheless. We now have a better understanding of how key informants in the areas of interdisciplinary education and collaborative patient centred care characterize and define success of programs, or what they deem as important to consider. Lastly, it appears that funding had a slight effect on interdisciplinary programs, in that funding status was related to whether the programs were long running (ran 3 or more times), as the analysis showed near significance. More specifically, 73% that ran 3 or more times received funding versus 33% of those programs that ran once or twice. Problematic/unsuccessful experiences identified to date – what went wrong? We must be cognizant that there were few unsuccessful programs reported in the online survey, and thus our analysis of those unsuccessful programs is limited. Qualitative data from the respondents (the data is included under “barriers” to programs and initiatives, Tables 7 & 12) who reported unsuccessful initiatives illustrates that lack of time, money, buy-in, and structural/organizational support had negative affects on these programs. Describe limitations & gaps There were relatively few reported initiatives and programs in the settings of rehabilitation and tertiary care. It may be that this is a function of a sampling bias of the snowball sampling technique, or it may be an accurate reflection that there are few initiatives occurring in these settings across Canada. Either way, it would be worthwhile for Health Canada to investigate initiatives taking place in tertiary and rehabilitation settings more fully. In addition, the strong majority of initiatives were not rigorously evaluated, for there were few programs/initiatives that included evaluation comparisons to participants/learners who were not involved in the programs, and there were even fewer efforts that involved random assignment to receive the initiative or not. As such, statements about the effectiveness of such studies cannot be drawn. This observation is consistent with previous chapters by Oandasan and Zwarenstein. Programs and initiatives tended to present their work rather than publish. This presents a challenge to a growing field and area of study, for if previous work cannot be drawn upon easily, there exists a risk that work will become redundant due to lack of opportunity to build on others’ 152
experiences. Two recommendations emerge from this finding. First, that initiatives and programs are encouraged to disseminate their work via publication. Second, that a clearinghouse or database be built and maintained in order to track and disseminate such work, especially those publications that fall under the category of “grey literature”. The current research team developed such a database that is housed with Health Canada, but without consistent attention, it will become dated and of limited use.
Observations and Conclusions We have learned a great deal in creating and implementing this survey that tries to capture the state of interprofessional education and collaborative practice in Canada. One of the key issues that is in need of address in future efforts using this type of survey methodology relates to a common language and categorization of initiatives so that researchers, educational planners, practitioners, and educators can communicate effectively with one another. The first area of confusion lies in the categorization and terminology used between interprofessional education and collaborative practice. It is our research team’s belief that there is a need to separate initiatives into (1) IPE at the training level (pre-licensure) and (2) collaborative practice IPE initiatives at the workforce level (post-licensure). Both types of initiatives are distinct and yet they are interdependent upon each other. That is, IPE needs collaborative practice workforce settings for trainees to learn in and collaborative practice settings—we believe although there is limited evidence to date to prove this – See Chapter 2— can benefit from having competent practitioners trained at the institutional level to be collaborators within workforce settings. Hence, what is distinctive about the collaborative practice setting is the practitioners. The individuals within these settings are licensed to practice and the IPE initiatives they are engaged in are conducted with the goal of improving practice and patient outcomes. The second area of confusion lies in the following question: Are there differences between the types of educational initiatives that are conducted in a collaborative practice setting compared with those situated in a higher learning institution? Our research team would say that the impetus of continuous quality improvement and the initiative component of changes in organization and delivery of care (some of the most frequently cited impetus and elements for collaborative practice initiatives reported in this survey) are different types of educational interventions than those implemented at a training level in higher education institutions. The goal for trainees engaged in IPE at higher education institutions is primarily to improve learner outcomes related to knowledge, skills and attitudes. Hence there is a need to distinguish between the collaborative practice setting and its forms of IPE interventions and the interventions conducted in higher education institutions. The reasons for this reside in differences related to goals, planning, financing and incentives. For the purposes of a survey, we believe it is important to ensure that there is clarity in distinguishing between higher education IPE initiatives and IPE initiatives that are conducted in collaborative practice settings. Furthermore we would question whether the initiatives conducted in collaborative practice settings should even be categorized as educational initiatives. If we do include them, there must
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be clear criteria for how we define educational initiatives. The third area of confusion lies in academic practice settings or what we have termed “mixed settings”. These settings often have both practitioners (post-licensure) and trainees (prelicensure) working together. The practitioners often are the teachers of the trainees. Consequently, when classifying educational interventions and taking into account the many mixed settings across the country, it is important to distinguish whether the goal of the educational initiative planned is related to enhancing learner outcomes (the most frequently cited in this survey were learners’ views on the learning experience and its interprofessional nature, and knowledge and skills linked to interprofessional collaboration ) versus patient or practice outcomes (the most frequently cited in this survey were changes in professional practice in terms of sharing responsibilities, and improvements in health or well being of patients / clients). We propose therefore that there may be an improved approach to distinguish interprofessional education initiatives according to the goals of the initiative. Perhaps using classifications such as: Interprofessional Educational Initiatives to Enhance Learner Outcomes versus Interprofessional Educational Initiatives to Enhance Patient/Practice Outcomes would provide enhanced clarity. The information from such distinctions would be more helpful for planners. Our survey methodological classifications arose from the Jet Review (6) conducted in the United Kingdom. After conducting the survey utilizing this classification strategy, we would recommend the changes as described above.
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References 1. Berg BL. Qualitative research methods for the social sciences. 2nd ed. Boston, MA ; Toronto: Allyn and Bacon, 1995. 2. Grbich C. Qualitative research in health: An introduction. London: Sage, 1999. 3. Dillman D. The design and administration of mail surveys. Annual Review of Sociology 1991;17:225-49. 4. Barr H. Strategies for change: ends and means in interprofessional education: Towards a typology. Education for Health 1996;9(3):341-52. 5. D'Amour D, C S, R. L. L'action collective au sein d'équipes interprofessionnelles dans les services de santé (Collective Action within Interprofessional Teams in Health Services). Sciences Sociales et Santé 1999;17(3):68-94. 6. Freeth D, Koppel I, Hammick M, Reeves S, Barr H. A critical review of evaluation of interprofessional education. London: LTSN, 2002.
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Appendices for Chapter Five: Examples of Interprofessional Education and Collaborative Practice: Findings from On-Line Survey
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Appendix 5-1 On-Line Survey Sample Introduction & Welcome Health Canada is launching a major initiative on interprofessional education and collaborative patient centred practice (IECPCP), and wants to hear your experience and opinions on the subject. We are a multidisciplinary group of researchers who have been commissioned to conduct an environmental scan on this subject, to provide background for the development of an IECPCP initiative, and plan proposal. We have been given your name as a key informant in this area, and would like to draw on your experience. Your responses will be dealt with in an anonymous fashion. If you would like to communicate with us in more detail, or have any questions, please email to
[email protected] a new, non personal email address. You may have knowledge about interdisciplinary and collaborative practice initiatives that are both successful and unsuccessful, and we understand and appreciate the value in hearing about both types of experiences. We would ask that you please fill in this within 72 hours. By filling out this questionnaire, please be aware the information you provide is being entered into a database, and as you have been identified as key informant in this area, the information you provide will be linked to your name. In order to gain further information on the interprofessional & collaborative practice initiatives you will be asked to describe, would you be willing to be contacted in future? Y N 1.
Please share with us the names of 3 individuals and their institutions who have been actively involved in the development of interdisciplinary education interventions of which you are aware. ____________________ ____________________ ____________________
2.
Please share with us the names of 3 individuals and their institutions who have been actively involved in the development of collaborative practice interventions of which you are aware. ____________________ ____________________ ____________________
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A. Educational Processes related to Interdisciplinary Education Interdisciplinary Education is defined here as “learning together with the specific goal of promoting collaboration" (Barr, 1996). Please describe either a successful or unsuccessful interdisciplinary education program of which you are aware. We are particularly interested in programs which have been sustained over a period of time. Please check one of the following: __ I know of an interdisciplinary educational program which I can report via this survey __ I do not know of an interdisciplinary educational program which I can report via this survey. (go to Collaborative practice section, page 8) 1. Will you be describing a successful or unsuccessful program? __ Successful __ Unsuccessful 2. Where did the program take place? Please provide the name of the institution ______________________ Was it in a: higher education institution service setting (clinical setting) mixed (a clinical setting with higher education links or vice versa) If in a service setting or mixed setting, was it: primary ambulatory care tertiary care rehabilitation other (please specify) ___________________ 3. Who were the learners? (professional/discipline affiliations) Fill in all the rows that apply (e.g. if nursing students were involved, fill out approximately how many learners were from nursing [column2] and their level of training [column 3]): Discipline
How many learners from this discipline took part?
When did the program take place in the learners training levels?
(approximate number) __nursing
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
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Discipline
How many learners from this discipline took part?
When did the program take place in the learners training levels?
(approximate number) __medicine
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
__social work
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
__psychology
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
__occupational therapy
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
__chiropody
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
__ pharmacy
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
__ physiotherapy
__ 0 __ 1 __ 2-4 __ 5-7
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW,
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Discipline
How many learners from this discipline took part?
When did the program take place in the learners training levels?
(approximate number)
__ nutrition
__ 8-10 __ 11+
PharmD, fellowship)
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training)
in clinical practice (e.g. professional development, in service training)
post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
__ other (please specify)
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
undergraduate program (in professional training) post-graduate program (e.g. residency) graduate program (e.g. MSW, PharmD, fellowship) in clinical practice (e.g. professional development, in service training)
4. What were the professional/discipline affiliations of the educators? (check all that apply) nursing medicine social work psychology occupational therapy chiropody physiotherapy pharmacy nutrition other (please specify) _________________________ 5. What was the length of the program? (months) ____________ 6. Was the program repeated? ___Yes ___ No 7. If yes, how many times? __ Run once only __ run 2 times __ 3 rimes __ 4 or more times 8. How many years has the program run? ___1 ___2 ___ 3 ___4 or more 9. Was funding received to support the project? ___Yes ___ No
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10. If yes, where did funding come from? (name of granting agency/foundation) _____________________ 11. Please indicate the impetus for the program. Was it (check all that apply) continuous quality improvement staff development research project curriculum development service/organization restructuring Other (please specify) __________________ 12. Please describe the program. Did it include (check all that apply) a lecture a full course a workshop/interactive seminar patient-centred case conference development of clinical tools patient interactions other, please specify _________________ 13. Were patients involved in the learning program? ___Yes ___ No 14. If yes, please describe what patient population that was involved (e.g. elderly; disease specific, etc)? ________________________________________________________________________ 15. How were patients involved in the learning program? _______________________________________________________________________ 16. Was the program evaluated? Yes No (If no go to question #22) 17. If yes, was it evaluated with: Interview Questionnaire/survey both __ Other (please specify) 18. When was the program evaluated? Check all that apply: After the program
Before & after
During & After
Before, during & after
Questionnaire Interview Both Other If the timing or methods of evaluation is not captured above, please briefly describe them:
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19. In the evaluation, were learners asked about…(check all that apply) Learners’ views on the learning experience and its interprofessional nature Changes in reciprocal attitudes or perceptions between participants Changes in interpersonal relationships and trust among team professionals Changes in professional practice in terms of sharing responsibilities Changes in perception or attitude towards the value and/or use of team approaches to caring for a specific client group. Knowledge and skills linked to interprofessional collaboration. Transfer of interprofessional learning to their practice setting and changes in professional practice Wider changes in the organization and delivery of care (organizational practice) Improvements in health or well being of patients / clients Program logistics, administration (scheduling etc) Improvement in accessibility and /or continuity of care 20. Were the above evaluations compared to a group of people who did not participate in the program? ___Yes ___ No 21. Were people randomly assigned to either receive the program or not?
___Yes ___ No
22. Were the results of the program published? ___Yes ___ No Where/When __________________________________________ 23. Were the results of the program presented? ___Yes ___ No Where/When ______________________________________________ 24. What educational materials were developed through this program? No materials were developed Curricula designs Teaching Methods Workbooks Manuals Workshops Other (please specify)________________ 25. Was the program successful? ___Yes ___ No Please briefly describe why? ________________________________________________ __________________________________________________________________________
B. Collaborative Practice Collaborative Practice is defined here as “the structuring of collective action through information sharing and decision making in clinical processes” (D’Amour, 1999). Please describe either a successful or unsuccessful collaborative practice initiative of which you are aware. We are particularly interested in initiatives which have been sustained over a period of time.
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Please check one of the following: ___ I know of a collaborative practice initiative which I can report via this survey. ___ I do not know of a collaborative practice initiative which I can report via this survey. (if no, please go to question # 52) 26. Will you be describing a successful or unsuccessful initiative? __ Successful __ Unsuccessful 27. Where did the initiative take place? Please provide the name of the institution ________________________________________ Was it a: higher education institution service setting (clinical setting) mixed (a clinical setting with higher education links or vice versa) If in a service setting or missed setting, was it : primary ambulatory care tertiary care rehabilitation other (please specify) ___________________________________________________ 28. Who were the participants? (professional/discipline affiliations) Fill in all the discipline rows that apply (e.g. if nursing professionals were involved, fill out approximately how many learners were from nursing [column2]): Discipline
How many health care professionals from this discipline took part? (Approximate)
__nursing
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__medicine
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__social work
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__psychology
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10
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Discipline
How many health care professionals from this discipline took part? (Approximate) __ 11+
__occupational therapy
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__chiropody
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__ pharmacy
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__ physiotherapy
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__ nutrition
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
__ other please specify
__ 0 __ 1 __ 2-4 __ 5-7 __ 8-10 __ 11+
29. What were the professional/discipline affiliations of those that organized the initiative? (check all that apply) nursing medicine social work psychology occupational therapy chiropody physiotherapy pharmacy nutrition manager other (please specify) _________________________
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30. What was the length of the initiative? (months) ____________ 31. Was the initiative repeated? ___Yes ___ No 32. How many times? __ Ran once only __ ran 2 times __ ran 3 times __ ran 4 or more times 33. How many years has the program run? ___ 1 ___ 2 ___3 ___4 or more 34. Was funding received to support the initiative? ___Yes ___ No 35. If yes, where did funding come from? (name of granting agency/foundation) _____________________________________________ 36. Please indicate the impetus for the initiative. Was it (check all that apply): continuous quality improvement staff development service/organization restructuring research project curriculum development Other (please specify) __________________ 37. Please describe the initiative. Did it include (check all that apply) clinical practice tools/guideline development patient care case conference a workshop/interactive seminar changes in organization and delivery of care (organizational practice) changes to program logistics, administration (scheduling etc) changes to improve accessibility and/or continuity of care for patients a lecture other (please specify) _________________________________ 38. Were patients involved in the initiative? ___Yes ___ No 39. If yes, please describe what patient population was involved? (e.g. elderly; disease specific etc.)? _________________________________________________________________________ 40. How were patients involved in the initiative? _________________________________________________________________________ _________________________________________________________________________ 41. Was the initiative evaluated? ___Yes ___ No (if no, they will go to question #47)
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42. If yes, was it evaluated with: Interview Questionnaire/survey both other 43. When was the initiative evaluated? Check all that apply: After the initiative
Before & after
During & After
Before, during & after
Questionnaire Interview Both Other If the timing or methods of evaluation is not captured above, please briefly describe it: __________________________________________________________________________ __________________________________________________________________________ 44. In the evaluation, were participants asked about …(check all that apply) Their views on the learning experience and its collaborative practice nature Changes in reciprocal attitudes or perceptions between participants Changes in interpersonal relationships and trust among team professionals Changes in professional practice in terms of sharing responsibilities Changes in perception or attitude towards the value and/or use of team approaches to caring for a specific client group. Knowledge and skills linked to collaborative practice Transfer of collaborative practice learning to their practice setting and changes in professional practice Wider changes in the organization and delivery of care (organizational practice) Improvements in health or well being of patients / clients Program logistics, administration (scheduling etc) Improvement in accessibility and /or continuity of care Other (please specify) _______________________________________________________ 45. Were the above evaluations compared to a group of people who did not participate in the initiative? ___Yes ___ No 46. Were people randomly assigned to either receive the initiative or not? ___Yes ___ No 47. Were the results of the initiative published? ___Yes ___ No When/Where _________________________________________________________________ 48. Were the results of the initiative presented? ___Yes ___ No When/Where __________________________________________________________________
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49. What materials were developed through this initiative? a training program in collaborative practice clinical tools designed to share information and/ or promote collective decision- making clinical and/or administrative protocols workshops workbooks no materials were developed other (please specify)________________ 50. What interprofessional opportunities were created from this initiative? Group discussion Interprofessional committee Interprofessional on-the-job training No opportunities created Other (please specify) ____________ 51. Was the initiative successful? ___Yes ___ No Please briefly describe why? ____________________________________________________ ____________________________________________________________________________ 52. We'd also like to hear about: a) the opportunities you are aware of that support interdisciplinary education and/or collaborative practice b) the policies/initiatives you are aware of that may be used to bring health professional students/professionals together to learn more about Interdisciplinary education and/or collaborative practice.... Are you interested in sharing this information? ___Yes ___ No (If no, please go to end of survey, page 15) If yes, what opportunities are you aware of that support interdisciplinary education and/or collaborative practice?
What policies/initiative are you aware of that may be utilized to bring health professional students together to learn more about interdisciplinary care/ and/or collaborative practice?
Thank you for participating in this important Health Canada initiative. The results of this survey will help future policy and change in interdisciplinary education and collaborative practice. Any questions/concerns, please email:
[email protected]
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Appendix 5-2 Funding Sources for Programs/Initiatives Described Interdisciplinary Education Programs Government Funding Alberta Health Innovation fund British Columbia Government (Ministry of Health Planning) British Columbia Medical Services Foundation British Columbia Ministry of Health British Columbia Ministry of Health Planning Bureau of Health Professions, United States Department of Health and Human Services Canadian Federal Government Department of Health (England, UK) Department of health (UK) Department of Human Services, Victoria, Australia Government of British Columbia Health Canada Health Canada - HIV/AIDS Strategy for Canada Human Resources Development Canada Ministère de la santé et des services sociaux du Québec Ministry of Health and Long Term Care (MOHLTC) Montreal Regional Health and Social Services Board Education Program NHS Executive (West Midlands, UK) Ontario Government- Ministry of Health and Long Term Care Ontario Ministry of Health Primary Health Care Transitions Fund Quebec City Regional Health and Social Services Board Saskatchewan Health United States Department of Health and Human Services Bureau of Health Professions United States Department of Health Resources & Services Administration University Funding Carl Moore Lectureship donations (McMaster University) Dalhousie University Dalhousie University, Health Studies Coordinating Committee Department of human resources and department of education & distribution of expertise (Institut universitaire de gériatrie de Montréal (IUGM) Institut universitaire de gériatrie de Montréal (IUGM) Foundation University of Alberta University of Alberta IPI NECHC University of Auckland, Vice Chancellors Award University of British Columbia College of Health Disciplines University of Manitoba University of Saskatchewan, College of Medicine University of Tasmania Department of Rural Health University of Tasmania Teaching Development Grant University of Tasmania, North West Rural Clinical School University of Toronto University of Toronto Centre for the Study of Pain University of Toronto Council of Health Science and Social Work Deans University of Victoria Centre for Curriculum Technology and Training
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Faculty/Deans/Academic Funds Ancillary funds charged to nursing students (University of Toronto) Associated Medical Services Senior Fellowship Associated Medical Services, Wilson Medical Education Association of Colleges of Medicine of Canada Canadian Working Group on HIV and Rehabilitation Granting agencies, foundations Hartford Foundation Health Sciences North In-kind support from each faculty Laurentian University student fees Laurentian University, Dean's discretionary funds Ontario Council of Graduate Studies Robert Wood Johnson Foundation Robert Wood Johnson Foundation Royal College of Physicians and Surgeons SmartRisk Foundation Student associations Student Fees Trust & Charitable Foundations University of Saskatchewan, Health Science Colleges University of Toronto Health Science and Social Work Deans University of Toronto Provost's office Health Associations/Agency Alberta Alcohol and Drug Abuse Commission Alberta Capital Health Authority Canadian Cancer Society (Saskatchewan Division) Canadian Diabetes Association Cancer Care Nova Scotia Health Care Organizations Heart and Stroke Foundation Saskatchewan Cancer Agency Pharmaceutical/Corporate Funding Bell Pioneers Dairy Farmers of Canada Janssen Ortho Merck Frosst Pharmaceutical companies Purdue Pharma Personal Funding Clinical earnings Fundraising Pastoral team
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Collaborative Practice Government Funding Alberta Alternative Payment Plan British Columbia Ministry of Health - Planning - Health Human Resource British Columbia Minister of Health Planning Government of Ontario Health Canada Ministry of Health and Long Term Care Primary Health Care Transition Fund Province of Manitoba Quebec Region Regional Health and Social Services Board Saskatchewan Health United States Bureau of Health Professions United States Department of Health and Human Services University Funding Middlesex University PhD studentship University Students' Union Faculty/Deans/Academic Funds University of British Columbia College of Health Disciplines University of Toronto Academies in the Faculty of Medicine Health Associations/Agency/Foundation/Hospital Aboriginal Healing and Wellness Strategy Alberta Mental Health (AMA) British Columbia Academic Health Council Canadian Health Services Research Foundation John A. Hartford Foundation Geriatric Interdisciplinary Team Training Program London Health Sciences Centre Mount Sinai Foundation Mount Sinai Hospital Ontario College of Family Physicians Physician Services Inc. Foundation South Thames Regional Health Authority Pharmaceutical/Corporate Funding Corporate Support Drug company sponsorship
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Appendix 5-3 Survey of the Canadian Deans of Medicine: Interprofessional Education Dear colleagues, Please take no more than 10 minutes to complete this survey. Kindly send it back to:
[email protected] Many thanks, Dr. Louise Nasmith 1. Please list any major curriculum initiatives in Interprofessional Education (IPE) : a. Undergraduate b. Postgraduate c. Continuing Education d. Faculty Development 2. Please describe any organizational changes (e.g. IPE committees or assistant deans) that have occurred to foster and help sustain IPE (including the different professionals involved):
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Chapter Six Examples of Interprofessional Education and Collaborative Practice: Findings from In-depth Interviews By Carmela Bosco
Introduction This chapter covers the key findings of current examples of interdisciplinary education and collaborative practice in Canada and abroad based on the stories and observations provided by individuals who participated in the in-depth interviews as part of the environmental scan for this report. The chapter begins with a summary of the methodology that was used in conducting the interviews and the questions that were posed to participants. This chapter includes an overview of the common themes in the descriptions of both successful and unsuccessful models of interdisciplinary education and collaborative practice by looking specifically to their development, implementation and evaluation in achieving positive outcomes. In-depth probing in the interviews provided additional information on the enablers and barriers encountered in the practice setting (i.e. acute or tertiary care) and what measures were taken to overcome these barriers. A summary of what lessons can be learned based on these experiences completes the chapter.
In-depth Interview Methodology To gain a more thorough understanding of the findings from the on-line survey (Chapter 5), it was important to undertake in-depth interviews with a selected sample of individuals, who were considered champions in the field. While initial questions started out broadly they become progressively narrowed as concepts and their relationships are discovered to be relevant or irrelevant.3 The interviewees were key informants identified from broad sampling of disciplines, across government, health care and educational sectors in Canada. Interviewees were identified in two ways: (1) their name/organization appeared across a significant number of the on-line surveys submitted (Chapter 5) and/or; (2) their initiatives were judged by the team to have valuable information that would further inform the environmental scan. Every effort was made to ensure that individuals interviewed had both positive and negative experiences implementing both educational and/or collaborative practice initiatives to ensure the knowledge about the enablers and barriers for IECPCP could be obtained. 3
Strauss AL, Corbin JM. Basics of qualitative research: techniques and procedures for developing grounded theory. 2nd ed. Thousand Oaks, CA: Sage Publications, 1998.
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A semi-structured interview guide was developed and implemented appended to this chapter (See page 188). All interviewees consented to being audio-taped and their interviews transcribed. Permission to disclose of their names and the information they provided in the interview for this report and participation in follow up activities related to IECPCP initiatives was obtained. Interview transcriptions were reviewed and shared among team members to ensure validity of the findings, thereby contributing to quality assurance of this initiative. The team selected five of each interdisciplinary education and collaborative practice models that were either successful or unsuccessful using English, French and First Nations examples. Twelve interviews were conducted from December 18, 2003 to January 13, 2004 by two members of the team. The average length of time for the interviews was 30 to 90 minutes. Of these twelve interviews, 10 were English and two were French. The following table is a listing of the interdisciplinary education and collaborative practice individuals who were contacted for the interviews with a brief overview of the educational programs or collaborative practice initiatives. Interdisciplinary Education Interviewee Dr. Madeline Schmitt & Noelle Andrus, University of Rochester (US) Dr. Hugh Barr, University of Greenwich (UK) Dr. John Gilbert, University of British Columbia Dr. Don Philippon, University of Alberta Bev Lafoley, Northeastern Ontario Medical Education (NOMEC) (Sudbury) Paule Lebel, Université de Montréal Collaborative Practice Interviewee Joan Barrie, Loon Lake Union Hospital (Saskatchewan) Dr. Andrew Cave, Department of Family and Community Medicine, University of Alberta Dr. Barry Goldlist, Toronto Rehabilitation Centre and University Health Network Joyce Helmer, Northeastern Ontario Medical Education NOMEC (Sudbury) Susan Wagner, Department of Speech-Language Pathology, University of Toronto Line Paré, Social Worker (Quebec)
Program Health Action Elective (Rochester University) - undergraduate UK National Health System - undergraduate & postgraduate College of Health Disciplines (UBC) - undergraduate & (some post-graduate) Health Sciences Council (University of Alberta) - undergraduate Northern Ontario Collaborative Practice (NOMEC) - undergraduate Université de Montréal - undergraduate Program Lake Loon Primary Care – Aboriginal site promoting parenting skills (Saskatchewan) Nurse-driven Asthma Clinic (Alberta) – asthma education in teaching clinic and private practice Regional Geriatric Program (Toronto Rehab, UHN) – provide rehab continuum of care services for elderly in tertiary setting Shkagamike-Kwe Health Centre – improve health and well-being of Aboriginals Academies of Health Disciplines – teaching through collaborative practice case studies Primary Healthcare (CLSC Haute-Ville-des Rivières, Québec) – providing community healthcare services
A detailed description of these programs is appended to this chapter on page 189 based on the information provided in the interviews.
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Overview of Interview Findings From the questionnaire, interviewees were asked to: • • • • • • •
Provide a description of their programs as it relates to interdisciplinary education and collaborative practice. Identify the external and internal drivers that influenced the development of their program. Identify individuals and partners involved in the planning and implementation of their program including roles and responsibilities and objectives. Outline the opportunities and factors that facilitated student learning and/or collaboration. From a system (macro), organizational (meso) and individual (micro) level, identify the challenges encountered to achieve collaboration, how they overcame the barriers as well as identify the enablers and their roles in program facilitation. Respond as to whether their programs have been evaluated to determine their effectiveness on patient outcomes. Outline measures that were employed to ensure programs continued their sustainability.
An overview of the program descriptions of interdisciplinary education and collaborative practice examples reveal that the practice setting for interdisciplinary education examples were all university-based. This finding is consistent with the on-line survey in that the majority of interdisciplinary education initiatives described there were situated in higher education institutions. All were affiliated with a teaching hospital, community or both, primarily in an acute care setting. Within the collaborative practice examples, most were community based with two affiliated with teaching hospitals providing tertiary care services. Again, this finding is consistent with the on-line survey findings in Chapter 5. Of the five collaborative examples, it included two Aboriginal centres as noted in the following table. Practice Setting University-based Teaching hospital Community* Private Practice Combined Settings
Interdisciplinary 5 3 5 3
Collaborative* 3 2 5 1 3
*Includes two Aboriginal Centres
Common themes noted in the interdisciplinary education examples were that: • All undergraduate programs within the academic institutions were successful and sustainable, however, were still facing challenges in obtaining program recognition among other faculties within the university. • Interdisciplinary undergraduate and postgraduate programs were funded either through the university global budget or through research grants. • Similar to the on-line survey findings, student participation was primarily at the undergraduate level. • Most universities offered interdisciplinary education courses as an elective within the program curriculum while there were two examples, the University of Alberta and
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•
University of Rochester, where it was mandatory that all health sciences students take an interdisciplinary education course. Not only were students learning the interdisciplinary skills and techniques either through the classroom setting, workshops, tutorial, and or seminars, but many also participated in community placements to learn and obtain “hands on” experience of collaboration in a clinical/health care practice setting with other health disciplines and be part of the health care workforce.
With the collaborative practice examples, four were identified as successful models and two were identified as unsuccessful. The following chart provides a description of the factors that contributed to their success and issues encountered that posed challenges making them unsuccessful. Collaborative Practice Overview Successful • • • • • •
Community leaders were brought early into the development and implementation of the collaborative practice and were supportive. There was an existing and effective health discipline team in practice. “Champions” considered as leaders and participants were committed to serve patient needs. Common orientation/grounding in patient-centred care There was administrative support for collaborative team. Resources were available for “on the job training” for health disciplines. Timeparticipants freed up from regular activities to participate Formal on the job training
Unsuccessful • • • • •
Program leaders encountered challenges to obtain funding for interdisciplinary team members. (i.e. funding removed/lost) Time constraints for interdisciplinary team to address or consult on patient care. The practice setting determined whether the interdisciplinary team can work together (i.e. difference within teaching hospital and private practice setting due to structural fee framework). Entrenched social and cultural issues not receptive to interdisciplinary care. e.g. difference in traditional verses western medicine). Community members had not supported the collaborative initiative because they were not brought in from the onset.
In the collaborative practice examples, two Aboriginal centres have had both successful and unsuccessful experiences. The key finding in the first example was that its success was attributed to a community-driven collaborative practice lead by the community leaders. In this case, community leaders were the Aboriginal Clans who played a key role in obtaining the resources and funding for the development and implementation of the interdisciplinary health care team. Community leaders ensured that the health disciplines team was educated on the cultural and health service needs of the Aboriginal community. For example, when describing the employment practices of hiring health care staff within the Centre, according to the interviewee as a standard hiring practice all potential hires are required to take an education
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course and will be evaluated by community leaders. In the second Aboriginal example, they did share the same experience and reported access to resources and funding to provide interdisciplinary care was restricted as problematic. In the program development of the IECPCP examples for both interdisciplinary education and collaborative practice, there were both similarities and differences in program objectives, players and partners’ roles in their implementation and the communication initiatives employed to promote and/or encourage IECPCP. In the analysis of these similarities and differences, the common themes were: • •
• •
•
The key program objectives were to foster collaboration between health professions through learning and best practices to improve quality of care and address health human resources. Government, academic and health institutions and community leaders were key partners in playing a role in the development and implementation of the IECPCP initiative. Government and institutions played a key role in providing the funding and resources for programs. Implementation of IECPCP initiatives was dependent upon “champions” who possessed the existing level of expertise and knowledge for team building. Roles and responsibilities were clearly defined at the various levels of program execution. Both the academic and health institutions primarily provided the funding and resources, while champions and community leaders provided the support for program implementation. Communications played a role in fostering collaboration that included newsletters, consultation meetings, tutorials and encouraging feedback.
The following tables provide a summary of the findings in these similarities and differences. Program Objectives
(Description: What were the key objectives for the IECPCP initiative?)
Interdisciplinary Education − Quality improvement in practice setting enabler for interdisciplinary education for quality improvement paradigm. − Establish priorities for determinants of health in community (i.e. health promotion and prevention) − Foster collaboration between health professions through student learning, team building, research and best practices (i.e. respect, understanding and trust) − Improve continuum of care for patients/clients / continuity of care − Initiate multi-disciplinary studies and impact on health care system − Address workforce issues through recruitment and retention strategies (i.e. remote/rural and northern communities)
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Program Objectives
(Description: What were the key objectives for the IECPCP initiative?)
Collaborative Practice − Improve health status of defined population groups (e.g. aboriginal health and elderly) − Rebalance health professional workloads − Alleviate physician workloads − Improve patient outcomes through disease management strategies − Provide patient-care centred approach (i.e. holistic, collaboration of traditional and western medicine)
Key Players and Partners
(Description: Who were the individuals that played a key factor in the development and implementation of the IECPCP initiative?)
Interdisciplinary Education • Government • Academic Institution/health councils • Faculty Deans (e.g. School of Medicine, Nursing & Pharmacy) • Faculty staff • Partnership with hospitals • Regional Health Authorities • Community Agencies (i.e. health depts. social service agencies ) • Academic community • Community leaders • Community workforce
Collaborative Practice • Academic institution/centre • Community leaders • Hospital management • Disease management centres (e.g. asthma clinic) • Existing health professionals in community (i.e. physicians, occupational therapists, physiotherapists and social workers) • Private sector (e.g. pharmaceutical company funding)
Program Implementation – Applies to IE and CP examples
(Description: What methods were executed to ensure implementation?)
• • • • • •
Pre-consultation with players/partners and community/hospital leaders. Development of program with existing level of expertise and experience for team building Obtain commitment of partners/enablers Meet community/university needs Secure champions Students/enablers participation and observation in the development of program
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Roles and Responsibilities
(Description: What role did players/partners have within the IECPCP initiative?)
• • • • • • • • •
Academic institution – provide funding and resources Faculty Deans – ensure program objectives are being met University Councils – monitor/evaluate program process Government – provide funding Champion – develop and execute program, ensure community involvement, teaching, obtain enablers, & conduct evaluation Community leaders – provide support, provide facilities and educate/advertise patients/public Faculty staff (i.e. educators) – work with patients/community, teaching External partners (private sector) – provide funding and resource support (i.e. researcher) Hospital staff – possess specialized services/experiences to administer programs
Communication
(Description: What methods were employed to ensure communication within the IECPCP initiative to ensure collaboration?
Interdisciplinary Education • Development of student manual • Scheduled lectures/meetings • Mandatory course • Encourage student feedback • Weekly tutorials
Collaborative Practice • Educational newsletter (i.e. Oh Dear Oh Dear) • Ad hoc committees • Interdisciplinary consult meetings • Practice setting consults (i.e. teaching clinics vs. private practice) • Teaching hospital – seminars and bedside teaching
In the interviews, participants were asked to provide specific details on the: • • •
External and interval drivers that have influenced the development of IE and CP initiatives. Enablers and facilitators encountered in the program development and implementation from a macro, meso and micro level. Barriers and challenges that they faced in the program development from a macro, meso and micro level.
The following provides a more in-depth look into the findings of these components to achieving IECPCP.
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Interdisciplinary Education Key Findings Key findings of the interdisciplinary education examples revealed that: • • • • • • • •
The call for change was in response to addressing health human resources in underserviced communities. Funding had been made available for IECPCP initiatives. However, it was not adequate to address student needs. (Gilbert) Health reforms in communities forced the IECPCP movement. Dedicated champions played a key role in fostering collaboration through interdisciplinary education activities The development of effective strategies to improve and enhance quality of patient care proved successful Academic institutions are more accepting of the IECPCP movement however resources are not available for implementation of educational initiatives. Time was a key factor to achieve IECPCP in the development of curriculum and obtaining support. The need for a central resource to drive education, research and faculty development. (i.e. CAIPE)
Speaking to the call for change, according to one of the interviewees, Hugh Barr, an international expert on interprofessional education from the United Kingdom, stated “there is a huge current trend towards interprofessional education and collaboration that it’s not just the UK but it goes back to the early writings of the World Health Organization and criticism of professional education systems particularly, medical education. The feeling that reform is needed within the professions and their education systems…” Specific details and issues raised from these interviews are noted in the following tables: Interdisciplinary Education External Drivers Internal Drivers • World trend towards health care teams (eg. • Champions lead the IECPCP vision (eg. World Health Organization) Dean) • Government priorities value IECPCP and • Institutional support & recognition at the provide supports including funding to the top hierarchy of institutions (eg. Dean’s education system. Health Council) • Health human resources - address • Institutional faculty expertise recruitment and retention • Institutional Reform (PBL curriculum) • Health and social service reform regionalization – priority to work in health care teams • Improve quality of care to patients by reducing medical error and improve continuum of care. • Improve population health – social accountability • Accreditation of IECPCP courses is beginning
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Interdisciplinary Enablers Macro – –
– –
Government funding for recruitment (i.e. human health resources) University leadership support – e.g. VP Academic • Provide funding/resources to fund IPE • (ideal = independent funding for IPE not from another faculty’s budget) • Support Faculty involvement (provide rewards, equal teaching credit, encourage participation) • Support curriculum reform – “timetabling” Champion – leadership/commitment National information center to drive education, research, faculty development (CAIPE)
Meso – – – – –
Development of Admin. Structure for Institutional Leaders e.g. Health Council of Deans Have devoted personnel for IPE (i.e. doctoral students – become educators/instructors and team builders Build in sustainability beyond the “champion” Build partnerships with community workforce & members for community team placements Health community leaders
Micro – – – – – –
Community member support Timetabling for trainees to learn together Faculty Development Community member and community workforce support considered equal partners - encourages participation Student associations – support and encourage participation Health informatics to encourage participation
Interdisciplinary Barriers Macro – – – – – –
Faculty and student recruitment and faculty development (i.e. Aboriginal students) not available Competing for tuition dollars Regionalization Access to comprehensive continuum of care - geography Regulatory issues (i.e. scope of practice) Utilization of community and hospital resources for interdisciplinary education
Meso – – – – – – –
University culture Acceptance by academic influencers Modifications to program curriculum (i.e., accommodate different curriculum and semester schedules) Educating people to get enablers Training of faculty members, faculty workload Level of understanding of various health disciplines role in IECPCP (i.e. turf issues) Bringing health disciplines together
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Interdisciplinary Barriers Micro – – – – –
Time constraints to structure programs Recognition of unregulated health providers as educators Time in obtaining support or “buy-in” is a gradual process Time tabling for trainees to learn together Faculty development
Collaborative Practice Key Findings Key findings of the collaborative practice examples reveal: • • • • • • •
Programs were developed in responding to a population health need. Collaborative practice champions were members of the community. Program funding has been available but has decreased over time. Current levels are not keeping pace with corresponding increase in demand for acute and tertiary services within these communities. Community leaders provide a significant role to ensuring program continues to be sustainable and available to patients. Incentives for interdisciplinary team would generate interest. Funding for interdisciplinary team to provide health services was not available. Understanding and having the knowledge about population needs was critical to the success of collaborative practice programs.
Specific details of these findings are noted in the following tables: Collaborative Practice External Drivers Internal Drivers • Address population needs • Champion – if part of community even better • Government priority programs • Buy-in from health professional team • Government funding availability eg. members research grants to reduce health utilization • Team/community members volunteer time • Champion interest • Patient needs in practice setting (i.e. • Community-driven ERs) • Changing health care system • Existing commitment from providers (i.e. geriatricians)
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Collaborative Practice Enablers Macro – – – –
Interdisciplinary team are community members to address population needs (i.e. aboriginal) Hospitals providing access to interdisciplinary care Government funding Changing health care system
Meso – – – – – – –
Community members provided facilities and advertised program (i.e. School Bands) Team volunteered their time Champions are a necessity Partnership between university and CLSC Regional board funding Change needs to come from the professionals, they must be involved in planning for interprofessional training and project Need to improve communication and reduce duplication of services
Micro – – – – – –
Desire from professionals to get to know each other and to improve their functioning To identify a common health problem to work on and to develop common knowledge Administrative support To accept that it is progressive change, no radical change Community provided equipment and education materials Support from health care providers and community leaders volunteering their time to IECPCP Collaborative Practice Barriers
Macro – – – – – –
Knowledge base of aboriginal culture in accepting western medicine Access to acute and tertiary services – geography Community commitment for participation Limited funding (i.e. funding for champion only) Level of funding has not kept pace with increased patient demand Availability of resources (i.e. hospital beds)
– – – –
Physician “buy-in” of educators Lack of incentives for participation Remuneration among interdisciplinary team (i.e. fee-for-service) Health human resources - recruitment of qualified educators, hospital administrative support Perception/bias about certain population groups
Meso
– Micro – – – – – –
Time constraints executing programs Finding appropriate facilities to conduct education sessions/office time (i.e. scheduling) Lack of recognition on collaborative practice initiatives Provider not interested – funding Threat of having to modify responsibilities Accountability related to lack of trust among professionals
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What We Can Learn From Interdisciplinary Education & Collaborative Practice Examples Features in IECPCP From the review and analysis of the findings for IE and CP there are common streams. Interdisciplinary education for collaborative practice is a priority among the academic and health care institutions, as well as within communities Funding is available from a macro level provided by the government and institutional leaders in health and education Community members and leaders provided the leadership, commitment and support (i.e. contributed personal time) IECPCP initiatives were established in responding to specific patient and/or population needs. Implementation of IECPCP initiatives were linked to reform initiatives at the provincial level. Willingness for change amongst all evolved over time. a champion is needed to lead – but secondary support is needed for sustainability There is a wealth of information in Canada but not readily accessible Existing successful programs have not received widespread recognition. Need to address systemic issues in order to move forward. For IECPCP to be successful, programs need to be responsive to cultural and social issues in addressing population needs. A key finding in these IECPCP features was that funding was a key enabler to ensure the program’s sustainability. In his interview in addressing the sustainability for the Regional Geriatric Program, Dr. Barry Goldlist stated, “…The only real substantial enabler was the fact that the government gave extra money to hospitals. If they hadn’t done that nothing would have happened…” Through these interdisciplinary education and collaborative practice examples, it provided several opportunities that included the integration of IECPCP in the educational curriculum and in communities funded by the institutions. It further enhanced team building early on in the student learning and encouraged health disciplines involvement with IECPCP educators/instructors. While in most cases a dedicated champion was necessary for the sustainability of these programs, it was apparent that there was a need for succession planning to ensure continued success. Funding was a critical piece in the program’s sustainability. For the most part, funding was available on a short term basis, whereas to ensure continued IECPCP success, a long term funding commitment was a dominant factor. Other factors that were identified as critical to ensuring the success of IECPCP was long term commitment and support from the partners as well as high level of interest from the academic institutions and communities.
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Overcoming Barriers In the successful IECPCP examples, participants were asked what measures they took to overcome the barriers they encountered in implementing IECPCP. Their responses are summarized below: Interdisciplinary Education: The need for effective planning of program curriculum Allow for flexibility for student training, program development, team building (i.e. scheduling) Academic institutions provide skills and knowledge that address students needs (e.g.. Aboriginal students) Demonstrate educators’ qualifications and expertise. Develop mandatory programs Establish teaching health services protocols for certain population groups Collaborative Practice: Achieve collaboration only with interested players/partners Providing patients with choices Consultation with key players and community to address needs Bring enablers/participants early on Ongoing communication – marketing programs
IECPCP and Patient Outcomes To determine the effectiveness of these IECPCP examples with respect to patient outcomes, participants were asked whether assessments or evaluations were conducted on the program’s effectiveness in achieving positive outcomes. Responses ranged from “evaluations were in progress” to “unable to conduct evaluations” due to limited resources and lack of funding and/or interest. Although evaluations on interdisciplinary education and collaborative program initiatives are limited, four IECPCP examples were evaluated. The methodology used for the evaluations was qualitative. Evaluations ranged from testimonials to completing evaluation forms. Two of the evaluative examples were published in peer review articles. This concurs with the findings from the on-line survey that few IECPCP initiatives are published. At the University of Rochester, student data evaluations have existed for seven years and it is used to enhance or modify interdisciplinary education programs.4 Within the Regional Geriatric Program in Toronto, lead by Dr. Barry Goldlist, he revealed that in his study elderly patients exposed to interdisciplinary care achieved better health outcomes. Elderly patients were able to continue to meet their health care needs from their homes and did not require acute care services following one-year after hospital discharge. Given the lack patient outcomes data, most interviewees agreed that more evaluative studies on IECPCP need to be done. This finding coincides to the chapters by Oandasan, Barker and Zwarenstein. 4
The Health Action Curriculum: A Resource Guide for Community-Based Interdisciplinary Education
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Summary Detailed information was gained during the interview process which proved invaluable to our research efforts. The level of expertise and guidance offered by the experts/participants should be further explored, especially if the IECPCP initiative is to move forward in Canada. The experts that were interviewed showed a keen interest in providing future input, if required. There was a consensus from the in-depth interviews that more needs to be done to move IECPCP forward in placing it in the mainstream of health care delivery. This included conducting evidence-based research on the integration of IECPCP in all practice settings, explore new funding models for collaborative practices, the need to effectively address social and cultural issues of population groups, and develop mechanisms to ensure the sustainability of IECPCP program initiatives.
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Appendices for Chapter Six: Examples of Interprofessional Education and Collaborative Practice: Findings from In-depth Interviews
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Appendix 6-1 In-depth Telephone Interview Guide Based upon your experience in interdisciplinary education and/or collaborative patient centred care, we have a number of questions we would like address in our conversation with you to help us understand this area further. 1.
Please describe the interdisciplinary education and/or collaborative patient centred care program that you are most familiar with.
2.
What were the external/internal drivers influencing the development of this program?
3.
Who were your partners, that is who was involved in the program planning?
4.
Who were the key players in designing and/or implementing the intervention? -how did you involve them? -what were their roles and responsibilities? -did you build group trust and cohesiveness – and how? -how did you ensure good communication?
5.
What was the overall goal of this activity at the interdisciplinary and discipline-specific levels? I.e. attitudes, skill development, team building. - What were the specific objectives of this program?
6.
What were the opportunities within the current learning/practice context: -the patient population -the practice site(s) -the learners in terms of disciplines and level of training -the health professionals -the timing (scheduling, length of program)
7.
What challenges did you encounter? - How did you overcome them?
8.
Were there any enablers/facilitators that you encountered in program development & implementation?
9.
Are you aware of any policies that have supported your collaborative practice/interprofessional education initiative?
10. How was an evaluation conducted? -What were the outcomes (learning/process) that were measured? 11. Was this program sustainable and why? Why not? 12. Research – next steps: What types of research needs to be done? In your experience, what are the critical issues that need to be done in moving foreword to interdisciplinary education and collaborative practice? What are the specific research needs that need to be done? What are the topic areas?
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Appendix 6-2 In-depth Interview IECPCP Initiatives Interdisciplinary Education Examples Program Name Health Action Elective, University of Rochester UK National Health Service College of Health Disciplines, University of British Columbia (UBC)
Program Leader/Informant Dr. Madeline Schmitt & Noelle Andrus, University of Rochester (US) Dr. Hugh Barr, University of Greenwich (UK) Dr. John Gilbert, University of British Columbia
Key Features -
-
Health Sciences Council, University of Alberta
Dr. Don Philippon, University of Alberta
-
Northern Ontario Collaborative Practice (NOMEC)
Bev Lafoley, Northeastern Ontario Medical Education (NOMEC) (Sudbury)
Université de Montréal
Paule Lebel, Université de Montréal
-
-
-
Established in 1997 as an elective and undergraduate program including 10 demonstration practice sites Focus on interdisciplinary education on public health Two academic semesters including health studies, medical, nursing and public health Policy and legislation of IECPCP in the education and health care systems in the UK. All health disciplines are required to take IECPCP training and education. Health disciplines work in collaborative practices in all health care settings. Established in 1996 as an elective program Part of the University Constitution Act Affiliated with 7 health faculties within the university including medicine, pharmacy and dentistry) 16 programs offered in interdisciplinary and collaborative practice for undergraduate with some postgraduate training Health Science undergraduates are required to take one mandatory course in first year and decide to take elective course Fourteen professions programs are offered to undergraduate students 800 students are in interdisciplinary care courses primarily 2nd and 3rd year students Courses are 5-week interval with groups of 6 students. Problem-based learning. Established in 1999 Partnerships with other universities (i.e. Western of Ontario, Queens University and University of Ottawa) Offer program/courses for undergraduates to learn about rehabilitation services in northern communities as resources for rehabilitation services is not readily available. Two teams of students participate in course/program primarily from other universities. Established in 1997 Post- graduate Given in 30 health care organizations 2 days training over a period of 3 weeks for professionals, training for mentor and individualized follow-up Also given in part to medical student Developed from literature review, interviews with experts, and interviews with professionals undergraduate
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Collaborative Practice Examples Program
Program Leader/ Informant
Lake Loon Primary Care (Saskatchewan)
Joan Barrie, Loon Lake Union Hospital (Saskatchewan)
Nurse-driven Asthma Clinic (Alberta)
Dr. Andrew Cave, Department of Family and Community Medicine, University of Alberta
Regional Geriatric Program (Toronto Rehabilitation Clinic, University Health Network)
Dr. Barry Goldlist, Toronto Rehabilitation Centre and University Health Network
Academies of Health Disciplines (Toronto)
Susan Wagner, Department of Speech Language Pathology, University of Toronto
Shkagamike-Kwe Health Centre (Sudbury) Primary Healthcare (CLSC Haute-Ville-des Rivières, Québec)
Joyce Helmer, Northeastern Ontario Medical Education NOMEC (Sudbury) Line Paré, Social Worker (Montreal)
Key Features -
Aboriginal health care site promoting parenting skills Population 2,500 in which 2/3 are Aboriginals are young families and children Nurse champion Education and collaborative seminars on parenting skill can only be done in the community not in hospital. Clinic is based on a UK model that was successful. Two nurses educators provide training to asthma patients in teaching clinic and private practice Provide care two mornings a week seeing patients for ½ hour patient visits Nurse volunteer time at teaching clinic as funding is not available. Clinic is in partnership with the local Alberta Asthma Clinic supported by the private sector. Private sector provides a researcher as a resource. Established in 1980s funded by the Ontario government on the premise that no single institution could provide coordinated range of services for elderly population in downtown Toronto. Two hospitals were initially involved in providing interdisciplinary care in meeting elderly health needs. Establishment of consultant teams of participating hospitals that meet 3 – 4x/yr Current sources of funding is government grants and hospital budget 175,000 elderly patients over 75 years of age 1 physician and 1 operations director with cross hospital appointment manage the program Health care team include, physiotherapists, specialized nurses, physicians and social workers) Focus is providing rehab continuum of care services for elderly in tertiary setting Established in 1993 with four academies in place based on a Harvard School model Health discipline students are educated in teaching hospitals Health disciplines include speech language pathology, occupational therapy, and physiotherapy. 80 students are participating University mandate in encouraging IECPCP Problem-solving technique to teaching Consideration for accreditation. improve health and well-being of Aboriginals CLSC established since 1975 Field concern by this experience is a family medicine unit Training nurses, doctors and social workers since 2001to interdisciplinary care Aim is to consolidate and pursue team development and to offer a interdisciplinary clinical field practicum for students from health disciplines Work on share responsibilities through protocols
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Chapter Seven Cultural Considerations in Interprofessional Education and Practice By Margaret Purden
Introduction The following framework has been developed to organize the discussion: 1) introduction to the issue of cultural diversity in health care; 2) definition of terms; 3) implications of cultural diversity for interprofessional practice will include the essential ingredients for a culturally sensitive practice setting, barriers and facilitators in achieving cultural diversity in health care agencies, and 4) implications of cultural diversity for interprofessional education will include the essential ingredients for a culturally sensitive curriculum, barriers and facilitators in achieving cultural diversity in the curriculum.
Search Strategy and Results In initial search was conducted to obtain literature on cultural considerations in interprofessional education and practice on December 19, 2003. It was decided that the initial part of the search strategy used for the ‘Jet Review’ (Freeth, Hammick, et al., 2002, 60/id) would be used in Medline restricted to the last 5 years which included the following search terms: interprofessional, interdisciplinary, interoccupation, interinstitution, intersector, interdepartment, interorganization, interprofessional relations, professional-patient relations, multiprofessional, multidisciplinary, multioccupation, multiinstitution, multisector, multidepartment, multiorganization. This core part of the search was combined with the following key words and phrases: cross-cultural comparison, cultural characteristics, cultural diversity, ethnic groups. Appropriate wildcards were used in the searching in order to account for plurals and variations in wording. A total of 660 citations were retrieved from this search. Scanning the results from this search yielded 173 abstracts on cultural diversity that clustered into the following 5 themes: intervention studies with minority patient populations, descriptions of programs for minority patient populations, observational accounts of health care needs of particular minority populations, cultural diversity within the health care profession and developing cultural competence for health care professionals. A total of 43 articles were retained for review. A final set of 14 articles was retained that addressed interprofessional collaboration/education within the context of culturally diverse communities.
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A second search was conducted on January 23, 2004 in CINAHL (Cumulative index to Nursing and the Allied Health Literature) to locate literature on interventions tailored to Canada’s aboriginal populations. Since very little has been published on this topic it was decided to do on general search on Canadian Aboriginals to capture the relevant publications. The CINAHL search was restricted to 1990 and included the following search terms: Native Americans, North American Indian, First Nation, Canadian Aboriginal, Aboriginal, and Canada. As in the first search, appropriate wildcards were used in the searching in order to account for plurals and variations in wording. When keywords such as “interprofessional” or “interdisciplinary” were combined with the search terms used to find the aboriginal materials, several important references were not retrieved. A total of 287 citations were retrieved from this search and 18 were retained for the report. In an attempt to locate literature specifically on interprofessional care and practice and multidisciplinary teams in relation to Canada’s aboriginal population the initial Medline search was executed again. However, this time the search terms used in the second search were combined with the results of the first Medline search. This strategy yielded only a few relevant articles. This same search strategy was then re-executed in CINAHL. This search retrieved several relevant citations that were not in the Medline search results. Finally, an author search was conducted for Dr. Ann Macaulay, who writes extensively on participatory action research and aboriginal populations with a focus on the theme of collaboration. This last search was done in the CINAHL, Medline, and PsycINFO databases, and retrieved approximately 30 articles, of which 3 were retained.
Definitions The terms interdisciplinary, culture, cultural diversity, cultural competency, cultural sensitivity, are concepts that emerged in the literature, not all of which have intuitive meaning. A summary of these concepts along with definitions provided by the various authors is presented below in order to expose and clarify the different meanings Interdisciplinary Interdisciplinary teams work together to address various issues over an extended period, the members participate and/or take leadership responsibilities because of their particular expertise as individuals or their relationships with clients, not simply because of the positions they hold (Boone, Minore, Katt, & Kinch, 1994, p.17). Interdisciplinary teamwork is characterized by shared purpose, creative problem solving, and synergy in which combined activities result in a product that is greater than the individual components (Fatout & Rose, 1995, p.51). Culture Traditionally, race and ethnicity have often been thought to be the dominant elements of culture (Ahmann, 2002). However, recent definitions are less rigid describing culture as “an organized group of learned responses that occur through interactions with others in society”. It is argued that culture should also include the elements of language, gender, socioeconomic status, housing
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status, and regional differences (Ahmann, 2002; Purnell, 2002). Purnell also includes the elements of education status, occupation, urban versus rural residence, marital status, sexual orientation, immigration status as secondary characteristics of culture. Cultural diversity The concept of cultural diversity refers to the differences between people based on a shared ideology and valued set of beliefs, norms, customs, and meanings evidenced in a way of life (American Nurses Association, 1991). Cultural competency Numerous definitions exist ranging from the attitudes and behaviours of the individual to the characteristics of the system. Definitions that focus on personal attributes have identified communication and self-reflection as key. For example, cultural competency involves appropriate and effective communication which requires the willingness to listen to and learn from members of diverse cultures, and the provision of services and information in appropriate languages, at appropriate comprehension and literacy levels, and in the context of an individual’s cultural health beliefs and practices (Task Force on Multicultural Competence, 1993). Norr et al. (2003) stress that cultural competence is an evolving process that depends on self reflection, self awareness, and acceptance of differences, and is based on improved understanding as opposed to an increase in cultural knowledge. From a systems perspective, Ramirez (2003) defines cultural competence as a set of behaviors, attitudes, policies, as well as education and training that enable a service, an agency or group of professionals to work effectively in cross-cultural situations. Cultural Sensitivity Goicoechea-Balbona (1997) defines the concept as being sensitive to the ways in which community members’ values and perceptions about health care differ from his or her own. It involves a willingness to use knowledge about culture while caring for patients and taking culture into account during discussions and recommendations for treatment (Dennis & Giangreco, 1996, Ulrey & Amason, 2001).
Implications of Cultural Diversity for Interprofessional Practice and Education Introduction The sociodemographic profile of North American society demonstrates diversity in ethnicity, culture, race and language (Ahmann, 2002; Masi, 1993). Across Canada and the U.S. health care institutions and community services programs and educational institutions are struggling with the challenges and opportunities to respond effectively to the needs of individuals from these diverse groups (Ahmann, 2002). Moreover, health care professionals must find ways to learn about the cultural aspects of health and healing. However, little exists in the form of published valid and 192
reliable research to assist with this, especially with respect to minority populations (Clarke, 1997). Academic institutions acknowledge that professional programs have not kept pace with the new social reality in health care and that changes in the curriculum are necessary in order to address cultural diversity more effectively and ensure that health professionals are prepared adequately to meet the needs of the entire population (Chevannes, 2002). In Canada, cultural diversity has long been recognized as an important strength and a fundamental feature of the national heritage. In the 1991 census, the most common ethnic groups after British and French were, German, Italian, Chinese, Aboriginal, Ukrainian, Dutch, and East Indian (Statistics Canada, 1996). Within the Aboriginal First Nations people almost half a million are North American Indians, 36,000 are of Inuit origin, and 135,000 are Metis. More than 1 million Canadians have some aboriginal ancestry. Half live in rural areas with nearly 300,000 domiciled in remote reserves, and living in poverty (Rourke, 2002). Each Aboriginal community is distinct with its own set of beliefs, values and traditions of healing (Reading, 2003). There is considerable evidence that Canada’s Aboriginal people have poor health outcomes with increased morbidity and life expectancy 6-8years shorter than Canadians generally (Norris, Kerr, & Nault, 1996; Rourke, 2002). In view of these disparities, the topic of cultural diversity will mainly examine health care and educational initiatives that have attempted to address the needs and concerns of Canada’s Aboriginal people. However, many of the issues raised in this discussion are not culture-specific, other ethnic populations live a similar reality (Chevannes, 2002). Thus, the challenges associated with cultural diversity are generic and likely to occur whenever patients value health practices and beliefs that differ from conventional Western health care. The theme of promoting cultural diversity in health care will be explored from two perspectives: creating practice environments that support culturally competent care and developing educational programs that foster cultural awareness and sensitivity among students in the health care professions. These two perspectives will be explored within the context of interprofessional relationships in order to address the question, “Does an interprofessional approach enhance both practitioners and students’ abilities to understand and provide culturally competent care?” The discussion is organized to address the essential ingredients of a culturally competent practice setting/educational program, and the barriers and enablers in achieving cultural competency in both the practice arena and the educational curricula. A summary statement will highlight the major trends and include recommendations for future directions.
Cultural Diversity in Interprofessional Practice The critical elements in providing culturally sensitive health services to Canada’s northern aboriginal people include: understanding and respecting the culture, securing the support of the community and taking an interdisciplinary team approach to the delivery of services. Indeed, health care in most aboriginal communities is organized to address these key elements. Health services are characterized by small, interdisciplinary teams of professionals working with paraprofessionals recruited from the community. The team is often eclectic and may include teachers, police officers, and clergy—professionals not usually part of the traditional health disciplines. This structure serves two purposes, to maximize accessibility to health care in remote
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areas, and to facilitate effective cross-cultural caregiving by non-aboriginal health care professionals (Boone et al., 1994; Minore & Boone, 2002; Smith, 2003). Previous work indicates that several conditions need to be present in order for these complex interdisciplinary teams of professionals and aboriginal paraprofessionals to function well (Minore & Boone, 2002). However, these standards are often not realized. The following discussion will elaborate on the essential ingredients to promote interprofessional practice in a culturally diverse context drawing on examples from the literature and the projects that were described in the in-depth surveys. Essential Ingredients In successful partnerships, team members have to understand their own roles as well as those of others, the common ground that exists between them, and any boundaries that need to be respected. It also involves realigning all traditional roles and synergistically advancing thought in a communal pattern. Disciplinary interests or personal agendas are secondary to the shared goals of the collaborators. Barriers Roles and Relationships Arriving at a consensus on roles and working relationships is a daunting task even for teams made up exclusively of health professionals, due to the discipline-based approach taken in education and the discipline-centric perspectives that exist (Frankel, Speechley, & Wade, 1996). Providing care to the aboriginal community not only requires addressing interprofessional issues but also finding ways of incorporating the aboriginal paraprofessionals into teambuilding efforts. This is further complicated by the variations in educational preparation and roles that exist among community workers. The lack of clear role expectations consistently emerges as the major source of frustration among paraprofessionals (Ward, 1991). Moreover, paraprofessionals are often excluded from interdisciplinary consultations that often occur at the level of the professionals located in a region center. Minore and Boone (2002) note that there are no mechanisms to ensure that information is exchanged with paraprofessionals and suggest that this may be a reflection of the lack of confidence professionals have in the knowledge, skills and judgment of their paraprofessional colleagues. Continuing education to advance professionals’ skills to address these issues often occur outside of the work arena and therefore removes learning about ethnic minority patients from the interdisciplinary context in which professionals practice (Chevannes, 2002). Community involvement The support and involvement of the community have been described as the essential prerequisites of successful programs. However, creating the conditions that foster collaboration and commitment are not easily achieved and little information exists that describes the process (Potvin, Cargo, Mccomber, Delormier, Macaulay, 2003). The challenge of securing community buy-in was evidenced in the parenting skills program at Loon Lake Primary Care site servicing 2000 Aboriginal people. The program was initiated by the government agency because community members identified parenting skills as the highest priority. However, after several years in operation the program is no longer sustainable and did not get picked up by the community. Program organizers speculate that one the reasons for dissolution is the lack of
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community participation and the community buy-in. In retrospect, Barrie notes (personal communication, 2003, see Chapter 6) open communication, regular meetings, building trust, and securing the community’s full support from the beginning were essential ingredients that were missing from the project that ultimately led to its termination. Enablers Ahmann, (2002) advocates collaboration with members of the cultural community to develop services and programs that meet the need of culturally and linguistically diverse groups served by the agency/institution. Additional collaborative ventures include: networking with advocacy organizations, working with community-based organizations on culturally appropriate prevention and public health programs, partnering with traditional healers to identify potentially harmful folk remedies and patients in need of medical attention, and working with patient advocates to help immigrant families to navigate the complex health care system. For example, participatory action research is a methodology used by researchers to collaborate with the Aboriginal community that is also evolving as an intervention for health promotion (Dickson & Green, 2001). Native communities value this approach because it is respectful of cultural values, builds relevant knowledge and skills and allows for the application of the results (Macaulay, Paradis, Potvin, Cross, Saad-Haddad, McComber et al., 1997). All aspects of the research are based on partnership and alliances between the researchers and community members and organizations (Cargo, et al., 2003). The Native staff oversees the decisions for the intervention and evaluation, so the project is consistent with the culture of the community. The Iewirokwas Program on the Akwasasne Reserve, the Innulitsivik Maternity project in northern Quebec and the Churchill Health Centre in Manitoba are successful examples of programs care where the community became engaged and committed. Traditional practices were respected and interwoven with conventional care as a result of collaborations between the local health-care professionals and members of the Native Association (B. Murray, personal communication 2003; Smith, 2003). Clients felt comfortable using the services and perceived that they were receiving excellent care as a result of the integration. In addition to securing community buy-in, an important investment needs to be made in developing collaborative relationships among the service providers. Shkagamik-Kwe Health Centre is an example of a successful practice providing services to 2,400 Ojibwa people in Sudbury (see Chapter 6). Key elements to its success include: community-sponsorship, a common philosophy, and the trust and respect that exist between and among the professionals. The interdisciplinary model of governance fits with the culture and values held by the community. People who work in the setting come with cultural beliefs that focus on the “good of all”. Although formal roles exist, professionals are not constrained by their titles and if a particular task needs to be done, everybody helps out to achieve the common good. Patientcentred care and collaboration are fundamental features of the service. Patients determine the point of entry by choosing the professional they wish to see, be it a traditional healer or a professional trained in western practices. All team members document in the charts, freely consult one another and with the permission of the client refer to team members. Because they work in close proximity, team member gain a better understanding of one another’s practice and
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interdisciplinary collaboration is further enhanced. A continuous challenge is the tension between culturally competent practice and western training. Western practitioners and aboriginal healers are encouraged to spend time with each other, to go to each other’s sessions, to take appointments with the healers, and to collaborate on the diagnosis. This approach has been found to facilitate mutual respect among the professionals. One method is not perceived to be superior to the other, but is appreciated as being different. In summary, interdisciplinary teams consisting of both professionals and paraprofessionals are an important part of the healthcare landscape for most Canadian aboriginal communities. However, they often fall short of functioning in a true interdisciplinary fashion because they are unable to achieve an “esprit de corps” among team members that creates a common culture that everyone can live with (Fatout & Rose, 1995). Many of the obstacles to effective teamwork can be traced back to a lack of appreciation of their own and one another’s roles while working within a complex care environment (Minore & Boone, 2002). Addressing these issues calls for future educational initiatives that emphasize learning how to work effectively with both professional and paraprofessional team members in a learning context where professionals and patients interact on an on-going basis (Chevannes, 2002).
Cultural Diversity in Interprofessional Education Rural and remote health is acknowledged to be a challenging care environment requiring advanced clinical skills, knowledge of the culture and health practices of rural society, and experience with interdisciplinary approaches to health care delivery. Currently, the curricula of most professional schools, including programs charged with preparing individuals for such work tend to concentrate on developing students’ competence in the requisite clinical proficiencies (Minore & Boone, 2002). Collaboration with colleagues across programs can be a useful process to increase cultural knowledge and to provide solutions to the cultural care needs of patients (Hilgenberg & Schlickau, 2002; Kulwicki, Miller, & Schim, 2000). Barriers Cultural competence Vukic and Keddy (2002) note that knowledge of a culture is a major factor in the effectiveness of health care in northern aboriginal communities, yet providers understand only the surface of First Nations’culture. Although descriptions of cultural characteristics and practices can be useful to healthcare students, they can also reinforce stereotypes and simplistic views of particular cultural groups as outsiders, and as different (Webb & Sergison, 2003). Similarly, simplistic representations of “culture” without regard to the historical or political context are also problematic, since they divert attention away from the underlying structural inequities influencing health and health care (Anderson & Kirkham, 1999). Cultural competence has yet to be made integral to health professions training or essential to standards of professional practice (Chin, 2000). Cultural issues receive minimal attention during the intense process of professional education. Cultural and ethnicity topics tend to be mixed in the generic clinical experience in school programs (Niemeier, Burnett, & Whitaker, 2003). In addition, availability of these courses and access to them is also variable across facilities
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(Niemeier, et al.). Graduate medical education programs emphasize “on the job training” and until situations are encountered that require specific attention to cultural issues, it tends not to be a focus of concern (Niemeier, et al.). Similarly, nurses have indicated that lack of appropriate training on transcultural nursing, in their undergraduate program has not prepared them to maintain effective relationships with Aboriginal people (Ntetu & Fortin, 1996). While our educational and training institutions are now focusing more on developing courses in cultural competence, completion of such courses is often not required. (Niemeier, et al). Absence of an interdisciplinary focus Although there is an increasing emphasis on interdisciplinary approaches in health science education programs in Canada, most programs do not include clinical practice for interdisciplinary training, opting for a classroom approach. Moreover, the focus tends to be on collaboration exclusively between or among professionals. There is little attention within any of the professional programs about working with paraprofessional caregivers (Boone, et al., 1994). For example, the Lakehead University program in northern nursing clinical practice specifically designed for the Aboriginal Community does not make explicit reference in its courses to working with community workers (Minore & Boone, 2002). In contrast, aboriginal paraprofessional programs do include sessions on the dynamics of working in a team with health care professionals. Not surprisingly, graduates of the health science programs are not always well prepared to work with their peers from the other disciplines. Moreover, they are particularly ill suited to work with the increasing numbers of paraprofessionals who are being hired to provide direct care in the remote areas of the country (Minore & Boone; Boone, et al., 1994). Enablers Courses teaching the latest information about culture-fair assessment and research practices should be prominent in pre-service educational offerings (Niemeier, et al., 2003, Panos & Panos, 2000). Undergraduate and graduate professional schools can include specific coursework on cultural diversity and make such courses a required part of the curriculum (Niemeier, et al.). Flores also advocates the use of both didactic and case-based formats, and having patients and their families share their cultural issues and stories with students. The inclusion of students from various disciplines in the learning exercise could also be a very powerful and effective way to introduce the notion of cultural assessment within an interdisciplinary context. Professional schools should also require a curriculum “track” or practicum experience that emphasizes cultural issues as a mandatory experience for graduation. (Chin, 2000). In these clinical experiences students should be given the opportunity to work with and learn from clinician mentors/ role models (within and outside of their discipline) who are expert in providing culturally competent care (Flores, 2003). These criteria should be evaluated as part of the Accreditation process for undergraduate professionals programs. Ballem (personal communication, 2003) describes an education initiative that explored interprofessional learning that brought together students in 9 different professional schools including nursing, medicine, social work, pharmacy and physiotherapy. Over a 6 to 8 week period students attended workshops, developed projects in groups, and worked in interdisciplinary teams in the Aboriginal community. Immediate responses from the students and the community were positive and students learned to cross-traditional practice boundaries to
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work collaboratively. Previous work suggests that the development of skills in interdisciplinary practice should be fundamental to all health sciences’ curricula both in the classroom and in clinical training (Flores, 2003). Minore and Boone (2002) go further in their recommendations specifying that course content should be expanded to include the roles and responsibilities of paraprofessionals—in order to focus on the entire team. Students in the health sciences need to be made aware of paraprofessionals’ contributions to patient care, and how to work more collaboratively with them. A future direction for interdisciplinary education may involve creating some opportunities for shared instruction between paraprofessional and health professional programs.
Conclusion and Future Directions Direction for Cultural Competence in Practice The lessons learned from the literature with respect to promoting cultural competence in practice setting include the following: 1. Effective cross-cultural caregiving requires that interprofessional collaboration be extended to paraprofessionals and key community workers and professionals who are not currently part of the traditional health care team. 2. Promoting cultural competency in practice calls for learning opportunities that bring professionals and paraprofessional community members together to explore ways to collaborate on actual patient care situations. 3. Securing the support and participation of the community is vital to the sustainability and relevance of health programs and services. The Participatory Action Research model describes a process of building community partnerships and may be adapted to health promotion activities. A successful collaboration is likely to result in the development of innovative services that are an eclectic blend of ideas and perspectives from traditional healing practice and conventional western health care.
Direction for Cultural Competence in Interdisciplinary Education The prominent themes that emerged from the literature on promotion of cultural competency in interdisciplinary education include the following: 1. Opportunities for interpersonal skill development from an interprofessional or transcultural perspective are lacking or are inadequate in most professional programs. Classroom teaching of cultural content does not address how to provide culturally sensitive care and may in fact oversimplify the cultural care needs of patients. Pedagogical initiatives need to incorporate culture-fair assessment workshops, case-based formats, and interactive sessions with patients
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and families. 2. Professional schools should include clinical experiences where students from the different professions work collaboratively in teams providing care to culturally diverse populations. 3. Students in health care need to be made aware of the contributions of paraprofessional community members to patient care, and how to work more collaboratively with them. The review of the literature and the national survey results provide increasing evidence that an interdisciplinary collaborative approach among professionals, paraprofessionals and the community is desirable and possibly the only feasible way in which health care can be delivered in Canada’s northern native communities and remote settings. Moreover, the principles underlying such an approach: openness, mutual respect, inclusiveness, responsiveness and understanding one another’s roles should be fundamental to the delivery of culturally competent services to all ethnic minority communities throughout Canada.
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References Ahmann, E. (2002). Developing cultural competence in health care settings. Pediatric Nursing, 28(2), 133-137. American Nurses Association, (1991). Position statement: Cultural diversity in nursing practice. http://nursing world.org/readroom/position/ethics/etcldv.htm accessed on January 26, 2004. Anderson, J., & Reimer Kirkham, S. (1999). Discourses on health: A critical perspective. In H. Coward & P. Ratanakul, (Eds.). A Cross-cultural dialogue on health care ethics. Waterloo, ON: Wilfred Laurier University Press. Boone, M., Minore, B., Katt, M., & Kinch, P. (1997). Strength through sharing: Interdisciplinary teamwork in providing health and social services to northern Native communities. Canadian Journal of Community Mental Health, 16, 15-27. Cargo, M., Levesque, L., Macaulay, A. C., McComber, A., Desrosiers, S., Delormier, T., & Potvin, L. et al. (2003). Community governance of the Kahnawake Schools Diabetes Prevention Project, Kahnawake Territory, Mohawk Nation, Canada. Health Promotion International, 18(3), 177-187. Chevannes, M. (2002). Issues in educating health professionals to meet the diverse needs of patients and other service users from ethnic minority groups. Journal of Advanced Nursing, 39, 290-298. Chin, J. L. (2000). Culturally competent health care. Public Health Reports, 115, 25-33. Clarke, H. F. (1997). Research in Nursing and cultural diversity: Working with First Nations Peoples. Canadian Journal of Nursing Research, 29(2), 11-25. Dennis, R. E., & Giangreco, M. F. (1996). Creating conversation: Reflections on cultural sensitivity in family interviewing. Exceptional Children, 63 103-116. Dickson, G., & Green, K. L. (2001). Participatory action research: Lessons learned with Aboriginal grandmothers. Health Care for Women International, 22, 471-482. Fatout, M., & Rose, S. (1995). Task groups in social services. Thousand Oaks: Sage. Flores, G. (2003). Providing culturally competent pediatric care: Integrating pediatricians, institutions, families, and communities into the process. The Journal of Pediatrics, July, 1-2. Frankel, B., Speechley, M., & Wade, T. (1996). The sociology of health and health care: A Canadian perspective. Toronto: Copp Clark. Freeth D, M. Hammick, et al., (2002) A critical review of evaluations of interprofessional education: 1-63.
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Goicoechea-Balbona, A. (1997). Culturally specific health care model for ensuring health care use by rural, ethnically diverse families affected by HIV/AIDS. Health and Social Work, 22,172180. Hilgenberg, C., & Schlickau, J. (2002). Building transcultural knowledge through intercollegiate collaboration. Journal of Transcultural Nursing, 13(3), 241-247. Kulwicki, A. D., Miller, J., & Schim, S. M. (2000). Collaborative partnership for culture care: Enhancing health services for the Arab community. Journal of Transcultural Nursing, 11(1), 3139. Macaulay, A. C., Paradis, G., Potvin, L., Cross, E. J., Saad-Haddad, C., McComber, A., Desrosiers, S., Kirby, R., Montour, L. T., Lamping, D. L., Leduc, N., & Rivard, M. (1997). The Kahnawake schools diabetes prevention project: Intervention, evaluation, and baseline results of a diabetes primary prevention program with a Native community in Canada. Preventive Medicine, 26, 779-790. Masi, R. (1993). Multicultural health: Principles and policies. In R. Masi, L. Mensah, & K.A. McLeod (Eds.). Health and culture: Exploring the relationship, Vol.1 (pp. 11-31). Oakville, ON: Mosaic Press. Minore, B., & Boone, M. (2002). Realizing potential: Improving interdisciplinary professional/paraprofessional health care teams in Canada’s northern aboriginal communities through education. Journal of Interprofessional Care, 16(2)139-147. Ntetu, A. L., & Fortin, J-D. (1996). Pour un réajustement des approaches auprès des Autochtones. The Canadian Nurse, March, 42-46. Niemeier, J. P., Burnett, D. M., & Whitaker, D. A. (2003). Cultural competence in the multidisciplinary rehabilitation setting: Are we falling short of meeting needs? Archives of Physical Medicine Rehabilitation, 84, 1240-1245. Norr, K. F., Crittenden, K. S., Lehrer, E. L., Reyes, O., Boyd, C. B., Nacion, K. W., & Watanabe, K. (2003). Maternal and infant outcomes at one year for a nurse-health advocate home visiting program serving African Americans and Mexican Americans. Public Health Nursing, 20(3), 190-203. Norris, M. J., Kerr, D., & Nault, F. (1996). Projections of the population with Aboriginal identity, Canada, 1991-2016. Research study prepared by Statistics Canada for the royal Commission on Aboriginal Peoples. Ottawa. Panos, P. T., & Panos, A. J. (2000). A model of a culture-sensitive assessment of patients in health care settings. Social Work in Health Care, 31(1) 49-62. Potvin, L., Cargo, M., McComber, A. M., Delormier, T., & Macaulay, A. C. (2003).
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Implementing participatory intervention and research in communities: Lessons from the Kahnawake Schools diabetes Prevention Project in Canada. Social Science and Medicine, 56, 1295-1305. Purnell, L. (2002). The Purnell model for cultural competence. Journal of Transcultural Nursing, 13(3) 193-196. Ramirez, A. G. (2003). Consumer-provider communication research with special populations. Patient Education and Counseling, 50, 51-54. Reading, J. (2003). A global model and national network for Aboriginal health research excellence. Canadian Journal of Public Health, 94(3), 185-189. Rourke, J. (2002). Building the new northern Ontario rural medical school. Australian Journal of Rural Health, 10, 112-116. Smith, D. (2003). Maternal-child health care in Aboriginal communities. Canadian Journal of Nursing Research, 35(2), 143-152. Task Force on Multicultural Competence. (1993). Summary of findings. Sacramento: California Department of Health Services, Office of Multicultural Health. Ulrey, K. L., & Amason, P. (2001). Intercultural communication between patients and health care providers: An exploration of intercultural communication effectiveness, cultural sensitivity, stress, and anxiety. Health Communication, 13(4), 449-463. Vukic, A., & Keddy, B. (2002). Northern nursing practice in a primary health care setting. Journal of Advanced Nursing, 40(5), 542-548. Ward, J. (1991). Developing community mental health services for indigenous people in northern Ontario. In B. Postl, P. Gilbert, J. Goodwill, M. Moffatt, J. O’Neil, P. Sarsfield, & T. K. Young (Eds.). Circumpolar health 90-: Proceedings of the 8th International Congress on Circumpolar Health. Winnipeg: University of Manitoba Press. Webb, E. & Sergison, M. (2003). Evaluation of cultural competence and antiracism training in child health services. Archives of Disease in Childhood, 88, 291-294.
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Chapter Eight Health Policy and IECPCP By Carmela Bosco
Introduction Factors such as time constraints, budget allocation, infrastructure, institutional climate and culture are all policy issues that need to be discussed and defined in order to move IECPCP forward in the Canadian health care system. The policy opportunities that can make interdisciplinary education for collaborative patient centred care a reality need to emerge from Federal, Provincial and Territorial legislative dialogue and universally coherent policy making decisions. In addition, an assessment of the policies that currently exist (both in Canada and abroad) that support and influence interdisciplinary education for collaborative patient centred care policy is required. This chapter addresses these issues and is structured as follows: 1. IECPCP Program Activities within Canada and abroad 2. Policy Barriers that impede IECPCP including those at the system, organizational and individual levels 3. Policy Enablers facilitating IECPCP 4. Policy Levers or measures that have been employed for IECPCP 5. Policy Issues that need to be considered 6. Next Steps for Health Canada in promoting and advocating for IECPCP We begin with a brief review of the policy literature.
Policy Literature Review A review was conducted of the grey literature from the past decade on reports that have addressed the issue of interdisciplinary education, collaborative practice and primary health reform. This included conducting an environmental scan of provincial health and education government websites, public health forums5, website searches through PubMed (Medline) and of 5
Canadian Policy Research Networks (http://www.cprn.com) Canadian Health Services Research Foundation (http://www.chsrf.ca/home_e.php) Public Policy Forum (http://www.ppforum.ca) Conference Board of Canada (http://www.conferenceboard.ca) Canadian Centre for Policy Alternative (http://www.policyalternatives.ca) Centre for Health Economics and Policy Analysis (http://hiru.mcmaster.ca/chepa) Centre for Health Services and Policy Research (http://www.chspr.ubc.ca) Manitoba Centre for Health Policy http://www.umanitoba.ca/centres/mchp National Institutes of Health (http://www.nih.gov)
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key national and provincial health care associations, health care and educational regulatory, malpractice and accreditation bodies, educational institutions, and international searches from United States and the United Kingdom. Informal discussions with policy influencers from government, health and education sectors also took place to obtain their policy perspectives with respect to IECPCP. A brief analysis of this review reveals that collaboration in primary health care delivery is “top of mind” with health, education and government decision-makers and Canadians. In addition to government activities, a number of conferences and discussion forums have taken place over the past five years to discuss solutions for renewing the health care system. Within these various national and provincial health forums, there is consensus that governments, health care providers, health and educational institutions want to work together to facilitate collaborative and cooperative leadership for health care renewal. There is support for patient-oriented service delivery and recognition for effective utilization of the skills and competencies of health human resources.6 However, the observation expressed to date within these venues is that renewal is a gradual process, achievable only by overcoming the barriers that have impeded the implementation of many reforms including IECPCP initiatives. These policy issues, that address some of the barriers, are explored more fully within the 6 major headings below.
1) IECPCP Program Initiatives Within Canada and Abroad IECPCP in Other Jurisdictions Based on the grey literature, IECPCP policy initiatives have been primarily implemented in the United States and United Kingdom. In the United States, while IECPCP does not appear to be a policy priority for state and federal governments, American academic and research institutions, such as the University of Rochester, University of Colorado Health Sciences Centres and the Institute of Medicine, have taken a leadership role in advancing IECPCP initiatives. Some universities have developed curricula in interdisciplinary education for health sciences students at the undergraduate level. As part of their “social accountability” to communities, these institutions, in partnership with their local communities and through corporate foundations, have taken responsibility to educate future health care professions about interdisciplinary care. In contrast, interdisciplinary care is engrained within the National Health Service in the United Kingdom (UK). Health and social care students are taught about interprofessional collaboration during their pre-registration programmes. At the international level, the UK’s health care system
C.D. Howe Institute (http://www.cdhowe.org) Canadian Institute for Health Information (www.cihi.ca) 6 The Health of Canadians – The Federal Role – Volume Six: Recommendations for Reform – October 2002 (Kirby Report)
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is recognized as a leader in IECPCP because for the past thirty years, IECPCP has been part of their health care and legislative framework. In fact, following the election of the Labour government in 1997, Prime Minister Tony Blair mandated that additional resources and funding be provided to further enhance interdisciplinary education for collaborative practice. Much can be learned from the UK experience. Canada In Canada, IECPCP policy initiatives have primarily been implemented at the federal and provincial levels spearheaded by the First Ministers of Health and the federal government who have provided significant investment toward primary health care renewal. Following the First Ministers’ Agreement in September 2000, an $800 million Health Transition Fund (HTF) was established to support primary health care projects across Canada. A provincial/territorial component (70% or $560 million) was allocated to provincial and territorial governments on a per capita basis to assist provincial and territorial governments in the implementation of their reform initiatives. A 30% component supported initiatives under three envelopes: national; multi-jurisdictional; and Aboriginal and official language minority communities.7 The Fund has supported a number of primary health care projects which, in turn, have been evaluated for their effectiveness. Of the 140 projects, 38 were national and 102 were provincial/territorial with 65 projects focusing on primary health care issues. In exploring examples of interdisciplinary education or collaborative practice models, three HTF projects evaluated ways to explore or improve “structured collaboration” among health practitioners addressing recruitment and retention problems by multidisciplinary medical services and teaching approach.8 Findings in these examples showed that although full collaboration did not take place, there was acceptance that with more time and experience, collaborative practice could be achieved. The three HTF projects associated with IECPCP were limited to “post-licensure” interventions occurring with health professionals already in practice as part of interventions within the practice setting. In February 2003, the First Ministers’ Health Accord created a five-year $16 billion Health Reform Fund targeted to primary health care, home care and catastrophic drug coverage. As the ultimate goal of primary health care reform is to provide all Canadians access to an appropriate health care provider, 24 hours a day, 7 days a week, the First Ministers expect at least 50% of Canadians to have timely access to this type of system by 2011.
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Health Care Renewal Accord 2003. www.hc-sc.gc.ca/english/hca2003/accord.html Project #1: Strengthening Multidisciplinary Teams in Coordinated Disease Prevention and Management (Calgary Health Region Project #2 Improving the Effectiveness of Primary Health Care Through Nurse Practitioner/Family Physician Structures Collaborative Practice. (University of Ottawa) Project #3: Primary Health Care Enhancement: Government of Newfoundland. 8
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Provinces and Territories Of the $560 million that has been allocated to the provinces and territorial government through the Health Transition Fund, most have implemented pilot demonstration project initiatives that include exploring interdisciplinary education and collaborative models. However, these initiatives are “works-in-progress” and it will take some time before concrete results are available for analysis. These initiatives are in partnerships with health care providers, community members, and academic researchers. Provincial health ministries have made primary health care a top government agenda. Most have established primary health care programs that can be used as the basis for exploring models of interdisciplinary care within certain health care settings as well as addressing health human resources planning. For example, through collective agreements with health professional groups, some provinces have implemented initiatives geared to further examine the feasibility of collaborative primary care practice level settings by testing concepts in local regions within the province.9 For example, the Ontario government has supported and funded the Ontario Family Health Network in which physicians can volunteer to be part of the Network in providing primary health care in collaboration with other health care providers such as nurse practitioners.10 The Quebec Government has also taken a firm stand in favor of collaborative practices in primary care with the Groupes de medicine familiale (GMF).
Health and Education Sectors Within Canada’s educational system, policy on interdisciplinary education has not been a top priority for most universities and provincial education ministries. However, some work on interdisciplinary education is already underway in Canada, including the recent collaboration between the Canadian Nurses Association, the Association of Canadian Medical Colleges, and the Canadian Association of University Schools of Nursing in partnership with Health Canada. The College of Health Disciplines at the University of British Columbia is also doing important work in this area.11 Certain academic and research institutions have taken the lead in exploring IECPCP models to include it as part of their health sciences program curricula, sometimes offered as elective courses, as exemplified by the Colleges of Health Disciplines at the University of British Columbia, the Health Sciences Council at the University of Alberta and the Centre for Collaborative Health Professional Education from the Memorial University of Newfoundland. The University of Alberta is the only university in Canada where health sciences students are required, as part of their education and training, to take a course in interdisciplinary education. Most health and education accreditation bodies are in the process of exploring the integration of interdisciplinary education and collaborative practice in academic teaching but it is not a high 9
2000 Agreement – Ontario Medical Association and the Province of Ontario, Ministry of Health and Long-Term Care 10 http://www.ontariofamilyhealthnetwork.gov.on.ca/ 11 Building on Values: The Future of Health Care in Canada. November 2002 (Romanow Commission)
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priority.12 From the environmental scan (see Chapters 5 & 6), those who participated in the on-line survey and in-depth interviews were asked whether they were aware of policy activities that support and advance IECPCP initiatives. Responses from the scan revealed some of the features of IECPCP-related policies in place: •
• • •
University policies that foster: o Faculty development in recommending and promoting interdisciplinary teaching and collaborative competencies (e.g. Academic Health Sciences Centre, University of Saskatchewan) o Collaboration with communities to address health care needs o Interprofessional continuing education programs by which, for example, nurse practitioners undertake CME with physicians. Funding policies for programs or grants awarded only to those initiatives that demonstrate interdisciplinary education and collaboration in partnership with recognized health research organizations, e.g. Alberta Health Innovation Funding. Provincial initiatives in primary care reform that address changes needed for health care systems frameworks and health care decision-making processes (i.e. Saskatchewan Action Plan for Health, 2001). Workplace policies that include job descriptions specifically addressing collaborative practice competencies and adapting physical practice settings to accommodate other health care practitioners.
Among the higher education institutions and their departments responsible for health professional training as well as health care professionals themselves, there is support for IECPCP but implementation has been slow because of barriers at both the institution and the practice settings. Collaboration amongst health care professionals within certain practice settings may be difficult to attain without a commensurate redefinition of health care practitioner and an assessment of how that might affect the provision of care.13 Moreover, within our current health care system framework, health care professionals practice in “silos”. As was learned in Chapter 3 most health care professionals are not formally trained to work in collaborative practices, hence many may express an unwillingness to work with other health care professionals due to the socialization processes they have undergone to create stereotypes, role identifications and professional values and beliefs.
2) Policy Barriers to IECPCP Based on the review of both published and unpublished literature, a number of barriers have been identified as critical, hampering effective collaboration in primary health care delivery. Although, we recognize that IECPCP is not limited to the primary health care field, many of the most recent government reports relate to collaboration within the health care system. It was felt 12 13
In-depth interviews from Chapter 6 IBID
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that these reports were important to review to gain pertinent information.14 Systemic Barriers We begin by providing an overview of the current systemic barriers, at the government, organizational and individual level followed by descriptions of the more specific policy barriers impeding IECPCP that include. • • • • •
legislative and regulatory; human health resources; economic; educational; and medico-legal liability.
From a broad systems perspective, it is well known that current professional practices work against the integration of services, fostering instead a system of separate “silos” of professional practice and imposing major constraints on the development of interdisciplinary work. While collaborative practices have worked in certain health care systems such as in the UK, applying those types of collaborative practices in Canada could be a challenge as demonstrated by the Alberta collaborative practice example highlighted in Chapter 6 from the environmental scan. In this example, the project leader had developed a successful collaborative practice model of a nurse-driven asthma clinic in the UK. However, when he adopted a similar program in Alberta, it was unsuccessful. It was recognized that systemic issues were the major barrier for why the initiative failed.15 At the government level, legislative and regulatory reforms need to keep up with changes and trends in the practice environment. This has largely not been the case as elaborated in this chapter. Barriers at the organizational level focus on the responsiveness and willingness of health care groups (i.e. nursing and physicians groups) to change or work together even though, according to the Clair report16, professional groups acknowledged the urgent need for health system renewal and offered their cooperation. While many of the professional organizations talk positively about the need to work together, in reality, they seem unwilling to give up parts of their “scope of practice” unless there are some incentives (i.e. compensation).17 14
(a) A Framework for Reform. Premier’s Advisory Council on Health. December 2001. Alberta. (Mazankowski Report) (b) Health Renewal. Report from the Premier’s Health Quality Council. New Brunswick. January 2002 (c) Emerging Solutions. Report and Recommendations. Quebec. December 2000. Clair Commission (d) Caring for Medicare: Sustaining a Quality System. Saskatchewan Commission on Medicare. April 2001 (Fyke Commission); (e) Patients First: Renewal and Reform of British Columbia’s Health Care System. December 2001 (f) The Health of Canadian – The Federal Role. (Kirby Report) Final report on the state of the health care system in Canada. October 2002 15 From Chapter 6, In-depth interviews. Dr. Andrew Cave. 16 Emerging Solutions. Report and Recommendations. Quebec December 2000 (Clair Commission) 17 A Framework for Reform. Premier’s Advisory Council on Health. December 2001. Alberta (Mazankowski
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Within institutions, support and funding for collaboration among health professions is fairly minimal due to the inherent incremental operating and administrative costs involved. For example, teaching hospitals would need additional educational resources to promote collaborative care within their programs. Unless such institutions are flexible to changing priorities and supporting collaboration, IECPCP will not be achievable in communities.18 For example, tertiary centres might add a specialized geriatric nurse to their emergency room team if they can prove this additional ‘cost’ is more than offset by reduced admissions and faster patient flow through for their geriatric patients. This positive experience may make the institution more amenable to other changes that may influence integrated primary health care.19 Policy makers must recognize that organizations and local/regional authorities must be given the autonomy to resolve barriers that impede the systemization of collaborative practices. Autonomy could be in the form of increased budget allocations, decentralization of services, increased human resource management, competency development, etc. To achieve collaboration at the individual level, there is a need to change prevailing mindsets on how health care professions can work together given the entrenched attitudes and views on health professions’ respective roles in health care delivery and on how professions may be resistance to change to collaboration through an IECPCP framework. Despite much rhetoric about interprofessional co-operation, in reality, the professions tend to protect their scopes of practice. Each profession appears willing to take on more responsibilities, but is unwilling to relinquish some duties to other professions.20
Specific Policy Barriers Legislative/Regulatory Our current legislative and regulatory framework is inconsistent across Canada with respect to scope of practices across the health professions. Each provincial regulatory body issues their own legislation and regulations that define health professions’ scope of practice, standards of education, ethics and competencies in practice, and systems of accountability. In Kirby’s review of the health care system, it was found that the process, which determines exactly how the legislation is “operationalized”, varies across provincial/territorial jurisdictions which is problematic to achieve IECPCP. Although there has been discussions on reviewing scope of practices21 22 23 a national regulatory Report) 18 From Chapter 6, In-depth interviews. Dr. Barry Goldlist 19 IBID 20 Building on Values: The Future of Health Care in Canada. November 2002 (Romanow Commission) 21 “Scope of Practice” Policy. Approved by CMA Board of Director. October 1, 2001. www.cma.ca 22 Sunrise/Sunset and Changes in Scopes of Practice Criteria Review: An HPRAC Discussion Paper. Ontario Health Professions Regulatory Advisory Council. June 2003 23 Scope of Practice Policy. Canadian Medical Association, Canadian Nurses Association and Canadian Pharmacists
Association. April 2003
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framework has not been developed to provide a process to define and operationalize scope of practices amongst health care professionals in Canada. Such a framework could aid in advancing opportunities for collaborative practice. For example, education and maintenance of competence are defined differently across many jurisdictions. In Ontario, the scope of practice for nurse practitioners is described in specific guidelines and parameters with a list of actions that nurse practitioners can perform, while the nurse practitioner’s scope of practice in New Brunswick is based on an exclusive list of what actions the nurse practitioner can perform.24 The impact these varying scopes of practice have creates confusion amongst health care professionals. In looking at the essential elements of collaboration found in D’Amour’s Chapter 2, it is recognized that without a clear understanding of health professionals’ roles, it will be a challenge to teach and/or practice collaboration to students and practitioners. In fact it will be difficult to educate the public as well which was alluded to by Linda Jones, from the Nurse Practitioners Association of Ontario, who presented at the public hearings of the Standing Senate Committee on Social Affairs, Science and Technology (Kirby)25: “…the lack of public understanding of the role, impacts utilization of nurse practitioners. If we are seen as physician replacements – you cannot see your family doctor, you must see your nurse practitioner instead – that will not enhance or increase public acceptance of us…”
Health Human Resources A major issue26 continues to be effective utilization of our health resources. The supply, mix and distribution, and how these various health care providers work singularly and together vary across different workplaces, communities, provinces, and territories. There are four factors that impact health human resources in particular: •
Supply and distribution – Problems experienced by communities in attracting and retaining health care providers are one of supply or distribution. In rural communities the issue is attracting family physicians where as from a province-wide or national basis, the problem is more one of distribution of physicians.
•
Skills and roles – There has been considerable discussion of the changing skills and roles of health providers in terms of what they are trained to do as part of their professional roles. Nurse practitioners, for example, are trained to provide some health services that used to be the exclusive responsibility of physicians.
•
Patterns of practice and professional autonomy – Patterns of practice differ among health care providers as well as their level of autonomy within their respective practice settings. For certain health professions, their patterns of practice have
24
“Working Draft Paper” Barriers to Effective Collaboration Between Nurse Practitioners and Family Physicians. Health Canada prepared by Canadian Nurses Association. March 2003 25 The Health of Canadians – The Federal Role – Volume Two: Current Trends and Future Challenges – January 2002 (Kirby Report) 26 Building on Values: The Future of Health Care in Canada. November 2002 (Romanow Commission)
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changed, but they have had little control over those changes. For example, within the institutional setting, fewer nursing administrators and less administrative support have resulted in an increased burden for nurses, leaving less time for direct care. Nurses have also been shifted in and out of their areas of expertise, for example, from the acute care to the home care setting, as a result of financial constraints on hospital budgets. For the most part, physicians have considerable control over their patterns of practice both as individuals and through their respective professional organizations. •
Quality of working life - Quality of work life issues which can range anywhere from actual work environment to one’s ability to influence how they work, are a serious concern. Morale has declined substantially among many profession and nursing organizations point to this as one of the reasons for a significant number of nurses choosing to leave their profession.
Health care renewal hold promise of a better utilization of the spectrum of health care providers through interdisciplinary team work and the integration and coordination of all health services.27 Moreover, it is not only about utilizing the full range of available professions but also utilizing their skills and competencies to the fullest.28 Looking to long-term solutions rather than “quick fixes”, policy makers, government and the health and education sectors have been exploring various initiatives to address the shortages of health human resources. But some of these initiatives cannot be pursued due to financial implications, regulatory and legislative frameworks, and resistance to the fact that change is inevitable. Economic Financial competition, especially within the fee-for-service environment and concerns regarding job security are considered barriers to a collaborative relationship between health care professions.29 The current fee-for-service funding structure in most provinces is a major barrier for health care professionals to work in collaborative settings. Reimbursement is primarily provided to physicians on a fee-for-service basis whereas other professionals are primarily on salary. The literature suggests that financial competition among health care practitioners may obstruct collaboration with physicians that would enhance patient care.30 Pringle et al (2000) 31argues that the current way physicians are paid in Canada works against collaborative interdisciplinary 27
The Health of Canadians – The Federal Role. Volume Five: Principles and Recommendations for Reform – Part 1. April 2002 28 The Health of Canadian – The Federal Role. Final report on the state of the health care system in Canada. October 2002 29 Society of Rural Physicians of Canada, “Nurse Practitioners and Rural Medicine: Voices from the Field”, Canadian Journal of Rural Medicine, 1998, 3(3): 159-62. 30 Pearson, Pauline and Jones, Kevin (1994), “The Primary Health Care Non-Team? (Dynamics of multidisciplinary provider groups) – Editorial, British Medical Journal, v.309, n 6966 p.(1387) 31 Pringle, Dorothy, et al. (2000), “Interdisciplinary Collaboration and Primary Health Care Reform”, Canadian Journal of Public Health”, vol. 91, NO.2
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practice in primary care. Way et al. (2001) suggest that changes are needed to policy and the health system, to find creative reimbursement mechanisms for health care professionals such as nurse practitioners and family physicians.32 33 At the public hearings in 2001, the Standing Senate Committee on Social Affairs, Science and Technology was told that the barriers are not exclusively legislative or organizational, however. They are also created by the way that funding is distributed throughout the health care system, and, in particular, by the overwhelming reliance on fee-for-service payment as the main method for remunerating physicians and/or other health care practitioners.34 Fee-for-service tends to actively discourage physicians from promoting teamwork, as their individual remuneration depends on the number of patients they see.35 There is no mechanism in place for paying for the additional services of others on the team including nurse practitioners, dieticians, social workers and counsellors.36 Education The current structures of the educational system vary from province to province. Within the academic and university setting, funding for professional education is "siloed". Education programs are not structured in such a way that they foster an understanding of the strengths and scopes of practice of health disciplines.37 Most health faculties within universities work fairly independently.38 These education barriers were also echoed from the interdisciplinary education interviewees as noted in Chapter 6. Moreover, most individual faculties may not be open to new concepts of teaching for interdisciplinary education as they may have a significant impact on current programs in which their education and training curricula are fairly entrenched. As a result, they are not willing to provide the resources and funding to develop teaching programs for interdisciplinary education. Secondly, they may not have faculty resources to provide new education and teaching on interdisciplinary care. Medico-Legal Liability Currently, not all health care professionals are required to obtain malpractice insurance coverage. The requirement for individual malpractice insurance varies according to type of practice and 32
Way D., Jones L., and Baskerville N.B. (2001), “Improving the Effectiveness of Primary Health Care Throughout Practitioner/Family Physicians Structure Collaborative Practice” 33 Way, Denial, Jones, Linda, and Busing, Nick (2000), “Implementation Strategies: Collaboration in Primary Care – Family Doctors & Nurse Practitioners Delivering Shared Care” 34 The Health of Canadian – The Federal Role. Final report on the state of the health care system in Canada. October 2002 35 IBID 36 A Framework for Reform. Premier’s Advisory Council on Health. December 2001. Alberta (Mazankowski report) 37 Dr. John Gilbert, Principal, College of Health Disciplines, University of British Columbia 38 The Importance of Interprofessional Education and Collaboration to the Future of Health Care in Canada. Dr. John Gilbert, Principal, College of Health Disciplines, University of British Columbia. Submission to the Commission on the Futures of Health Care in Canada (Romanow Commission) 2001
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type of health care professional. Within hospital institutions, health care employees (i.e. nurses and laboratory technicians) are provided with malpractice insurance as an employee benefit. Within private health care settings such as pharmacies and commercial laboratories, the corporation/employer pays for the liability insurance. Historically, health and private insurance companies have provided malpractice insurance to health care practitioners. However, due to the high incidence of liability suits and awarded settlements, private insurance companies have gradually discontinued this coverage for health care practitioners. In recent years, organized nurse, physiotherapy and chiropractic groups have established their own malpractice insurance member organizations to provide assistance and support for malpractice insurance with the exception of the Canadian Medical Protective Association which has provided malpractice coverage for Canadian physicians for over 100 years.39 Coverage for malpractice insurance for health care professions is provided for health care services performed within their scope of practice recognized under provincial legislative and regulatory controlled acts. Insurance providers will not provide coverage for services performed outside of health practitioners’ scope of practice. Medico-legal and malpractice organizations have expressed concern about new, innovative and evolving models for primary health care delivery that raise the potential for increased liability for health care professions working in non-traditional settings especially for those professions that are unregulated and may not have malpractice insurance.40 There is uncertainty about the legal liabilities inherent in the working relationship among health care professions as they relate to scope of practice and responsibilities.41 Fuelling the uncertainty is lack of clarity around the understanding of liability issues among health care providers and the availability of liability insurance coverage.42 A primary concern is that not all health care professionals carry liability insurance and therefore this has implications for membership on a health care team. For those without liability insurance the question arises: Which member(s) of a health care team are ultimately responsible for adverse patient care outcomes? Notwithstanding the aforementioned concerns, collaboration among health practitioners is a possibility within the malpractice insurance framework. For example, the Canadian Medical Protective Association believes that all nurse practitioners must have “adequate” liability insurance. ”If adequate professional liability protection is carried for health professionals such as nurse practitioners….., this should not be a barrier to nurse practitioners working in a collaborative role with physicians”. 43 All these barriers present major hurdles for policy decision-makers.
39
A Physician’s Foresight, A Profession’s Pride. History of the Canadian Medical Protective Association. 19012001. 40 Canadian Medical Protective Association Discussion Paper. Physician liability concerns in primary and secondary health care reform. August 2002 41 Ontario Medical Association & Registered Nurses Association of Ontario. The RN(EC)-GP Relationship: A Good Beginning Goldfarb Intelligence Marketing, Thursday, May 22, 2003 42 IBID 43 Canadian Medical Protective Association’s letter to Canadian Nurses Protective Society. December 2002.
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3) Policy Enablers for IECPCP Initiatives have been put into place that have enabled and encouraged IECPCP within health and education. Enablers are policy tools or mechanisms that facilitate IECPCP. These policy enablers are described below: Funding Government funding including innovation grants has been used as a policy lever to affect change that has successfully built the momentum for health care renewal. For example, in 1994, the “Supporting Self-Care” project was initiated by Health Canada. While this program focused primarily on collaboration between family medicine and nursing, it also led to a number of projects that demonstrated how teams of health care providers could work together and involve patients/clients in decision making. One project dealt with how health professionals can become more skillful and successful in supporting self-care and developing a framework.44 The “selfcare” concept provides the opportunity for physicians and nurses to work collaboratively in patient-centred practices.45 Moreover, it is an ideal example of fostering practitioner autonomy within a collaborative practice. Research Investment in current research activities (i.e. Health Transition Fund) has promoted stronger links between researchers and decision makers. High quality research in identifying trends in an integrated primary health care delivery model is the key to better health as it drives improvements and innovations in health care and has the potential to reshape the health care system. To achieve high quality research in IECPCP, criteria requirements could be developed for funding and conducting research activities that would yield data on resource intensity and patient outcomes and that would include the collaboration of researchers and policy makers. Findings from this type of research can be used for comparison with current approaches. Clinical Education Academic institutions have employed, as a method of teaching, the problem-based learning/team building approach that has been successful in fostering small group learning which has been found to be a useful form of teaching in interdisciplinary education. (See Chapter 3) Consideration should be given to reinforce the problem-based learning learning experience by funding academic pilot projects that promote innovative, interdisciplinary educational experiences using this model of teaching. The other area that currently exists that provides a nidus for teaching opportunities in the pre-licensure years of training is in population health,
44
Supporting Self-Care: The Contribution of Nurses and Physicians, An Exploratory Study. Health Canada 1997. McCormack, D (2003). An examination of the self-care concept uncovers a new direction for healthcare reform. Nursing Leadership 16(4) 48-62.
45
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health promotion and the role of health professionals in the area of social accountability within the community. Many health professional training programs offer teaching in these areas which provide opportunities for health professional learners to work together addressing shared learning objectives. Lastly, the community and hospital clinical practices that all health professional learners engage in offer yet another place to enable trainees to learn, however has not be capitailized to date. Best Practices Interdisciplinary Care Tools Interdisciplinary tools such as care maps or best practice guidelines are a useful tool for collaboration in the practice setting. To facilitate and support the team approach, a provinciallycoordinated process should be undertaken to develop a series of care maps (or clinical paths) for major health conditions/diagnoses. The maps would identify standards pertaining to expected care requirements and the time frames within which interventions are anticipated to be initiated. The maps would also identify the roles of each profession to ensure quality, seamless care. Care maps have been utilized in certain health care practice settings, primarily in institutions.46 47 48 There is a need to identify some best practice sites and research common characteristics that are indicators of success.49
4) Policy Levers Supporting IECPCP Support from politicians and decision-makers is critical to the promotion and advancement of IECPCP. Policy levers have played a key role towards the advancement of IECPCP through federal/provincial/territorial programs, strategies and initiatives. The following policy levers are identified:
i) Public Health/Emergency Response In the past year, there was much international attention about how Canada’s health care system responded to infection and disease control through the SARS epidemic. This resulted in a collaborative effort in a time of crisis, among federal, provincial and local governments in working with hospitals, health care practitioners such as physicians and nurses at all levels and in all practice settings, to effectively manage and control further outbreak. Public health enforces government, health care professions and universities to work collaboratively to examine policy and practice in response to emergency care.50 46
Curley C, McEachern JE, Speroff T. A FIRM trial of interdisciplinary rounds on the inpatient medical wards. Medical Care 1998;36(8 supplement):AS4-AS12. 47 Jitapunkul S, Nuchprayoon C, Aksaranugraha S, Leenawat B, Kotepong W. A controlled clinical trial of multidisciplinary team approach in the general medical wards of Culalongkorn hospital. Journal of Medical Association Thai 1995;78(11):618-623. 48 Schmidt I, Claesson, CB, Westerholm B, Nilsson LG, Svarstad BL. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. Journal of the American Geriatrics Society 1998;46(1):77-82 49 Health Renewal. Report from the Premier’s Health Quality Council. New Brunswick. January 2002 50 Speech by Mr. Hugh MacLeod. Assistant Deputy Minister, Acute Services Division. Ontario Ministry of Health
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ii) Patient Safety As an important health care issue, much has been reported in Canada and abroad on the incidence of medical errors and the need to introduce mechanisms for effective reporting of adverse events, and implement fundamental changes on the collaborative role of patients, professionals and accreditation groups in building a culture of patient safety.51 52 53 Substantive patient safety activities are currently taking place in Canada. Most recently, in December 2003, the creation of the Canadian Patient Safety Institute (CPSI) based on the recommendations of the National Steering Committee on Patient Safety in 2002 and which is supported by the First Ministers’ Accord on Health Care Renewal. Within an IECPCP framework, systemic issues, legal/regulatory, evaluation, education/professional development (in building competencies for patient safety) and dissemination of information all need to be addressed with respect to patient safety. The mandate of CPSI is to foster the sharing of knowledge and information on patient safety practices, influence change in culture and support change in systems to improve patient safety and collaborate with stakeholders to support patient safety improvements. iii) Education As highlighted in Chapters 4 & 6, academic institutions support the need from senior administration that have the authority to decide on education policies and resources. Implementation changes would include course and faculty development, operating interdisciplinary education funding and support from governments. Secondly, education is a lever for encouraging collaboration in clinical teaching in hospitals. This can facilitate collaboration: • • •
through clinical rounds, bringing both educators and professions together gain clinical mentors on board for interdisciplinary education and develop a knowledge base on how it works in practice settings.
There are several examples in which educational institutional policy has affected how education can foster collaboration. For example, The Saskatchewan Action Plan for Health (2001) and the Fyke Report have provided the province with a very strong policy framework and ten year blueprint to make interdisciplinary education a reality. It includes a strategic description for health science education that includes the construction of a new health science building that will facilitate interprofessional education. The College of Health Disciplines of University of British and the Health Sciences Council of the University of Alberta are supported and funded through university policies for interdisciplinary education. Lastly, the accreditation bodies such as the Royal College of Physicians and Surgeons of Canada are incorporating new accreditation and Long Term Care. Annual General Meeting of Ontario Hospital Association. (Toronto) November 2003 51 To Err is Human. Building a Safer Health System. Institute of Medicine. National Academy Press. 1999 52 Patient Safety and Healthcare Error in the Canadian Healthcare System. A Systematic Review and Analysis of Leading Practices in Canada with Reference to Key Initiatives Elsewhere. A Report to Health Canada by G. Ross Baker & Peter Norton. 2002. 53 Building A Safer System. A National Integrated Strategy for Improving Patient Safety in Canadian Health Care. National Steering Committee on Patient Safety. September 2002
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guidelines fostering collaboration through its CanMEDS 2000 project as a desired future direction of postgraduate medical education (PGME) in Canada. Reforms are taking place within university baccalaureate degree programs for certain health care professions such as nursing, physiotherapy and midwifery. These changes will provide these graduates with both a depth and breadth of knowledge and the skills sets required to practice in complex environments and to work in collaboration. This would ensure consistency across the country on education requirements and will help to create more similarity in educational preparation between these health disciplines. These initiatives will help at address legislation for the scope of practice for health care practitioners but also to encourage collaborative scope of practices.54 iv) Legislation Regulatory and legislative frameworks can also act as levers to promote collaboration among health practitioners which has been the case for pharmacists in the province of Alberta.55 In certain provinces, changes in regulatory and legislative frameworks have recognized the trends in health care delivery on collaborative scope of practice as exemplified by Quebec in 2002 through Bill 90.56 Under this legislation, provisions for certain health practitioners, such as nurses and pharmacists, authorize them to perform certain medical services, traditionally performed by physicians, in well-defined practice settings. Across Canada, many registered nurses work in expanded roles through legislative and regulatory changes. The availability of (and requirements) training for these roles varies among provinces and territories as does the legal recognition of nurses in advanced nursing practice roles. For example, seven provinces offer Master of Nursing degree programs while six provinces provide the legal authority for nurse practitioners to provide health care including the Province of Quebec which is anticipating to registering its first nurse practitioner in 2004. 57 The need to utilize provincial regulations and legislation to foster collaboration among regulated health care professions has become paramount because of changing clinical realities in terms of education, accreditation standards, treatment modalities, and institutional settings. Regulation affects more than just health care professions. Given the importance of education, it is arguable that education programmes, whether concerned with accreditation or continuing competency should receive closer scrutiny. Alberta’s legislation, for example, expressly provides that education programmes are to be evaluated as part of the request for a change in regulation of a
54
Collaborative and Multidisciplinary Primary care – A Physiotherapy Perspective. Address to National Forum on Primary Health Care Reform by Ken Higgs, Past President. Canadian Physiotherapy Association. September 19, 2003. 55 Optimizing Drug Therapy in Alberta: Pharmacists Independently Prescribing in a Collaborative Health Team Environment. Prepared by the Alberta College of Pharmacists Steering Committee on Pharmacists Prescribing. September 2002. 56 National Assembly of Quebec. Bill 90. An Act to Amend the Professional Code and other Legislative Provisions as Regards to The Health Sector. June 2002. 57 Health Care in Canada 2003. Statistics Canada. Canadian Institute for Health Information
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controlled act.58 v) Social Accountability Recently, educational institutions have been actively assuming their role in “social responsibility” to promote quality of care within their communities and foster interdisciplinary collaboration. Educational institutions, particularly medical schools, have been taking an active role in exploring the meaning of social accountability in interdisciplinary education. Examples include the Royal College of Physicians and Surgeons of Canada, the Association of Canadian Medical Colleges and the Canadian Association of Medical Education.59 Educational institutions are adapting the concept of social accountability to meet public expectations that government and the professions work collaboratively to ensure that the highly valued Canadian health care system continues to provide the necessary access and quality required to meet the needs of the population. Key principles of social accountability include the need to: • • •
maintain competency in response to the changing needs of communities; conduct evidence-based research that tests new models of practice; and work with all levels in government, health and education to ensure the health care system continues to be sustainable.
The development of an effective social accountability model for other health science schools beyond medical will provide the basis for all partners to work collectively on meeting the needs of the Canadian population in a collegial and collaborative manner.60 vi) Aboriginal Health Initiatives are underway in most provinces to improve and promote health and wellness within the Aboriginal population. There is much collaboration among Aboriginal and community leaders and health care providers to ensure that social and cultural issues are being addressed and that providers are educated on forms of traditional healing as part of primary health care. vii) Health Care Transition Fund (HCTF) As referenced in Chapter 3, funding through the HCTF for innovation and demonstration projects that were completed in 2002 have been a good starting point in encouraging IECPCP. A review61 of the primary health care HCTF projects in primary health care found that changing professional roles requires strong communication and education strategies and that there must be incentives for interdisciplinary collaboration. Further analysis and evaluation should be conducted to build on the structures and recommendations contained within the findings of these projects, particularly considering that these types of practice models have proven to be effective 58
Sunrise/Sunset and Changes in Scopes of Practice. Criteria Review: An HPRAC Discussion Paper. June 2003. Health Professions Regulatory Advisory Council. Ontario Ministry of Health and Long Term Care. 59 Social Accountability: Moving Beyond the Rhetoric. Plenary Session of the Annual Meeting of Association of Canadian Medical Colleges and Canadian Association for Medical Education. Quebec April 2003. Proceedings 60 Social Accountability. A Vision for Canadian Medical Schools. Health Canada. 2001 61 The Health Transition Fund. Synthesis Series: Primary Health Care. Ann L. Marble & John Marriott.
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in primary health care delivery in communities. viii) Alternative health care funding Alternative funding through alternative payment plans can influence change by creating new roles for practitioners that promote collaboration and new health care delivery models. Exploring other innovative compensation models (i.e. salary) in practice settings can encourage collaboration. For example, some provinces have initiated efforts to explore how physicians and other health care practitioners can work together and be reimbursed within a comprehensive primary care setting. The Group Health Centre in Sault Ste Marie, Ontario goes one step further and is a tangible example of how this collaboration can be achieved between physicians and other health care practitioners within an alternative funding model.62 While most of these policy levers have been identified, they have not, however, been fully employed and evaluated to determine (either positively or negatively) their effectiveness in advancing ICEPCP. It is an enormous undertaking to affect change in supporting health care system renewal. Furthermore, incentives need to be put into place to encourage collaboration.63
5) Policy Issues for Consideration Key policy issues that must be taken into consideration to further advance IECPCP include: a) Health and education training programs •
Review current education and training programs for health care providers to focus more on integrated approaches for preparing health care teams. Education programs should be changed to focus more on integrated, team-based approaches to meet health care and service delivery needs. The Health Council of Canada should help co-ordinate efforts to achieve these changes and encourage best practices. 64
•
Propose that teaching institutions adapt training programs designed for future professionals in the health and social services sector to fit with the new realities of the health system and with the demands of interdisciplinary team work in the workplace. This would include the provision of clinical education funding (i.e. establishing clinical teaching units) to support non-medical clinical education in academic health science centres.65
62
http://www.ghc.on.ca The Health of Canadians – The Federal Role. Volume Two: Current Trends and Future Challenges (Kirby Report) January 2002 64 Building on Values: The Future of Health Care in Canada. November 2002 (Romanow Commission) 65 IBID 63
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b) Effective health human resource planning •
Implement a nation-wide, long-term, made-in-Canada, human resources strategy. Human resources in health care must be amongst the top health care policy priorities for all levels of government. It is important that the federal government be integrally involved in order to help resolve the many health care human resource challenges facing the country. This includes assisting the provinces in their efforts to reform primary health care, because ways of effectively deploying human resources are intimately tied to the reorganization of primary health care.66
•
Initiate collaborative stakeholder consultation – There should be a coordinated effort to include all stakeholders to work collaboratively on health resources. For example, employers of human health resources need to be part of the solution and professional unions should also participate. Universities need to be more responsive to public need and prepare for health human resources planning. (Gilbert)
c) Regulatory and Legislative Framework for IECPCP •
Review how IECPCP would affect change in the scopes of practices and patterns of health disciplines. Working with accredited and regulatory bodies, determine how collaborative practices affect changes in health care service delivery, particularly through new approaches to primary health care. With the growing emphasis on collaborative teams and networks of health providers, it may mean that traditional scopes of practices may need to change. This suggests new roles for nurses, family physicians, pharmacists, chiropractors, case managers and a host of new and emerging health professions. New scope of practice rules and other measures need to be developed to enable all health care providers in the primary care sector to provide the full range of services for which they have been trained.67
•
Explore innovative changes to entry/licensing that require program content in fostering collaborative practice to meet identified competencies.68 One of the major obstacles to achieve within an IECPCP framework are the existing rules which define what the various health professions can, and cannot do with their scope of practice. Primary health care needs to be coordinated, accessible to all and provided by health care professionals who have the right skills to meet the needs of communities being served. Multidisciplinary team work must therefore be a vital part of primary health care delivery. However, the goal of this team work should not be to displace one health care provider with another, but rather to look at the unique skills each one brings to the team and to co-ordinate the deployment of these skills. Current consultations are taking place on changes to entry-to-practice credentials in the health professions that provide the
66
The Health of Canadians – The Federal Role. Volume Two: Current Trends and Future Challenges (Kirby Report) January 2002 67 The Health of Canadians – The Federal Role. Volume Five: Principles and Recommendations for Reform – Part 1. April 2002 68 The Health of Canadians – The Federal Role. Volume Four: Issues and Options. September 2001
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opportunity to address credentials in collaborative practice settings.69 d) Funding Priorities Priorities should be established in providing separate funding programs and/or initiatives that foster interdisciplinary education and collaborative practice for education, research and practice.
e)
•
Undertake a review of existing program funding requirements on how health science professional education programs are funded. It has been suggested (Kirby) that additional accountability measures need to be in place that are more outcomes-focused. Priorities should focus on quality, setting standards, outcomes measurements, and accountability.
•
Support research on health care delivery models that facilitate collaboration by health discipline working in teams in various practice settings.
•
Explore alternate compensation (non fee-for-service) models for health care practitioners providing health care that allow health care professions to work in collaborative environment in primary health care delivery. This would include developing mechanisms to involve all health care practitioners including funding for consultation Aboriginal Health •
Establish a clear structure and mandate for Aboriginal Health by developing partnerships that use the funding to: • address the specific health needs of their populations; • improve access to all levels of health care services; • recruit new Aboriginal health care providers; and • increase training for non-Aboriginal health care providers.70
•
69 70
Address cultural and political diversity issues that are entrenched such as within the Aboriginal populations. Health care providers and educators must respect the values and customs of these diverse groups. Both the cultural diversity and the diversity of political organizations such as local Band Councils, and regional Tribal Councils, must be reflected in whatever approaches are used to improve access and health for Aboriginal peoples. Given this diversity, it may be best to emphasize regional or local solutions that can be more focused on specific communities or community needs rather than searching for broad solutions that are unlikely to address the unique needs of different communities across the country. Local and regional approaches may also be more effective in attracting more Aboriginal peoples to various health care professions and in recruiting non-Aboriginal providers to work in Aboriginal
(www.hc-sc.gc.ca/English/care/credentials/index.html) Building on Values: The Future of Health Care in Canada. November 2002 (Romanow Commission)
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communities.71 f) Implementation of primary care reform •
Policy decision-makers within ministries of community and social services and health should work collaboratively to share the knowledge that will generate through the implementation of the primary care reform initiatives through the HTF in particular, and explore which models of organizations are more or less supportive of the development of collaborative practices.
6) Next Steps for Policy Many health policy reports concur that in formulating policies on IECPCP in our health care delivery system, there is a need to expand our knowledge base on what is feasible within the current health care and education framework. Although we currently have had sufficient health research expertise that has explored collaborative primary health care, it has only peripherally addressed the impact of IECPCP on human and financial resources. Despite increasing calls for interprofessional collaboration, particularly in relation to primary health care, there is limited research on effective ways of implementing new mixes of skills and providers in health care delivery settings. New work environments and new divisions of labour call for new approaches to collaboration among health care providers to maximize the use of the health workforce. There also is limited information about the health care workplace regarding organization, planning, the nature of group practice, payment mechanisms and incentives, and professional responsibility. To move IECPCP forward, efforts should be made to evaluate our current policies that frame our health and education system. Based on this policy analysis, it is possible to overcome the barriers that impede collaboration. Next steps to achieve IECPCP policy development include: • • • • • •
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Demonstrate to health care professions and institutions on the need for health system renewal. Execute public education or awareness initiatives on the value of interdisciplinary teams through evidence-based research and patient outcomes. Consider the IECPCP approach as a strategy for health human resources by ensuring that the right provider, with the appropriate competencies to treat the patient while ensuring access to health care, is the most cost-effective way. Obtain and leverage support from high profile champions who are interdisciplinary care providers. Profile current IECPCP examples that have been successful. Develop cost-effective approaches that don't require much funding or resources to reprofiling existing initiatives.
IBID
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According to Dr. John Gilbert72, Principal, College of Health Disciplines, University of British Columbia, at the government level, there are many policies in place that foster IECPCP either within the educational or health sector. However, he states, “...but in order for policies to be effective they have to have resources behind them…”
Summary An IECPCP policy directive that is patient-centred will play a critical role in developing the health care renewal framework. The time is now to obtain the commitment and resources that are needed to move IECPCP forward. Governments, institutions, health care providers, decisionsmakers and Canadians must work collaboratively to prioritize the policies and determine what should be executed to achieve interdisciplinary education for collaborative practice.
72
See Chapter XXX, In-depth Interviews.
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Chapter Nine Implementing New Approaches to Interdisciplinary Education and Collaborative Practice: Lessons from Organizational Literature on Change By Liane Ginsburg and Deborah Tregunno
Introduction Issues related to change management are relevant to the discussion around promoting interdisciplinary education (IDE) for collaborative practice (CP) in several regards. Change management issues are likely to arise in the domain of education as well as the domain of practice. Moreover, there are likely to be numerous, perhaps very different, changes that are sought in each domain in addition to those that are sought across the two domains. In the educational setting changes related to the implementation of new curricula or new approaches to learning may be required and broader issues related to changing attitudes are also likely to be relevant. In the practice setting there will no doubt also be a series of tangible changes sought, perhaps related to new approaches to teamwork, in addition to the types of attitudinal changes described in the educational setting. The change literature is vast and, given the wide range of changes, (a sample of which are noted above) it is useful to consider various models. It will be constructive to draw on micro models of change at the individual and group level as we try to understand collaborative practice (CP) implementation issues at the front lines. There are staged models of change (that explain the link between attitudes and behaviours) that can be useful to the extent that attitude change is seen as central to implementing interdisciplinary education (IDE) and CP, or IDE for CP. Finally, there is an empirically well developed body of literature in organization theory and organizational strategy that is useful for identifying the key issues related to change at the more macro organizational and policy levels. Using Organizational Change Theory to Understand Response to Change Implementation is the critical stage between the decision to change and adoption of innovation in an organization. Implementation theories (Porras & Robertson, 1992) and organizational change models (e.g. Gustafson, Sainfort, Eichler, Adams, Bisognano et al, 2003; Olsson, Lic, Ovretveit and Kammerlind, 2003) provide a link between the problems identified during organizational diagnosis and the solutions or action steps needed to address them. Gustafson and colleagues (2003) outline an eighteen factor organizational change model that has been found to have predictive validity for successful implementation of health care improvement projects. Consistent with Roger’s (1995) model of innovation, the organizational change model addresses the importance of context and feedback.
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An organization’s context plays an important role in enabling effective change, as it sets the stage for the social construction of roles and relationships. Organizations are the people within them, and structural changes such as changes in technology, communication networks and roles, are effective to the degree that they are associated with changes in members’ attitudes and behavior. Organizational climate and culture are one way to think about organizational context. The climate of an organization is inferred by its members. Inferences about the organization’s climate are based on the practices, procedures, policies and routines of organizational members, as well as the kinds of behaviors that are expected and those that get rewarded. To change climate, certain practices have to stop, while others start (Schneider, Brief and Guzzo, 1996). Interconnected with an organization’s climate is its’ culture – the beliefs and values of organizational members. According to Schien (1990), culture manifests itself in three levels in an organization: observable artifacts, values, and underlying assumptions. Artifacts are readily observable and include physical layout, statements of philosophy and dress codes. Values determine what people think should be done, and are linked with organizational norms and ideologies. Underlying assumptions are unconscious and never questioned unless they are challenged or queried by individuals external to the culture. As illustrated by Bate, Khan and Pye (2000), an organization’s culture is continuously constructed and reconstructed through interaction and intervention at the every day level of functioning. In other words, employee values and beliefs (part of culture) influence their interpretations of organizational policies, practices and procedures (part of climate). Therefore, sustainable organizational change requires attention to both people’s experience of structure and process (climate) and what they believe the organization values (culture) (Hatch, 1997)— planned change that is in conflict with organizational values would commonly lead to resistance. Unfortunately, there is little empirical evidence supporting an optimistic view of cultural change. For all the interest in the dynamic nature of climate and culture, the crucial question of what factors influence organizational climate and culture remains poorly explored empirically. From a recent review of the nursing literature that explores the relationship between organizational climate and culture as well as nurse, patient, and organizational outcomes, it is clear the process by which organizational climate and culture are fashioned and refashioned remain largely unexplored (Tregunno, 2003). In addition, empirical work tends to view organizational climate and culture as an independent, rather than dependent variable, and there is limited evidence to support measurement validity and responsiveness to change over time. Given the importance of context, it is not surprising that Gustafson et al (2003) found that flexibility, or the degree to which the change design fits into existing context, is predictive of successful change. The climate of the work environment, including well defined reporting relationships (Schneider and Goldwasser, 1998) and staff incentives (Paolillo and Brown, 1978) have also been shown to influence the success of change initiatives. Moreover, attention to new skill development and training through the use of peer role modeling may reduce resistance by those affected by a change (Kotter and Schlesinger, 1979).
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Tension for change and dissatisfaction with the current process is another key predictor of successful change (Gustafson et al., 2003). Because it is difficult to create tension for change, the organization’s circumstances and needs must be fully analyzed prior to implementation of a change initiative (Argyris, 1970). Staff resistance to change is less likely when the benefits of the change are communicated and demonstrated (Romano, 1995; Rousseau and Tijoriwala, 1999). Moreover, because individuals are bounded in their capacity to attend to all (or even most) environmental stimuli, decision-makers are selective in their focus of attention to issues and answers (Ocasio, 1997). Feedback on the status and results of a change initiative is a key source of attention for both organizational decision-makers and those affected by the change. On a cautionary note, Rogers (1995) reminds us that feedback is sought from a variety of sources, and that subjective opinion from peers is often more convincing than empirical evidence. Finally, a simple implementation plan, complete with well defined roles, responsibilities, schedule and feedback increases the likelihood of successful change (Rousseau and Tijotiwala, 1999). In the context of IDE or CP, it is clear that context is a key factor to be considered in program design, implementation and evaluation. Success will depend on continuous and collective learning, experimentation and demonstration of the link between improved collaboration and enhanced patient outcomes. Transformational cultural change required to achieve widespread adoption of IDE and CP will not happen quickly, or easily. On an optimistic note, the structures and design parameters put in place for IDE and CP may act as levers for longer-term cultural change. Using Organizational Change Theory to Address Barriers to IDE and CP Previous chapters have identified a number of barriers / enablers to achieving interdisciplinary education for collaborative practice. For the purposes of this chapter we address the following issues related to Change Management at the: (1) Individual Level: a) the existence of strong disciplinary cultures b) the need for measurement and feedback on the process of change (2) Organizational Level: a) the resistance to change b) the conditions for change . 1) Antecedents for Successful Change at the Individual Level 1.1. Strong Disciplinary Cultures A commonly identified barrier to achieving both IDE and CP is the strength of separate disciplinary cultures. This has been described as a macro-structural barrier to collaboration by D’Amour and colleagues in their chapter. Each discipline has been established and functions in a highly specialized role with discrete professional competencies and cultures. These form territories that emphasize differentiation rather than integration. Evidence of how systemic this
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barrier is can been seen from the work by Oandasan & Reeves in their chapter which demonstrates that trainees come to their programs with preconceived stereotypes that may form the root of strong professional identities. Suggestions by Oandasan & Reeves regarding the importance of a continuum of learning utilizing different shared learning strategies from the beginning of training and into practice may help support tolerance and mutual respect across disciplines—something that is an important step on the way to achieving shared value systems. The same strong disciplinary cultures are also evident among faculty in educational settings. This is consistent with the literature on organizational change which shows that individuals and organizations possess and are constrained by their mental models (Zajac & Bazerman, 1995; March, 1991), naturally tend towards what they know (Levinthal and March, 1993), and engage largely in imitative behaviour (Amburgey and Miner, 1992). While largely at the organizational level, Argyris (1976) acknowledges that this inability to move outside of the prevailing value set is seen at the individual and group levels as well. Cavaleri (1994) argues there are ways in which organizational learning and change can be achieved. Drawing on the ‘people as interpretive systems’ idea, Cavaleri argues that people have a world view through which they interpret what they see and how they see it. Until this world view changes, people are unable to see situations differently (professional views regarding autonomy in clinical decision making provide an excellent example of entrenched views). Cavaleri suggests that the ability to see things objectively is increased when we are “continually challenged by competing alternative perspectives” in which the dialectic process increases the opportunity for constructive conflict, ultimately, making people’s views more objective through this generation and availability of information about how the system operates” (1994: 263). Such a means for overcoming the barriers to learning is in line with suggestions from Argyris (1976)73. Moreover, the process Cavaleri describes is not dissimilar from the critical processes decision theorists describe as being necessary for successful decision making (Rogelberg, Barnes-Farrell & Lowe, 1992; Fredrickson and Mitchell, 1984; Eisenhardt, 1989; Schweiger, Sandberg & Ragan, 1986; Nutt, 1989; Jehn, 1995). For instance, techniques such as dialectical inquiry, which help to reveal blind spots in people’s thinking, are suggested in order to achieve decisions with positive outcomes as well as and double-loop learning. This line of reasoning suggests that an approach to implementing change in the area of interdisciplinary education and / or collaborative practice which is modeled on successful decision-making strategies (e.g. the use of constructive conflict, confronting people with new paradigms) has potential as a vehicle for challenging people’s underlying assumptions and mental models and enhancing their ability to think in more interdisciplinary terms. Unfortunately, there is more empirical evidence supporting a pessimistic view of learning and change while there is little to support a more optimistic view. Consider empirical work on decision making at the individual level on framing and reliance on heuristics (Kahneman & Tversky, 1979), the group level (Janis, 1982), and the organizational level (Levinthal & March, 1993; Zajac and Bazerman, 1991, Miller, 1993; Schwenk, 1984) all of which reveals the cognitive limitations of mental models and the resulting lack of rational and optimal behaviour by individuals, groups and organizations. The reality is that decisions are often made in what is
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an inherently non-rational, often highly political, manner. People make different decisions depending on how a problem is framed (Kahneman & Tversky, 1979), people behave differently when they perceive the decision as a risk vs. an opportunity (Jackson & Dutton, 1988; Staw, Sanderlands, & Dutton, 1981), and people often make decisions based largely on the wishes of those to whom they are accountable. (Tetlock 1985). These blind spots, or cognitive limitations, make it difficult for health professionals to see things from other disciplinary perspectives. This poses serious challenges for implementing changes in the areas of IDE and CP which, by definition, requires an interdisciplinary approach. 1.2 Measurement and Feedback At the individual level, staged theories have been offered to describe a path to action. Much of this work is rooted in the theory of reasoned action (Fishbein & Ajzen, 1975) and suggests that individuals pass through a series of stages as they approach a new behaviour. For instance, the awareness-to-adherence model, which outlines the steps to clinical practice guideline compliance (Pathman, Konrad et al., 1996), suggests that when physicians comply with practice guidelines, they must: (1) become aware of the guidelines, (2) then intellectually agree with them, (3) then decide to adopt them in the care they provide, and finally, (4) regularly adhere to the guidelines at appropriate times. Based on these kinds of staged theories, it could reasonably be argued that implementing change in the area of IDE and CP requires first dealing with awareness and attitudinal issues. Only after attitudes have been successfully changed to support the ideas of IDE and CP can behaviour change be expected. We draw attention to these kinds of staged models because although they are common in the organizational and health behaviour literatures, they may not always provide the best approach to changing behaviour at the individual provider or learner level. First these models leave little hope for change among those who ‘fall off the path’. Second, Starbuck and Hedburg (2001) have convincingly argued that regulation and other kinds of forced change mechanisms can disrupt these kinds of models—mandated actions can take individuals from the awareness stage straight to the adherence stage. That regulation and other more coercive forces for change can so easily invalidate staged models, again, points to their power as levers for change. Although staged models of change may not provide the best explanation of what motivates change at the individual level, the role of feedback in motivation and behavior change is well understood and useful to consider. Feedback is a source of information for people about their prior behavior or the results of their behavior. Feedback is intended to reinforce behavior or to suggest changes. In terms of its relationship to organizational change, feedback has implications and relationships to a host of motivational concepts including goal setting, self-efficacy, and attribution tendencies. Lant and Hurley (1999) note that when receiving feedback, individuals’ need some criterion (e.g. a goal) against which they can judge the feedback they receive.
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Social Learning Theory describes the relationship between these related motivational concepts and suggests that feedback operates as part of the self-regulatory processes set in motion when individuals accept a goal and work toward attaining it (Bandura & Cervone, 1983). Personal standards are translated into goals and when one works towards a goal, feedback provides information about the degree to which the goal has been attained. Depending on one's level of self-efficacy and the attributions he/she makes, discrepancies between goals and performance either sustain motivation or cause abandonment of the task (Bandura & Cervone, 1983, Evans, 1986). For instance when feedback is received indicating failure to attain a goal or standard that was set, one may attribute failure to attain the goal to a lack of ability which would, in turn, lower self-efficacy and/or cause abandonment of the task altogether. Conversely, if failure to attain the goal was attributed to a lack of effort or to external circumstances, self-efficacy would not decrease and task persistence would be the likely outcome. Under the right conditions, individuals seek and are receptive to feedback because they are inherently motivated to want to know ‘how they are doing’ in terms of both (a) how they are perceived as well as (b) how well they perform (Ashford & Cummings, 1983). From this perspective people are information seekers in an environment that offers a variety of data or queues from multiple sources. In the context of implementing change in the areas of IDE or CP it is clear that various sources of feedback will be required to continue to motivate change. Feedback to individuals engaging in IDE and initiatives is particularly important given the previously identified problems related to the fact that IDE and initiatives often fail to provide learners with structured feedback (identified in the chapters by Barker and Bosco). In the absence of this feedback learners lack the impetus or motivation to engage in collaborative activities and, at the same time, the value of such initiatives is not conveyed and may even be undermined. The same argument can be made for professionals in the practice setting. Measurement, evaluation, and feedback pertaining to IDE and CP is therefore critical for conveying the importance of these initiatives and motivating change in these areas. 2) Antecedents for Successful Change at the Organizational Level 2.1 Logistics as a Barrier Successful change depends on a process that is hard to manage and involves multiple stakeholders who take on different roles at different stages in the implementation process. As noted by Oandasan and Reeves in their chapter, logistics surrounding the organization of interprofessional education for interprofessional collaborative practice are exceptionally complex. Various chapters have identified a series of barriers at the organizational level related to implementing changes in the practice environment. These relate to availability of resources, need for training, need for clear leadership (both formal and informal), and the need for a decentralized decision making structure that encourages professional involvement and support. Another important barrier relates to availability of resources within the context of competing priorities. Clearly, resources are required for changes in the domain of IDE (e.g. resources would be needed for things like IDE curriculum development and implementation, faculty development and resolution of workload issues, and, potentially, wholesale redesign of existing educational programs). Changes of this nature are multifaceted and can therefore be resource intensive (involving substantial human and financial resources).
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2.2. Leaders/Champions as Enablers The organizational literature outlines various strategies available to help overcome structural barriers to change including the use of a change champions (e.g. Irving Doran et al, 2002), training (Kotter and Schlesinger, 1979), and resources (Damanpour, 1991). From the organizational behavior literature it is clear that formal leaders set the strategic direction for change, establish structures and parameters for implementation, allocate human and fiscal resources, and stimulate change interest and commitment across a variety of stakeholders (e.g. clients, clinicians, managers, educators, regulators, funders, etc.). Empirical evidence supports the notion that leader commitment and ongoing involvement are key features of successful organizational change (Gustafson et al, 2003). Leonard-Barton and Kraus (1985) found that technological change was more successful when decisions about innovations were made at a high level within the organization. Senior leadership support has also been found to explain variance in perceptions of usefulness of hospital performance data (Soberman Ginsburg, 2003)— a first step toward using these data to bring about change. Kanter (1983) suggests that ongoing support from senior leaders is more likely if the change efforts contribute to the achievement of leader and organizational goals and that resistance to change is less likely if the people affected are provided feedback on the change project. As with senior managers, middle managers are more likely to support a change if they believe that success will promote their own organizational goals (Schneider and Goldwasser, 1998) and if they feel involved in planning for the change (Rousseau and Tijoriwala, 1999). Successful implementation of IDE therefore requires the support of senior level readers who help highlight and respond to various tensions for change, set performance goals, and hold individuals accountable for implementation outcomes. Bate, Khan and Pye (2000) proposed a model for managing organizational change that accounts for the relationship between culture, structure, and leadership. This four phase change model (cultural framing, soft structuring, hard wiring, and retro-specting) focuses on the process by which organizational leaders utilize structural features to reframe organizational practices, relationships, and culture. In their analysis of structural and cultural change in a large hospital trust in England, Bates et al (2000) described a leadership style that was inclusive and collaborative, and employees were given a voice in restructuring decisions. Leadership for change was dispersed across the organization, and local leaders, who played a key role by sanctioning practical experiments, emerged from a variety of places. Bates et al (2000) argue that the coercive/charismatic leadership style typically associated with major change initiatives would have been ineffective in this context. Because of the wide dispersion of power between multiple professional groups within the hospital and widespread discredit of the formalized hierarchy, the dispersion of the leadership amongst local leaders was felt to be an important factor in successful change. In addition to the importance of understanding the context of change, Bates and colleagues highlighted the role for senior leaders to establish broad organizational parameters, including delineation of roles and responsibilities to facilitate change. Framing the change within these parameters facilitated a strong sense of ownership and commitment to successful implementation of change. The emergent and shared leadership depicted by Bates et al (2000) is consistent with the notion that a change agent plays a key role in establishing a climate for creating, garnering financial resources, implementing and sustaining change (Gustafson et al, 2003). For instance, the importance of an opinion leader or champion is well documented in
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quality management literature, including leadership from physicians (Irving, Doran, Baker et al, 2002) and front line managers (Carman, Shortell et al. 1996). Evidence from the organizational literature suggests that support for IDE by informal opinion leaders may be a determinant of successful change. For instance, networking and negotiation by mid-level managers in continuous quality improvement initiatives (Rousseau and Tijoriwala, 1999) and clinical opinion leaders (Carman, Shortell et al. 1996) are essential components of the improvement process. Other evidence shows that nurse leader access to power, information, opportunities and resources creates an environment that enhances leader perceptions of influence (Upenieks, 2003; Wilson and Laschinger, 1994). The same argument can be made for emergent IDE and leaders in the practice setting. Shared leadership information, resources, and involvement in IDE and CP decision making is therefore essential to develop a critical mass of individuals willing to engage in practical experiments and sustained change. 3) Antecedents for Successful Change at the Systems Level In addition to the strategies outlined above (e.g. efforts to create shared values/ mental models related to collaboration, the use of feedback to motivate change, leadership and change agents, conveying priorities via resource allocation decisions) the organizational literature suggests that if we want to be successful, we cannot rely solely on factors that promote mainly incremental and voluntary approaches to implementing IDE for CP. The punctuated equilibrium model is consistent with the organizational literature explaining groups’ and organizations’ inability to change—e.g. it is the strength of the underlying views, approaches and values that limit change. In addition, initial conditions (such as the status quo which consists primarily of non-interdisciplinary approaches to education or collaboration) are seen as tenacious and resilient. Under this model mild incremental changes or adjustments can and will occur provided they don’t fundamentally challenge the “deep structure”. Gersick (1991) suggests that major changes are so difficult as a result of barriers in cognition, motivation, and obligation (e.g. the stabilizing effects that scientific communities exert by socializing students – something that is akin to the kind of professional socialization within disciplines in health care. Under the punctuated equilibrium model and models of simplicity and inertia described above, it is often only serious threats of organizational failure which provide the impetus for change. In the Canadian health care system the threat of organizational failure is unlikely to function as a critical driver for change. The above models do, however, provide sufficient empirical evidence (lacking in the health care literature) to remind us that planned change at the organization level in the areas of interdisciplinary education and collaborative practice face considerable challenges related to cognition and initial “status quo” conditions. Accordingly, efforts to implement changes in the areas of IDE and CP will require the use of substantial and prolonged mechanisms to challenge existing views, including feedback and information on the merits of the proposed changes. Even still, other more radical, enabling forces for change will also be required. Adaptation theories such as institutional theory are useful for understanding the impact of the external environment on organizational entities and propose that “changes in the strategy and
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structure of individual organizations [take place] in response to environmental changes, threats, and opportunities” (Hannan & Freeman, 1989: 12). According to institutional theory, over time, institutional pressures are said to lead to the emergence of common organizational practices (Scott, 1995). DiMaggio and Powell (1983) suggest that there are three forces that lead to institutional isomorphism (e.g. that lead members of an organizational field to resemble one another. (institutional isomorphism) (DiMaggio & Powell, 1983). 1. coercive forces - pressures exerted on the organization such as external conformity pressures from regulatory agencies 2. mimetic, forces - stem from and cause organizations to imitate their peers as a mechanism for combating uncertainty and ambiguity 3. normative forces - stem from professionalization and are fostered by formal education and professional networks where individuals with common professional bases are socialized to view the world and work in a similar manner In his analysis of realistic change projects for health care organizations and the health system Denis (2002) suggests that a more radical approach is appropriate—intensive targeted efforts that challenge prevailing views and norms currently acting as natural barriers to IDE and CP are needed; however, they are likely to be far more successful if accompanied by the kind of coercive mechanisms embedded in regulatory or policy level changes (described by institutional theory (DiMaggio & Powell, 1983)). Accrediting bodies and the requirements they can put in place represent the kind of coercive institutional forces that can help facilitate meaningful change in the area of IDE and perhaps . Regulatory or legislative changes may be useful for “forcing” change in certain areas or they may simply be necessary for permitting certain kinds of changes. For instance, introduction of Bill 90 in Quebec and similar legislation in Ontario discussed in previous chapters were important for removing barriers to shared practice that existed in defined clinical areas. Institutional theory suggests that the kind of additional enabling forces required to bring about change in the area of IDE and CP may be the kind of coercive forces described by DiMaggio and Powell (1983). Indeed, in their study of Total Quality Management (TQM) adoption in hospitals, Westphal, Gulati, & Shortell (1997) found that the adoption of TQM by hospitals is externally controlled by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) which reviews quality of care and accredits hospitals (and is equivalent to the Canadian Council on Health Services Accreditation). In addition to this coercive pressure, they suggest there may also be mimetic forces at work explaining TQM adoption.
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Conclusions & Recommendations The organizational behavior literature alerts us to the fact that moving from existing models to new models of IDE and CP poses multiple challenges. This kind of change involves sometimes dramatic structural change, reconsideration of important issues related to professional autonomy, as well as fundamentally new approaches to teamwork. Much of the evidence provided in previous chapters suggests that current changes in IDE and CP are incremental. That is to say, many of the examples discussed demonstrate improvements in the present situation, while keeping the general framework of education and care delivery intact. However, the organizational change literature is clear that more substantive changes are what contribute to sustained change. Based on this review, recommendations are made in two areas: (1) to limit the incidence of learning failure and (2) to limit the incidence of implementation failure. Recommendations to reduce the incidence of learning failure •
The scope of change required in the academic and practice setting to implement and evaluate IDE will require challenging professionals’ underlying values, assumptions and mental models. The use of constructive conflict has potential as a vehicle for challenging people’s underlying assumptions and mental models and enhancing their ability to think in more interdisciplinary terms. Sustained efforts will be needed to help people confront their underlying assumptions and any evidence of success will be a useful tool in such endeavours.
•
Experimentation with different forms of IDE and CP requires managers and practitioners to develop a culture supportive of risk taking and shared leadership. This will require a major change in performance incentives, including the development of performance metrics and accountability structures. In addition, incentive mechanisms should require consideration of medium and long-term performance outcomes.
•
Approaches to learning vary, and so successful implementation of IDE and require both individual and collective learning.
Recommendations to reduce the incidence of implementation failure •
There is not one best model of change that can be applied in this area. IDE and CP require change in different domains (education and practice) and at different levels in the system (individual/team, organizational, system/policy). An approach to implementing change in the areas of IDE and CP that relies on both intrinsic, voluntary approaches to change and more extrinsic, forced mechanisms is likely to be more successful than strategies that rely exclusively on one approach or the other.
•
Approaches which recognize that certain kinds of change are easier to implement than others are more likely to succeed (e.g. structure change facilitates process and culture change; process change is easier to achieve than culture change). 233
•
Different models (e.g. incremental versus radical or “punctuated” change) offer a variety of benefits and drawbacks. For instance within a incremental model, initial steps toward IDE may involve implementing individual courses that include students in medicine, nursing, and other disciplines and measuring their effects. These changes can take place relatively quickly. More radical changes involving new programs, curriculum changes, and accountability requirements (e.g. accreditation standards) would require substantially more time and would face more substantial barriers. However, it can also be argued that the latter, more structural changes are required to entrench IDE and promote CP over the long term.
•
Reorganization into a framework where interdisciplinary education for collaborative practice becomes the norm will necessarily require clear policy direction, support and incentives (financial or otherwise) to bring key players on board. However, consistent with suggestions for bringing about change in the area of restructuring primary care, policy “direction” must be balanced enough to provide local agents with sufficient flexibility to implement changes in a manner that is consistent with the unique needs and interests of various settings.
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Chapter Ten IECPCP Framework By Danielle D’Amour and Ivy Oandasan
A Framework for IECPCP The researchers propose an IECPCP framework (See page 252) based on the literature reviews and environmental scan conducted for this report. Establishing an evidence-based interdisciplinary education for collaborative patient-centred care framework can impact the success of health system renewal. The framework for IECPCP must be flexible and must be able to function along a continuum based on patient needs and is capable to adapt to systems changes. Through effective analysis and implementation of the framework it is anticipated that best practices will be achieved and improved patient-centred care outcomes will be accomplished. However, this can only be proven with formalized evaluations and research.
The Components of the Framework The framework is built to highlight the linkages between interdisciplinary education and collaborative practice. The first square deals with factors that affect a health professional learner’s opportunity to become a competent collaborative practitioner. Micro, meso and macro level factors are highlighted which stem from the findings from this report. The learner lies in the core of the first square and is impacted by all the factors that influence his/her ability to gain competencies to be able to work collaboratively with other health care professionals. The second square deals with the factors that affect patient care outcomes through collaborative practice settings. The micro, meso and macro level factors influencing the opportunity to enhance patient outcomes through collaborative practices are highlighted. The patient lies in the core of the second square and his/her health care outcomes will be affected by the processes of structuring collaboration among health care professionals. Research including evaluation, informs both interdisciplinary education and collaborative patient centred care practice. It provides feedback that crosses the micro, meso and macro levels and informs how to improve both the educational and the practice environments. The patient/client is central to the collaborative practice setting. To be effective, patient-centred care, must address the needs of the patient and their wishes must be understood related to their readiness and acceptance to collaborate in their care. In particular, issues related to cultural diversity and its impact on patient centred collaborative practice should be considered as was discussed by Purden in Chapter 7. To highlight the specifics related to each of the components of the framework an elaboration is henceforth provided.
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Interdependency Between Interdisciplinary Education and Collaborative Practice Through our research efforts, it was recognized that there has been confusion related to the types of educational interventions that have been documented in the literature to date. The question that arises stems from what outcomes are being measured from the various educational interventions. There is a spectrum of educational outcomes that can be measured as noted in Figure 1 from the modified Kirkpatrick’s Model of Educational Outcomes that was revised by the Jet Review. (Freeth, Hammick et al. 2002) Figure 1: Modified Kirkpatrick’s Model of Educational Outcomes for IPE By the Jet Review (Freeth et al. 2002:14) Educational Outcome Reaction Modification of attitudes/perceptions Acquisition of knowledge/skills Behavioural change Change in organisational practice Benefits to patients/clients
Description Learners’ views on the learning experience and its interprofessional nature Changes in reciprocal attitudes or perceptions between participant groups. Changes in perception or attitude towards the value and/or use of team approaches to caring for a specific client group. Including knowledge and skills linked to interprofessional collaboration Identifies individuals’ transfer of interprofessional learning to their practice setting and changed professional practice Wider changes in the organisation and delivery of care. Improvements in health or well-being of patients/clients.
At the academic institution level, educators are most interested in developing and implementing teaching opportunities that improve learner outcomes like modifying attitudes, acquiring knowledge and skills, and changing behavior. The impetus to innovative teaching lies in whether or not the theme or subject matter that is taught improves patient outcomes when the learner is in practice. The ultimate outcome for educational interventions is to improve patient outcomes. It is most difficult, however, for educators to measure patient care outcomes based on the educational interventions developed for trainees at the pre-licensure level. They can measure and it is their mandate to measure learner outcomes related to competency attainment before they leave the academic institution and go out into practice. The authors decided that there would be value in distinguishing “Educational Interventions to Enhance Learner Outcomes” and “Collaborative Practice to Enhance Patient Outcomes” to provide clarity. The rational for this categorization was discussed by Barker in Chapter 5. By creating this categorization, there is an opportunity to examine the factors which influence the specific outcomes while acknowledging their interdependence. The interdependence between Interdisciplinary Education and Collaborative Practice is one of our most important findings for this report. Separating practice from education in our framework provides clarity about the structural processes that impact the advancement of IECPCP from a micro and meso level but recognizes that at a macro (systemic) level advancement can only be made with the understanding that interdisciplinary education and
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collaborative practice are interdependent. The linkage between interdisciplinary education and collaborative practice can be further explained in the following way: 1.1. Collaborative Practice Settings To impact learner outcomes, it is important to have clinical settings where collaborative practice is modeled. Without this form of role modeling and without teachers who are able to “walk the talk”, it will be very difficult to teach collaborative practice. Therefore finding and creating these settings will be very important. The models introduced by D’Amour in Chapter 3 could be transformed into tools to help locate and create collaborative practice settings for learners. By creating a body of knowledge from role models who practice collaboratively, we can come to an understanding of the types of competencies that are required of health practitioners to work optimally in collaborative practice settings. These competencies are necessary for the development of formalized learning at both the academic institutional level (pre-licensure) and continuing education (post-licensure) level. D’Amour et al, identified the interactional determinants which could be the basis of competencies as highlighted by Oandasan & Reeves in Chapter 4. 1.2. Formalized Interdisciplinary Education in Academic Institutions As Zwarenstein and Reeves reiterated in Chapter 2, available evidence is limited as to whether pre-licensure interdisciplinary education improves patient outcomes at the post-licensure level of practice. As the framework depicts, there are so many factors that can influence patient care outcomes aside from an educational intervention that improves collaborative competencies at the pre-licensure level. In the future, should evidence findings reveal that pre-licensure collaborative competencies can indeed change behavior in practice, it should take into account the organizational and interactional determinants as seen in the right hand box of the conceptual framework. It is known that in the post-licensure level of training, there is mounting evidence that outcomes for specific patient populations can be improved when using collaborative practice methodologies. It is hypothesized that future graduates who are skilled to practice collaboratively are likely to seek out settings that promote this approach to practice. Eventually, there will be a critical mass of settings and patient populations benefiting from this approach that can be studied to provide the evidence for improved patient outcomes. As this is evidence that is hypothesized at this time, a dotted arrow has been placed extending from the “interdisciplinary education to enhance learner outcomes box” to the “collaborative practice to enhance patient care outcomes box”. By increasing a workforce that has health professionals competent to work collaboratively with the values developed early on, we expect that collaboration may become more of the norm than the exception in the future.
Interdisciplinary Education to Enhance Learner Outcomes To address the framework developed, we begin by looking at the “Interdisciplinary Education to Enhance Learner Outcomes” section. Learners are central to the interdisciplinary educational processes as depicted in the square. Socialization factors are situated between the learner and the educator. By socialization we mean that the professional cultural beliefs and attitudes developed
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by health professionals can impact on their willingness to collaborate with other health professionals. Students are socialized into their professional roles. This identity is often shaped by the role modeling exemplified by the educators/mentors. Therefore, the professional beliefs and attitudes of educators related to collaborative practice are critical. Students, in turn, influence educators, and there may be a bi-directional socialization process that occurs over time and across generations. Educators can either be enablers or barriers to the learner’s opportunities to gain collaborative competencies. Teaching factors interact with faculty and learners and can influence the socialization process as was discussed in Chapter 4 by Oandasan and Reeves. Teaching factors address issues related to the methods of teaching interdisciplinary education. They include: educational theory, strategies that take into account the timing of uni-multi-and interprofessional learning, the learning context and faculty facilitation. The interaction between the teaching strategies employed by faculty and the faculty and learners’ own attitudes and belief systems lie at the micro level affecting individual learners’ chances of gaining collaborative competencies. At the meso level, issues to consider are related to the institution which governs what is taught to health professional trainees. Institutions could be defined as higher education academic institutions or hospitals where the administrative leadership has the power to influence the value of IECPCP within its institution. Bosco clearly outlines this finding in Chapter 6 related to the outcomes of the in-depth interviews conducted for the environmental scan. Without the development of the vision for IECPCP at the institutional level it will be difficult to mobilize for change. Ginsberg and Tregunno in Chapter 9 substantiate this finding through their review of the change management literature. Offering academic or staff incentives, approving logistical decisions related to scheduling health professionals or trainees to work together, and providing separate and protected funding for interdisciplinary education initiatives, can help in the advancement of IECPCP at the institutional level. The micro and meso level determinants of interdisciplinary education are interactional. This is depicted in the framework using a circular motion. They influence and inform each other. One may be catalyst or another barrier. The relationship is dynamic. At the broader systemic (macro) level, government decisions coming from different levels, federal, provincial and regional, which translate into health, social policies and cultural matters, can all impact institutional level decisions related to IECPCP. Also, the systemic structure such as the educational and professional systems will influence the success of IECPCP projects. The educational system, particularly the university, is structured on a disciplinary basis that can maintain a climate of segregation between disciplines. This in turn can influence the opportunities afforded to teaching interdisciplinary education by faculty which may impact the socialization processes of trainees and ultimately their acquisition of collaborative competencies. It has been found that health professional learners enter their educational programs with cultural beliefs, attitudes and values which are nurtured during their formal training years through socialization processes (Chapter 4). Although socialization has been identified as a micro level factor in this framework it may also be considered a macro factor as the professional culture may be so widespread that learners are affected by this culture often even before entering their training programs. The authors decided to place the professional cultural belief system and attitudes as both macro and micro level factors. Due to its pervasive nature, professional culture
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values can affect all levels within the interdisciplinary education section of the framework as well as the collaborative practice setting. In terms of outcomes, the authors believe that the health professional learner must gain specific knowledge, skills and attitudes as required competencies. These competencies are the major outcomes for “Interdisciplinary Education to enhance Learner outcomes”. Many of these competencies, as outlined in Chapter 3 by D’Amour et al., address essential interactional determinants that professionals who work in collaborative ways have been found to demonstrate. These determinants including willingness to work together, trust, communication and mutual respect can be transformed into competencies that learners should be taught. Elaboration of these competencies was highlighted by Oandasan and Reeves in Chapter 4. Although the major outcomes for this section are related to collaborative competencies for learners, it is rare at this time for health professionals to be involved in formal learning opportunities to gain these competencies. Yet, there are many health professionals who have acquired collaborative competencies without formal training who are currently working in collaborative practices. They are the exception rather than the norm. It is for this reason that in the framework a dashed arrow has been utilized extending from the learner competency outcome box to the health professional in the collaborative practice setting box. The dashed line recognizes that health professionals may have developed collaborative competencies without formalized training. Currently there is a lack of formalized educational methods used to enhance the post-licensure health professionals’ opportunities to gain these specific competencies. The specific wording of these educational methods can be debated. The authors have chosen to use the terms “Professional Development” to depict types of educational methods that can be used to teach post-licensure health professionals collaborative competencies highlighting the role of the practitioner as a learner. Continuing Education (CE) is a term that can be used to describe teaching methodologies that impart improved knowledge and skills for health professionals to affect patient care. The goal of CE lies in improving patient outcomes. The lines of distinction between professional development and CE are unclear and have been so even beyond the discussion of IECPCP. This was highlighted by Oandasan & Reeves in Chapter 3. The notion of “faculty development” must be also described, as the educators who are the health professionals who are working at the post-licensure level require skills to teach curricula developed for IECPCP. Not all health professionals are expected to be educators, hence those who do choose to teach this area must be given “faculty development” methods which are specific for teaching skills but of importance for role modeling. These “would –be” health professional educators must be collaborators themselves who have developed collaborative competencies in some way, practicing in a patient-centred collaborative manner. It is unclear what impact formalized competency based educational initiatives would have for health professional post-licensure learners in the practice setting. From the second square of our framework, we do know that competencies alone will not transform health professionals into working collaboratively as there are so many interactional and organizational factors that influence opportunities for collaboration to occur. What is hypothesized but not yet proven is that training provided to both pre-licensure and post-licensure health professionals to obtain collaborative competencies will improve patient care outcomes if they work in an environment that supports collaborative practice.
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Interdisciplinary education is dependent on the collaborative practice settings as competencies are derived from what is known about the processes involved in collaborative practice. Learning experiences should be based in settings that house successful collaborative practices from which students can draw role models and experience working collaboratively together. In summary, it is evident is that competencies alone will not improve patient care outcomes unless the enablers and barriers at the collaborative practice settings are addressed. The interdependency between interdisciplinary education to enhance learner outcomes and collaborative practice to enhance patient outcomes is highlighted.
Collaborative Practice to Enhance Patient Outcomes The second square addresses the patient-centred practice setting and lists the key elements of collaboration in health care institutions. Such collaboration takes various forms in permanent teams or in teams assigned to meet specific needs of patients. The make-up of each team depends on the complexity of the needs it addresses. Patients are thus at the center of collaborative care since they are the very reason behind the interdependency of the professionals. Patients are at the same time active members of the teams and recipients of the team care. Their privileged position in the team still depends on their willingness and ability to participate in the planning and delivery of health care. Shared patient-oriented goals unfold when patients are the focus of the team. Such focusing on patients’ needs is necessary but not sufficient. Several interactional factors can affect the level of collaboration within the team. Awareness by team members of these interactional factors such as a sense of bonding with one another and willingness to work together, contributes to building a sense of mutual trust amongst health professionals who are working within teams. In order to build trusting relationships, professionals must know each other personally and professionally. Participants in such a team can therefore transcend their inclination towards exclusive professional “turfs” and contribute, instead, to sharing common professional territories. However, it is important to recognize that collaboration exists not only within a team, but in the context of a larger organizational setting that influences it in a significant way. A review of published research by D’Amour et al (Chapter 3) and Ginsberg and Tregunno (Chapter 9) shows that several organizational factors influence collaboration, especially the dominant organizational philosophy which must recognize the team as a distinct entity with the capacity to make its own decisions in matters affecting it. Governance is, in that respect, a key element that includes leadership. Collective leadership and interprofessional leadership should be studied more thoroughly. Other organizational factors, such as the structure of health care delivery and the degree of integration between the various levels of an organization and between different organizations must also be taken into account. Formalization or rules that regulate the team is another key element since it explicitly defines the rules and agreements within health care teams.
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On a broader level, the systemic structures of the Canadian society, such as those found in professional and educational systems, have a strong impact on the development and regulation of professional boundaries. The latter are among the main obstacles to collaboration in the health care system inasmuch as they maintain professionals in a competitive mind frame instead of fostering a spirit of collaboration. On the other hand, social values and/or societal pressures can drive innovative ways of working and can compel professionals to be open to new orientations and new ways to practice. Policies and regulations can facilitate this opening by removing some of the current obstacles such as the absence of collaborative care incentives. According to the literature, interprofessional collaboration has a four-fold impact. Several authors, in particular West, Borrill, and Ungsworth (1998) and Feeley, N., & Gottlieb (in press), have identified potential effects of collaborative care. Such effects can be observed in terms of clinical outcomes as has been discussed by Zwarenstein and Reeves in Chapter 2, but also of service quality, more specifically in terms of health care accessibility and continuity. The satisfaction of professionals in terms of work appreciation and well-being can also be affected. The health organizations also benefit from collaborative care since professionals work more efficiently as a result of reduced duplication in services and greater latitude for creativity. The expected impact on the overall health care system is in terms of cost and responsiveness. Systemic Factors – Macro Level As captured in Chapter 9, change management strategies need to be explored on influencing systemic changes at the macro level. These efforts would include creating shared values in health, social and education from policies developed at various levels of government fostering collaboration. Emphasis needs to be placed in influencing our professional systems that define scope of practices and how health professionals work with each other structurally within Canada. The regulatory bodies within the professional system have a strong influence on advancing IECPCP particulary as decisions related to accountability and liability fall within their jurisdiction. The educational systems need to consider the structural basis for which training at the post-secondary education levels are provided to health care providers and decide if there is a way to decrease the climate of segregartion between disciplines. Accreditation bodes for the health professions can be a driving force to move change at the various facultlies and institutions that currently train our health care workforce. Lastly, the entrenched socio-cultural values of health care providers, patient population groups and the population at large are needed to achieve IECPCP. The framework supports a patient-centred approach to IECPCP policy development. In reference to Bosco’s chapter (Chapter 8), at the systemic (macro) level, the framework highlights the need to foster collaboration amongst health care professionals instead of our current system where independent health professionals work in “silo” like fashions. At the meso level, depending on the responsiveness and willingness health care institutions and organizations through their leadership can set priorities and be flexible in providing support and funding for interdisciplinary education and collaborative initiatives. As such, governments should be exploring legislative and regulatory reforms in keeping with changing trends in interdisciplinary education and collaborative practice environments. Health professions’ willingness to work together under this framework would require new roles and responsibilities that may affect the current scope of
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practices at the micro level.
Research to Inform and Evaluate At the base of the framework lies research. At this time, we are still acquiring a body of knowledge related to interdisciplinary education and collaborative practice. Through further research, within both the quantitative and qualitative research domains, further enhancement of our knowledge base of what works or does not work in IECPCP will be gained. Through the development of clear outcomes and benchmarks using rigorous methodologies in both the learning and practice environments we will gain more understanding related to the place of IECPCP in these settings. Further research in this field will provide guidance with respect to which populations benefit from a collaborative approach, which health professionals should be involved, and how health professionals should collaborate with each other. The answers to these questions will help inform the teaching environment and suggest strategies to help trainees become competent collaborative practitioners. The research in this area to date has been conducted with few frameworks to guideline the types of questions and methodologies used. The dissemination of findings has been haphazard, with problems related to the transparency of the initiatives developed and evaluations used. There is a need therefore to ensure that findings are disseminated widely with assurance that methodologies used are written in a way that are easily understood and can easily be reproduced. The large arrows in the framework represent a circular motion highlighting the iterative feedback loop that crosses all micro-meso and macro levels for both Interdisciplinary Education and Collaborative Practice categorizations. The arrows also recognize that research in interdisciplinary education and collaborative practice can inform each other. Research informs and evaluates the processes involved in IECPCP. If we are to advance IECPCP, then there is an urgent need for collaboration to occur among educators, researchers, and policy makers. IECPCP will materialize only when we can address the enablers and barriers that exist at the micro-meso and macro levels. It is only when key players involved at the systemic, organizational/institutional and practice/teaching setting collaborate to drive the research questions and commit to implementing processes for IECPCP when answers are known, will IECPCP truly become a reality in Canada.
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Next Steps The IECPCP framework needs to be supported at the system level by key decision-makers and champions who believe in the need for IECPCP advancement in Canada. Research is needed to advance interdisciplinary collaboration by building knowledge through well developed evaluation methods that crosses and intersects all of the determinants that exist at the macro, meso and micro levels. As IECPCP related initiatives already exist in parts of Canada, we need a process by which we can share this knowledge with educators, researchers and policy makers in Canada. To this end, the researchers have outlined recommendations and research priorities in the following chapter, which is felt, will provide the information needed to build the body of knowledge related to IECPCP that may ultimately influence the policies developed to advance this approach in our health care system.
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References Borrill, C., West, M.A., Dawson, J., Shapiro, D., Rees, A., Richards, A. et al. (2002). Team working and effectiveness in health care. Findings from the health care team. Effectiveness project. Aston Centre for Health Service Organization Research. D'Amour, D. (2002). La collaboration professionnelle: un choix obligé. In O.Goulet & C. Dallaire (Eds.), Les soins infirmiers. Vers de nouvelles perspectives (pp. 339-363). Boucherville: Gaetan Morin Éditeur. D'Amour, D., Goulet, L., Pineault, R., Labadie, J. F., & Remondin, M. (2003). Comparative study of inter-organizational collaboration and its effects in four Quebec socio-sanitary regions: the case of perinatal care. Montréal: Groupe de recherche interdisciplinaire en santé. Université de Montréal. D'Amour, D., Sicotte, C., & Levy, R. (1999). L’action collective au sein d’équipes interprofessionnelles dans les services de santé. Sciences Sociales et Sante, 17(3), 68-94. Feeley, N., & Gottlieb, L (In Press) Collaborative-partnership: A delicate balance. Toronto: C.V. Mosby Freeth, D., M. Hammick, et al. (2002). A critical review of evaluations of interprofessional education: 1-63.
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A Conceptual Model of Interdisciplinary Education for Collaborative Patient Centred Care Interdisciplinary Education to Enhance Learner Outcomes
interdependent
Collaborative Practice to Enhance Patient Care Outcomes
Systemic Factors (Macro) Educational System - Professional System Institutional Factors (meso)
Teaching Factors (micro)
Leadership
Teaching strategies
Incentives Facilitation
Logistics
Learner/Health Professional Outcomes
Theory Learning Context
- knowledge * roles - skills * communication * reflection - attitudes * mutual respect * willingness to collaborate * open to trust
Interactional Factors (micro) Shared goals/ vision
Rules to regulate the team
Patient/Provider Outcomes - Patient * Clinical outcomes * Quality of care
- Professionals * Satisfaction * Well-being
- Organization
Competencies
Learner Funding
Organizational Factors (meso)
Patient
* Efficiency * Innovation
- System Governance
Trusting relationship
* Cost effectiveness * Responsiveness
Research To Inform & To Evaluate - Develop ways to understand the processes related to teaching & practicing collaboratively - Develop specific outcomes related to the learning and practice environment - Measure outcomes/benchmarks using rigorous methodologies - Ensure research methods are transparent - Encourage dissemination of findings
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Chapter Eleven Recommendations for Health Canada Health care renewal is a priority for all levels of governments, institutions, health care providers and Canadians. Innovative, cost-effective measures and policy initiatives must be explored and implemented to ensure the sustainability of our health care system. The First Ministers’ of Health have identified that changing the way health professionals are educated is a key to health system renewal. Each chapter of this report addressed a component of IECPCP and provided highlights on the trends and issues impacting IECPCP, based on the experience of other jurisdictions and initiatives currently taking place in Canada and abroad. From the findings of the literature review and environmental scan conducted, the authors of this report provide the following recommendations and the action steps for consideration to move IECPCP forward in Canada. COMMON IECPCP LANGUAGE
Recommendation #1 Adopt a common language for IECPCP •
Develop terminology for IECPCP: Consensus must be reached on the terminology that is being used by those working in the area of IECPCP. It should be inclusive and holistic in its meaning. There is a need for a common language and defined terminologies when discussing collaborative practice and interdisciplinary education. Educators, researchers, practitioners and policy makers must ensure that they are using terminology that is understood by all as we advance IECPCP in Canada.
•
Define level of training of health professionals: There is a need to be clear about the level of training of health professionals involved in IECPCP initiatives. In our report we have used the terms pre-licensure and post-licensure to define those in training versus those in practice. However this distinction also has its own nuances particularly when trying to match learners according to level of training. Many professions now offer graduate level degrees (Masters in Social Work, Masters of Nursing) which are often embarked upon by professionals after licensure whereas within professions like medicine, trainees do not receive licenses to practice until they complete their specialization residency programs in Canada.
•
Make explicit the types of outcomes that are being considered in any initiative embarked upon: As was seen in our Conceptual Framework in Chapter 10, there is a distinction between educational initiatives that have learner outcomes as the priority and collaborative practice initiatives that consider patient or system outcomes as the priority. Although the outcomes may be different, there is a need to ensure that the interdependent linkage between interdisciplinary education and collaborative patient-centred care is understood.
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Clearly identify types of interdisciplinary education initiatives: Establish clarity on the types of interdisciplinary educational initiatives based on level of training of practitioners. For those in the pre-licensure level of training, most initiatives will be developed in the higher education institutions that ultimately lead to the attainment of collaborative competencies. At the level of practitioners, post-licensure initiatives need to clearly define whether the outcomes of interest, are to improve patient care or to improve practitioner collaborative competencies (where the practitioner is the learner). If the outcome is improved patient care then the types of interventions may be quality improvement initiatives, or practice guidelines/practice tool development. Many of these initiatives fall in the realm of continuing medical education to improve the professionals’ methods of improving patient care. If the initiative is developed to improve collaborative practices (by aiming to specifically address competencies for practitioners to work collaboratively together), then the use of on the jobtraining initiatives and staff/professional development may provide clarity as to the purpose of the initiative. These could be classified as “collaboration improvement initiatives”. Yet a third form of interdisciplinary education, in the form of faculty development, may be directed to health professionals who are educators that need to gain the competencies to both work collaboratively and to teach collaboration to trainees. There may be overlap in the types of initiatives developed at the post-licensure level, but it is clear that the outcomes of any program developed must be clear about the specific types of outcomes desired (learner, patient or professional, organization, & system) as outlined in the conceptual framework.
VISION FOR INTERDISCIPLINARY EDUCATION FOR COLLABORATIVE PRACTICE
Recommendation #2 Advocate and support for the education of health professionals that values collaborative patient centred care. •
Coordinate government activities to address barriers to IECPCP: There is a need for coordination among federal, provincial and territorial ministries of training /education and health along with academic institutions and health organizations to address enablers and barriers that may influence the advancement of IECPCP. It is time for improved communication amongst the policy makers and decision makers to agree on what priority they believe IECPCP should have in the future of health care renewal. These decisions often translate into significant funding mechanisms, funding that will be required to transform the current educational system that trains future health professionals. It is through the vision of policy-makers at the macro-systemic level that change can be influenced.
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Consult with professional bodies on IECPCP standards and competencies: Accreditation bodies for health professional educational programs should consider whether they value the need to teach IECPCP. If they do value IECPCP, then accreditators must be clear about the types of collaborative competencies they believe health professionals should demonstrate before completing their training. If competencies are to be developed and introduced into 252
accreditation standards, special attention should be placed on the descriptions used and terminologies developed to ensure clarity and consistency across health professions. •
Develop operating principles for IECPCP: that will achieve consensus on a core set of competencies about the provision of patient-centred care and working in interdisciplinary teams. The principles will take into account new realities of the health care system and the health workplace trends including the need for quality assurance and improved patient safety. This requires a concerted collaborative effort across health discipline training programs.
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Coordinate academic institutions and leaders across disciplines to enhance IECPCP: Academic institutional leaders should coordinate themselves across health disciplines to enhance IECPCP in their own institutions. A governing body, developed from the consortia of academic leaders, could provide the decision making power to create academic, and financial incentives for faculty; to break down logistical barriers including scheduling difficulties; to provide funding to support initiatives in order to create a culture that values collaboration that can be instilled amongst the faculty and learners.
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Review of current education and training programs: for health care providers should be undertaken to determine what is presently taught about collaborative practice for patient centred care. Specific inquires into how the various disciplines define interdisciplinary education must be accounted for in a review of this nature as many have different understandings of this domain.
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Identify teaching strategies to be employed that will define outcomes: Teaching strategies used to advance IECPCP should be theory-driven. The types of initiatives developed should have the potential to be used across health professional educational programs and throughout the continuum of learning. Rigorous evaluation methods must be used to capture defined outcomes in the educational arena related to IECPCP. These outcomes must be clearly defined, presented transparently and disseminated widely.
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Develop IECPCP Faculty Development Initiatives: In collaboration with academic institutions and through faculty development, methods should be developed to prepare educators to teach interdisciplinary education. Facilitation methodologies and faculty development training program must be evaluated and their findings disseminated to others embarking upon IECPCP teaching initiatives in Canada.
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Create ways to address the socialization factors that can enhance the development of positive attitudes towards other health professionals and collaborative working relationships. The socialization factors must concern both educators and learners as many educators are practitioners working in practice settings. Through champions at both the local and system level, it may be possible to encourage a climate that values collaborative working relationships.
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Develop role models for collaborative practice: In advancing IECPCP, our future health care workforce will be dependent upon equipping our learners with the appropriate knowledge, skills and attitudes to work in collaborative practice settings. One of the key determinants of
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creating a vision and recognizing the value of IECPCP is to have health care professional learners training with collaborative practitioner role models. These role models would be working in settings that provide excellence in collaborative patient-centred care. Thus, there is a need to locate and foster the development of such centres of excellence in collaborative practice settings that improve patient care outcomes. The work by D’Amour et al in Chapter 3 can help develop tools to identify and to build collaborative practices that can be used as educational training sites in communities and hospital settings.
VISION FOR PATIENT-CENTRED COLLABORATIVE PRACTICE
Recommendation #3 Advocate and support for patient-centred collaborative practice.
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Research and identify collaborative practice interventions that achieve improved patient outcomes: Research and implementation for post-licensure interdisciplinary collaborative interventions in the practice settings offer substantial promise given that there is evidence that some of these interventions for having an impact on health care system problems. There is a need to identify which populations, under what conditions and in what environments, can collaborative practice optimize patient care. It is clear that not every patient requires a collaborative patient centred care approach to management. However the evidence is accumulating through empirical research providing the necessary information of what health problems, which patient populations and which health care settings improve outcomes using collaborative patient centred care approaches. Professionals in the workplace may be more willing to depart from perceived professional norms that resist collaborative practice if the evidence provided is compelling enough to change the way they provide patient care.
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Identify determinants that affect processes of interprofessional collaboration: The environment in which collaborative practice takes place is influenced by structural, professional and personal determinants that affect the processes of interprofessional collaboration. The combined influence of multi-level factors makes collaboration a most complex phenomenon to implement and to study. There is a need to gain a better understanding of these factors through empirical exploration.
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Determine patient’s role in IECPCP: The patient is central to the interdisciplinary team, yet it is not clear how to optimize the patient’s involvement to achieve a collaborative patientcentred practice. It is recommended that a body of knowledge be developed to determine the role of the patient in interdisciplinary collaborative patient-centred practice, taking into account socio-cultural considerations of patients and providers.
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Develop evidence-based interprofessional collaboration inventions particularly in the primary care settings: Efforts to move towards widespread implementation of interprofessional collaboration should focus on those for which there is reliable evidence (many of which are hospital-based). In addition, substantial efforts should be made to develop interprofessional collaboration interventions in settings where we do not have as much information. Of importance is the need to consider the primary and ambulatory care settings (as few studies have been conducted and are urgently needed), and that initiatives are moved rapidly through pilot testing to rigorous large-scale trials.
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Identify the organizational determinants that impact collaborative practice: Current research has highlighted areas related to the understanding of the interactional determinants of interprofessional relationships such as willingness to collaborate, mutual trust, respect and communication. Emphasis must be placed on the organizational determinants and their impact on collaboration, including the effects of organizational governance and formalization processes (as depicted in the Framework model in Chapter 10). There is a need for a better understanding of interdisciplinary team management and on the types of leadership required.
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Identify role and responsibilities of health professionals in IECPCP: Collaborative practice requires changes in the way health professionals practice: changes in power sharing and decision-making, autonomy and responsibility both within the team and with the patient. There is a need to understand these changes and in particular the impact of overlapping professional responsibilities.
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Explore incentives that will foster collaboration: Experimentation with different forms of Collaborative Practice requires managers and practitioners to develop a culture supportive of risk-taking and shared leadership. This will require a major change in performance incentives, including the development of performance metrics and accountability structures.
POLICY TO ADVANCE IECPCP
Recommendation #4 Explore policy initiatives that will advance IECPCP •
Consult and explore with professional bodies on the impact of scope of practices in IECPCP: A dialogue with accrediting and licensing bodies and professional health associations should be initiated. An exploration of scopes of practice, shared decisionmaking, accountability, liability and patient safety issues should be discussed. The impact of such discussions may lead to changes in licensure requirements fostering collaborative practice, and scope of practice issues to address health human resources. Possible dialogue opportunities may include a think tank, symposium or summit comprised of educators, policy makers from government and accrediting/licensing bodies and practitioners.
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Review legislation on current and related IECPCP initiatives: An analysis through legislative tracking of changes in provincial legislation should be conducted to determine their success for supporting/facilitating interdisciplinary care. For example, track the success of the enactment of Bill 90 in the Province of Quebec.
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Review current scope of practice rules and determine implications for malpractice liability within an IECPCP framework: An independent review of scope of practice rules and other regulations affecting what individual health professionals can and cannot do and the medicolegal liability implications. The purpose is to consider developing proposals that would enable the skills and competencies of diverse health care professionals to be utilized to the fullest and enable health care services to be delivered by the most appropriately qualified professionals.
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Determine the benefits of informatics in IECPCP: In partnership with Canada Health Infoway, determine how informatics could foster collaboration among health care providers.
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Explore funding models for IECPCP: Appropriate funding models for interdisciplinary and collaborative models of care should be examined. This would include analysis and reporting of trends in the Canadian health workforce, including critical issues related to the recruitment, distribution, and remuneration of health care providers.
CHANGE MANAGEMENT CONSIDERATIONS
Recommendation #5 Use change management strategies that will facilitate collaboration amongst health care professionals. •
Initiate dialogue with stakeholders in exploring necessary changes to advance IECPCP: The scope of change required in the academic and practice setting to implement and evaluate interdisciplinary education will require challenging professionals’ underlying values and assumptions. Sustained efforts will be needed to help people confront their underlying assumptions. Any evidence of success related to IECPCP initiatives implemented paired with improved measured outcomes will be useful to influence change.
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Determine successful models of change approaches to IECPCP: There is no one best model of change that can be applied to IECPCP. Interdisciplinary education and collaborative practice require change in different domains (education and practice) and at different levels in the system (individual/team, organizational, system/policy). An approach to implementing change in the areas of interdisciplinary education and collaborative practice that relies on both intrinsic, voluntary approaches to change and more extrinsic, forced mechanisms is likely to be more successful than strategies that rely exclusively on one approach or the other.
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Identify change management approaches that can be easily implemented: Approaches should be considered that recognize that certain kinds of change are easier to implement than others and are therefore more likely to succeed. Structural change can facilitate process and culture change; changes in process are easier to achieve than changes in culture.
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Consider change management models and determine their application in the current health care system: The use of different change management models (e.g. incremental versus radical change) should be considered, recognizing that they offer a variety of benefits and drawbacks. For instance within an incremental model, initial steps toward interdisciplinary education may involve implementing a new course on IECPCP. However, more radical changes like changing accreditation standards would require substantially more effort and would face more substantial barriers. It can be argued that using radical change methods can entrench interdisciplinary education and promote collaborative practice in the long term.
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Develop change management policy strategies for IECPCP: IECPCP should be reorganized into a framework where it becomes the norm of practice and education therefore requiring clear policy direction, support and incentives (financial or otherwise) to bring key players on board. However, policy “direction” must be balanced enough to ensure sufficient flexibility to implement changes in a manner that is consistent with the unique needs and interests of various settings.
CULTURAL DIVERSITY CONSIDERATIONS IN IECPCP
Recommendation #6 Address socio-cultural and diversity issues among population groups with special consideration for Aboriginal health when advancing IECPCP. •
Address cultural and political diversity issues among population groups: Health care providers and educators must respect the values and customs of these diverse groups, and this must be reflected in both the design and the delivery of health care services and curriculum implementation related to IECPCP. Such socio-cultural considerations are important for the health care team members, educators, learners and the patients involved.
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Explore models that will foster collaboration in culturally diverse communities: The Participatory Action Research model shows promise as an approach to build collaborative partnerships with culturally diverse communities. There needs to be further examination of its applicability to health promotion activities in the practice arena and its relationship with IECPCP and research related to IECPCP.
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Develop IECPCP mandate for Aboriginal Health: Establish a clear structure and mandate for Aboriginal Health by developing partnerships to use funding to address their specific health needs, improve access to all levels of health care services, recruit new Aboriginal health care providers, and increase training for non-Aboriginal health care providers.74
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Provide research funding for Aboriginal Health in IECPCP: Additional funding should be provided to Canadian Institutes for Health Research, to increase participation of Canadian health researchers, including the Aboriginal peoples themselves, in research that will improve the health of Aboriginal Canadians. This would include resources to expand its research capacity and to strengthen its research translation capacity in the field of Aboriginal health. More information is needed concerning Aboriginal models of care that includes the role of the Aboriginal healer as part of a health care team. More understanding of this role could be developed through research that seeks an understanding of processes and impacts of including the Aboriginal healer in models of care that treat conditions affecting a significant percentage of Aboriginal people (such as diabetes).
BUILDING SYSTEMIC SUPPORT FOR IECPCP
Recommendation #7 Build upon current federal/provincial/territorial initiatives that facilitate the development and implementation of IECPCP. All levels of government and national and provincial health professions organizations have supported and executed initiatives aimed at fostering interdisciplinary education and collaboration. Champions of IECPCP have been instrumental in advocating IECPCP but they cannot do it alone. Current initiatives provide opportunities for leverage with existing government and stakeholder initiatives such as the Health Council of Canada that will not only provide the tools for policy and legislative development in IECPCP, but will also achieve the goals of the IECPCP initiative mandated by the First Ministers of Health. These opportunities should not be overlooked. Steps to consider building on this momentum include: •
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Identify current federal, provincial and territorial initiatives that can be leveraged to achieve and promote the goals of the IECPCP initiative: For example, in December 2003, the federal government created the Health Council of Canada and the Canadian Institute for Patient Safety. As their mandates are to advise and monitor the implementation of the 2003 Health Care Accord, a key objective is to foster and share information and knowledge about patient safety. This includes building on and complementing current initiatives that foster collaboration among players in the health care system.
Building on Values: The Future of Health Care in Canada. November 2002 (Romanow Commission)
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Solicit feedback from stakeholders on the impact of IECPCP in their environments: Provide a forum for consultation with all government, educational and health sectors of all health disciplines and organizations and Canadians (including accreditation, certification and licensing boards), to actively solicit input of their perspectives on how IECPCP would impact their environments. This would also provide further opportunity to identify “leaders” who are interdisciplinary care providers among these sectors who can “champion” and promote the advancement of IECPCP.
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Develop and implement a policy process for IECPCP: Within the federal, provincial and territorial governments, establish a process to develop policy and keep IECPCP on the federal government's agenda. The objective is to advocate and promote the benefits of IECPCP. Specific activities could include initiating dialogue with individual Members of Parliament including provincial Ministers of Education and Health as well as with federal, provincial and territorial representatives to discuss opportunities and issues concerning IECPCP in the health care system. The adaptation of the model of the advocacy effort employed in the Province of Saskatchewan where IECPCP efforts have been actively promoted would help to “start up” this effort at the national level.
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Consult with community leaders and communities to foster IECPCP: The involvement of communities and community leaders from all population groups in the development, implementation, support and facilitation of IECPCP is vital to ensure its sustainability in communities.
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Develop a public awareness campaign: aimed at building support for and promoting the IECPCP initiative to targeted audiences and to all Canadians. Public awareness activities should include promoting the current success of IECPCP initiatives and the value of interdisciplinary health teams through evidence-based research and patient outcomes.
CENTRE OF EXCELLENCE FOR IECPCP
Recommendation #8 Create a centre of excellence for IECPCP. •
Explore strategies to effectively develop and support IECPCP knowledge transfer: Based on the literature review and environmental scan conducted to date, it is apparent that there is a need for information and knowledge transfer to be centralized in Canada for those embarking upon IECPCP initiatives. As the resources and expertise are available in Canada, there needs to be a central support for the management of IECPCP information.
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Establish a repository or a central resource where health practitioners, government, educators and researchers obtain information for the development and implementation of IECPCP in their practice/educational environments. The repository could include a clearinghouse or a database built and maintained in order to track and disseminate such work, especially those publications that fall under the category of "grey literature". Consideration 259
should be given to provide funding and manpower to operate and maintain the repository. This important resource could be housed within the Centre for Excellence for IECPCP. •
Create a forum for information exchange and knowledge transfer: Through the development of a Centre of Excellence for IECPCP an opportunity to develop linkages with academic institutions in Canada and abroad that have researchers/educators dedicated to the advancement of IECPCP can be fostered. This would encourage dialogue in the sharing of philosophies of interdisciplinary education in teaching, and testing models of collaboration for pre and post licensure health professionals. Bringing international and national experts together will encourage consensus building in the development of a national strategy to link education and practice.
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Establish an “Outcomes Commission”: Under the auspices of a national Centre for Excellence in IECPCP an outcomes commission would be responsible for tracking the progress of the research conducted under the five year primary health IECPCP initiative. This commission can help to identify further research questions that need to be answered by having a firm grasp of the body of knowledge that is being built related to IECPCP in Canada and abroad. ESTABLISHING RESEARCH PRIORITIES FOR INTERDISCIPLINARY EDUCATION FOR COLLABORATIVE PRACTICE
Recommendation #9 Build body of knowledge by funding IECPCP research initiatives based on criteria that will facilitate an understanding of the processes and outcomes related to models for IECPCP . Researchers can provide valuable knowledge that policy makers and planners can use to develop more efficient, effective health services within an IECPCP framework. Efforts should be placed on promoting research transfer by putting research into action. Not only will health care utilization data be captured, but research also will ensure improved quality of care and implementation of performance measurement tools as well as promote program successes. Furthermore, knowledge transfer can be used to examine areas that have not been successful, and identify where our energies and efforts need to be focused to ensure interdisciplinary education for collaborative practice. There would be an opportunity for leaders in IECPCP to disseminate their findings. In building this knowledge transfer, the following steps should be considered. •
Actively engage in the establishment of linkages and partnerships with other health research stakeholders (Canadian Institutes of Health Research, Health Canada and the Canadian Health Services Research Foundation, Social Sciences and Humanities Research Council etc.) to develop funding mechanisms to support research in interdisciplinary education and collaborative practice ensuring sustainability. This would include devoting additional funding to health services research and clinical research, and that it collaborate with the provinces and territories to ensure that the outcomes of such research are broadly diffused to health care providers, managers and policy-makers. 260
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To build a body of knowledge related to IECPCP, creating both educational and collaborative practice frameworks, theory, process and evaluation. Research must be conducted using well-designed qualitative and quantitative research methodologies. A body of knowledge is required to create a foundation for educational, practice and research endeavors. IECPCP has a few building blocks developed but more needs to be created through sound research in the future.
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Develop and conduct randomized control trials of new interdisciplinary education models: Once educational and practice models have been developed and piloted, their effectiveness needs to be evaluated. Randomized control trials should be carried out to understand the impact of these new models of interdisciplinary education in academic institutions, in the practice setting and on patient care outcomes. In addition, qualitative data needs to be collected to help explain the nature of the effects of such interventions. The technical challenges of these studies are not to be underestimated given the long path from prelicensure education to improved patient care and health care outcomes in the practice setting.
FUTURE RESEARCH PRIORITIES FOR INTERDISCIPLINARY EDUCATION FOR COLLABORATIVE PRACTICE Given the information gaps of the current research, parameters for core criteria must be set for IECPCP research that will improve evidence-based research, provide better knowledge transfer, and enable the development of change strategies that will effectively foster collaboration. Priorities for conducting and funding IECPCP “Request for Proposals are described below: 1. Post-licensure collaborative interventions: Health Canada decision makers should choose a number of high priority health problems and designs aimed at encouraging a small number of skilled multidisciplinary research teams to conduct comprehensive studies on post-licensure collaborative interventions for one or more of these problems. These studies need to cover the development of interventions and their comprehensive evaluation. Once models have been developed and piloted, their effectiveness needs to be evaluated. Randomized control trials need to be carried out to understand the impact of these new models of collaborative practice initiatives. Qualitative data needs to be collected to explain the nature of the effects of IECPCP interventions. We recommend studies be conducted measuring: Outcomes a) The Patient –What health problems and/or practice settings (e.g. Primary care) do collaborative practice models improve both individual patient and population health outcomes? b) The Professionals - How does collaborative practice effect job satisfaction and wellbeing, recruitment and retention, productivity, efficiency, and professional development? Gaining a perspective from both patients and providers on their views on IECPCP and its personal impact on them should also be included.
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c) The Organization- How does collaborative practice impact quality of services in terms of efficiency of health care services (i.e. reduce waiting list and duplication of services), recruitment and retention, patient safety, evidence-based practice and cost effectiveness? d) The System – What cost benefit does IECPCP contribute to the entire health care system. What is the effectiveness of IECPCP in improving efficiencies? What are the population health outcomes? Processes As important to outcome measurements, is the need to conduct research that looks at the dynamic processes that occur related to organizational factors and interactional factors affecting IECPCP. There is a need to conduct research that looks at the dynamic processes that occur between health professionals as they work in teams. In addition, ways to promote collaboration, through the use of the incentives for collaboration, the change processes and tools that support change need to be considered. We must come to an understanding of the organizational factors and interactional factors that exist amongst health care professionals, patients, and the environment from which they work. 2. Pre-licensure Educational interventions are difficult to measure in terms of their impact of patient outcomes. Within academic institutions the primary outcome is on learner outcomes with the hope that when they graduate from their training programs they will eventually impact patient outcomes through the competencies gained. It is important to try to address the transitions between student learning from education institutions (pre-licensure) into practice settings (post-licensure) and how educational interventions ultimately affect patient care. A consensus should be reached on a number of approaches to interdisciplinary education that should be tested, selecting those which have advantages in terms of feasibility, affordability and acceptability. A program of research should be considered to fund pilot implementation of a small number of these using mixed methods of rigorous qualitative and quantitative studies. These studies should address: Outcomes a) What are the competencies that can be taught to learners? b) What methods can be used to assess students’ competencies? Process a) Teaching Factors - What models for teaching collaborative competencies show the most promise? Future initiatives need to incorporate teaching strategies based on theoretical models, focus on the context of learning and draw on the role of facilitation. b) Institutional Support - What methods can be measured to demonstrate the effect of institutional/organizational levers to impact interdisciplinary education? How can these methods be developed and implemented? c) Educators – Acknowledging the impact of professional beliefs and attitudes that may be imparted to trainees from educators, what faculty development methods can be developed in order to impart the values of collaborative practice to learners? 262
3. Address interprofessional collaboration and education within the context of culturally diverse communities. Within cultural and diverse patient population groups, this would include valuing and respecting cultures and social influences and recognizing the role of the patient in patient centred collaborative practice. Research should be conducted to determine: a) What collaborative practice means to different communities (what is their understanding and vision of culturally specific collaborative patient centred care?), and how it is received by them? Who would be the health practitioners involved? b) How would collaborative practice best be implemented in various communities? c) What are the distinct features of IECPCP that may or may not work for certain population groups? d) How can IECPCP address gaps in health care access and the provision of continuity of care for certain population groups? e) How can we build bridges between traditional and western medicine for collaborative practice? g) What is the patient’s role in patient-centred collaborative practice and how can we best involve the patient while taking into consideration patient’s views and cultural factors? 4. Research teams must demonstrate collaboration between educators, practitioners, institutional/organizational leaders and policy-makers who have expertise and experience in IECPCP and/or like initiatives. Multi-method research approaches using the expertise from a multi-disciplinary team initiating, implementing and evaluating proposals should be encouraged. Highest priority should be given to proposals that demonstrate the interdependency between interdisciplinary education to enhance learner outcomes and collaborative practice initiatives that enhance patient outcomes as well as addressing the effects of micro-meso and macro level influences on IECPCP. 5. To ensure sustainability of research on IECPCP beyond the 5 years of this initiative, there is a need for consultation with other major research granting agencies to fund interdisciplinary education/practice initiatives in the future. As the body of knowledge is just beginning to grow, time and research is needed to develop and test frameworks that we hypothesize will positively affect patient outcomes and the health of Canadians. 6. To reduce duplication in research efforts and to ensure that the science of IECPCP is based on rigorous empirical work we support the establishment of a permanent “Outcomes Commission” under the auspices of a national centre for excellence in IECPCP. Such a commission would have the responsibility of measuring outcomes, tracking progress and reporting results specific to the IECPCP initiative. The commission would conduct audits/surveys on the research being conducted over a three to five year period to effectively measure and report outcomes within an IECPCP framework.
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Summary of the Report The stage is set for Canada’s readiness to move IECPCP forward. Patients and consumers are now increasingly informed about their health. As a result, there is a need for a new relationship of shared decision-making between patients and health care providers. This highlights the importance of patient-centred care. Although Canadians are positive about access to health care services in their communities, there is room for improvement.75 There is readiness among all levels of government and among national and provincial health professions organizations who have supported and executed health reform initiatives aimed at fostering interdisciplinary education and collaboration. Some academic institutions have taken the lead to introduce new models of teaching for students that will enable them to be equipped with the appropriate skills and competencies to provide interdisciplinary care. Leaders of IECPCP have been instrumental in advocating IECPCP but they can’t do it alone. To advance IECPCP in Canada it should not be surprising that a collaborative approach must be taken amongst educators, practitioners, researchers, policymakers and clients/patients. As the framework developed by the authors of this report propose, there are various enablers and barriers that act as determinants that need to be addressed at the micro-meso- and macro- levels for both interdisciplinary education to enhance learner outcomes and collaborative practice to enhance patient outcomes. We wait for the day when we can test and implement what has been learned from the body of knowledge which is currently growing in this area. We know that interdisciplinary education and collaborative practice is on the agenda not only for all levels of government but also among the academic and health care institutions, and within Canadian communities. What we don’t know is the level of priority in the implementation of IECPCP initiatives within these jurisdictions. We know that funding for IECPCP related initiatives is available from a macro level provided by the government and institutional leaders in health and education. Canadian communities and leaders have provided the leadership, commitment and support for the development and implementation of IECPCP related initiatives. However, we need to learn about the level of leadership and commitment among regulatory bodies and health professions, as they will play an influential role in advancing IECPCP, and in establishing the IECPCP priorities at the meso level. We do know that collaborative practice interventions can improve patient outcomes but we need to identify which populations groups effectively respond and benefit from illness management interventions through collaboration. There is consensus that systemic issues need to be addressed to effectively respond to population health needs (i.e. cultural and social influences), in order to move IECPCP forward. However, we know that there are significant hurdles to overcome to achieve change. Big hurdles would include change in cultural values and beliefs of health professions towards collaboration and 75
Canadian Medical Association. National Report Card 2003. Summary Report conducted by Ipsos-Reid. July 2003.
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formalized interdisciplinary education activities that are grounded with clear competencies that may help to address or shift some of the attitudes for future health professions. Understanding and having the knowledge about population needs is critical to the success of collaborative practice programs which requires the need for a national central resource to drive education, research and faculty development. (This would include tailored IECPCP research activities on studies of the effectiveness of interdisciplinary education and collaborative practice interventions in studying patient outcomes). Further, more can be learned from drawing upon existing and successful IECPCP related initiatives that have not received wide-recognition. This would serve as a valuable resource in building a knowledge base of many examples of IECPCP initiatives as well as learning more about how interdisciplinary education for collaborative practice can enhance patient outcomes. In addition, we anticipate that evidence will benefit the teaching of interdisciplinary education for all health care professions both at the pre-licensure and post-licensure levels. The importance of this report is that it can help to address the compelling issues facing the protection and sustainability of our health care system. The findings of the report which have culminated in the development of an evidence-based framework may help to address critical factors such as patient safety, health human resources, quality assurance and effectiveness and efficiency in our health care system. Moreover it provides a better understanding of how health professionals can effectively work together in a way that is patient-centred. The authors of this report applaud the First Health Ministers and the federal government on its leadership and support for health system renewal. Moreover, its recognition that changing the way health professionals are educated is a key component of health system renewal. The researchers commend these efforts and stress that a long-term commitment is required by all key stakeholders working collaboratively together in order to advance IECPCP in Canada for the future of our health care and the well-being of our citizens.
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APPENDICES FOR THE IECPCP REPORT
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Appendix A Focus Group Questions For IECPC National Committee Members You are all members of this Health Canada inquiry into interprofessional education and interprofessional collaboration, and were chosen for this committee on the basis of your experience in, and thoughts about, these matters. Our research team is conducting an environmental scan for Health Canada of this field, and we would like your help. In order for the information we provide to be constructive to you and Health Canada, we would like to know your current opinions related to: 1. The current state of IECPCP in Canada based upon your experience. 2. The direction of IECPCP in five years given the current state of the health care system. 3. The unknown factors and the most important unresolved issues on collaborative practice and interdisciplinary education that you want to address in this research study.
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Appendix B ISSUES AND QUESTIONS FOR THE RESEARCH REPORT 1. BACKGROUND ON INTERDISCIPLINARY EDUCATION FOR COLLABORATIVE PATIENTCENTRED PRACTICE • Discussion of concepts of interdisciplinary education and collaborative patient-centred practice • Current state of interdisciplinary education for collaborative patient-centred practice in Canada o At the entry to practice, graduate and continuing education levels o Extent of networking and sharing of best practices, in education and practice, for collaborative patient-centred care 2. BENEFITS, COSTS AND OUTCOMES OF INTERDISCIPLINARY APPROACHES IN EDUCATION AND PRACTICE 3. DESCRIBE THE KEY ELEMENTS OF INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE. • What are the features, or “ingredients”, of effective, professional, evidence-based collaborative practice? What are the features of effective interdisciplinary education? • Include an assessment of special cultural considerations (i.e., Aboriginal) for both. 4. WHAT EXAMPLES OF INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE CURRENTLY EXIST? 5. DESCRIBE THE BARRIERS TO INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE. •
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Describe barriers at the system, organizational, and individual levels. For example: what federal/provincial/territorial (f/p/t) policies, organizational management systems, educational delivery systems, professional / personal characteristics, and social influences impede interdisciplinary education and collaborative practice? Consider problematic / unsuccessful experiences identified to date, assess “what went wrong”.
6. DESCRIBE THE ENABLERS TO INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE. •
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Describe enablers at the system, organizational, and individual levels. For example: what f/p/t policies, organizational management systems, educational delivery systems, professional / personal characteristics, and social influences enable interdisciplinary education and collaborative practice? Consider positive / successful experiences identified to date, assess “what went well”.
7. IDENTIFY CURRENT F/P/T POLICIES IN HEALTH AND EDUCATION THAT SUPPORT INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE. •
What policy levers have been identified and employed?
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8. IDENTIFY ADDITIONAL F/P/T POLICIES, PROGRAMS, STRATEGIES AND INITIATIVES, OR CHANGES THEREOF THAT WOULD FURTHER ADVANCE INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE. • • •
What policy levers have been identified, but not employed and evaluated (whether positive or negative)? What are the barriers? Identify change management strategies to overcome barriers. What policy issues need to be considered?
9. ANALYSIS • • •
Assess the “readiness” for interdisciplinary education and collaborative practice in Canada. What steps need to take place to make Canada “ready”? Describe the outcomes of interdisciplinary education and collaborative practice. This would include general and specific outcomes whether intended or unintended.
10. DESCRIBE CHANGE MANAGEMENT AND KNOWLEDGE TRANSFER STRATEGIES • •
What change management strategies have been successful in promoting uptake (theory to practice) of interdisciplinary education and collaborative practice? What change management strategies have been successful or unsuccessful in overcoming barriers or overcoming resistance?
11. DESCRIBE THE RELATIONSHIP COLLABORATIVE PRACTICE. • • • • • • •
BETWEEN
INTERDISCIPLINARY
EDUCATION
AND
What are the required competencies for students or practitioners (i.e., knowledge, skills, personal attributes, other) required for collaborative practice? What curriculum elements, and teaching methodologies, would best maintain the requisite competencies? What are the optimum learning conditions to promote collaborative practice? Describe current gaps in the health care education system. What do students need from their education system to “get there”? How should the education system be changed to meet these needs? Describe the characteristics of students/practitioners receptivity to change in terms of culture, attitude and values Does interdisciplinary education lead to collaborative practice? Does collaborative practice lead to improved patient outcomes?
12. COMPARE SIMILARITIES AND DIFFERENCES AMONG THE INITIATIVES IDENTIFIED. 13. CREATE AN INVENTORY OF BEST PRACTICES IN INTERDISCIPLINARY EDUCATION AND COLLABORATIVE PRACTICE. •
What can we learn from current examples of interdisciplinary education and collaborative best practice?
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14. PROPOSE EVIDENCE BASED, CONCEPTUAL FRAMEWORKS. •
Identify options for conceptual frameworks. Encompass the health system, organizational (educational or hospital institution, health care or professional organizations), and individual perspectives (professional competencies).
•
Take into account policy levers, supportive organizational, professional, personal and social characteristics.
15. IDENTIFY FUTURE RESEARCH PRIORITIES •
Describe gaps identified in the literature review and environmental scan.
•
What are the research priorities, in both the short and long term, to advance interdisciplinary education and collaborative practice through an improved evidence base, better knowledge transfer and change strategies?
16. IMPLICATIONS FOR POLICY, PROGRAMS AND STRATEGIES TO PROMOTE INTERDISCIPLINARY EDUCATION FOR COLLABORATIVE PATIENT-CENTRED PRACTICE
270
Annotated Bibliography
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