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Working and learning together ii47
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ii48 McPherson, Headrick, Moss
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Working and learning together ii49
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ii50 McPherson, Headrick, Moss
dilution of professional identities.33 34 Some profes- pursued the same goals using strategies respon-
sional bodies have indicated concern that IPE sive to local resources and culture. Three mod-
could diminish the autonomy of professions els emerged, depending on local requirements:
who have worked very hard to attain it.46 A fear + The academic model featured faculties from
that professional identity may be lost should schools of medicine, nursing, social work,
not be dismissed as an irrational concern. and other disciplines teaching geriatric
There are examples of such things in our teamwork.
history47 48 and suggestions about IPE include + The clinical model placed the healthcare
that “ . . . a new common foundation delivery site in a leadership position, work-
programme will be put in place to enable ing with trainees placed there by partner
students and staV to switch careers and academic programmes.
training paths more easily”.49 While there is a + The mixed model included elements of both
role to be played by having a work force that the academic and clinical models—for
can “substitute for one another” when appro- example, with the same faculty members
priate, there is a real need to be clear about serving as both educators and clinicians.
what IPE should be aiming to achieve. We An independent team of researchers for-
would suggest it is not to have everyone learn mally evaluated the programmes, and the
the same things, but rather to learn to following needs have so far been identified53:
understand and capitalise on the diVerent (1) to locate champions: someone with author-
competencies various professions bring to ity and influence in each participating profes-
patient care. sion to support the initiative;
One reason that attitudinal barriers may be (2) to pick a skilled programme manager:
extremely pervasive and diYcult to address is someone responsible for bringing people to-
in part because they cross over into clinical gether and coordinating the work among part-
practice. Clearly, a student who sees competi- ners;
tion rather than collaboration among profes- (3) to train faculties and clinicians first: teach-
sionals in practice will discount prior classroom ers must be able to incorporate team principles
based teaching that claims the benefits of inter- and skills into their work and model them for
professional work. While some argue that such learners;
factors support IPL being located primarily in (4) to create a long term benefit for clinical
the clinical or community setting (where it can partners and institutions: a programme that
build benefits for patients at the same time as creates value for everyone involved is more
one is building benefits for learners),50 it has likely to be successful than one that moves from
been successfully introduced in a number of one grant to another;
diVerent clinical and academic settings. (5) to include a home healthcare setting as part
of the programme: in the care of the elderly,
visiting patients in their homes broke down
barriers among the professions and highlighted
Some recent examples the value of each contribution;
There are a number of examples of good prac- (6) to provide booster doses of GITT: contin-
tice, some of which have been comprehensively ued attention to team training and communi-
documented elsewhere.33 51 52 We mention here cation is needed to sustain initial gains.
two initiatives in the USA where multisite
demonstration projects have recently been INTERDISCIPLINARY PROFESSIONAL EDUCATION
completed, the first involving qualified practi- COLLABORATIVE (IPEC)
tioners working with older adults53 and the sec- The Interdisciplinary Professional Education
ond involving both undergraduate trainees and Collaborative (IPEC) began in 1994 with four
qualified practitioners.40 50 54 Both groups grap- sites which increased to 10 in 1997.40 50 54 The
pled with the barriers described above but cre- Institute for Healthcare Improvement spon-
ated interprofessional learning experiences that sored the initiative with support from the
have been sustained over an extended period. Health Resources and Services Administration
Each has incorporated evaluation as part of (US Public Health Service) and start-up funds
programme planning, and used their multisite from the Pew Health Professions Commission.
structure to generate lessons for future work. The formal demonstration project ran until
1999 and participants continue to collaborate
GERIATRIC INTERDISCIPLINARY TEAM TRAINING on a variety of follow up projects. The goal of
(GITT) the IPEC was to improve health, health care,
The GITT included eight sites working under and education of the health professions—
sponsorship from the John A Hartford Foun- especially IPE—through the use of continuous
dation.53 The goals included: (1) creating improvement methods. Its objectives were to:
national training models based on partnerships + equip health professionals with the ability to
between “real world” providers of geriatric care continually improve the health of the
and educational institutions that train health individuals and communities they serve;
professionals; and (2) developing well tested + integrate practice and learning in continu-
curricula for geriatric interdisciplinary team ous improvement as part of the daily work of
training. delivery of health services and education of
The emphasis was on graduate level trainees the health professions;
(advanced practice nurses, master’s level social + expand our learning with regard to improv-
workers, and medical residents (registrars) in ing health and the education of the health
the primary care fields). Each of the eight sites professions.
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Working and learning together ii51
Across the 10 sites participants included mounting IPE programmes, not the least of
pre-qualification and graduate learners in which is eVective partnership and appropriate
health administration, health education, health resource allocation. In order to justify the sub-
information, medicine, nursing, pharmacy, stantial investment of time and resources
physician assistants, physical therapy, psychol- required, there are a number of steps that need
ogy, public health, recreation therapy, social to be taken.
work, and statistics. With the expansion of the
collaborative in 1997 there was a particular Steps to professional education that
focus on community health under a pro- prepares learners to collaborate for the
gramme called “Community Based Quality best care of patients
Improvement Education for the Health Profes- If interprofessional working is central to good
sions”. Most sites began with a community patient care, then being able to work in a team
health need—for example, health services for and collaborate with other professionals can no
the homeless in Philadelphia, self-care of longer be an “optional extra” but must become
people with diabetes in rural South Carolina, a core competency. We need approaches that
preventive services for the elderly in rural will help all healthcare professionals to become
Oregon—and then built educational experi- more eVective collaborative workers, not sim-
ences into eVorts to meet that need. Like the ply to improve relationships but to achieve bet-
GITT, each IPEC site agreed on the common ter outcomes in health care. For any education
goals and then developed a strategy responsive programme to work it has to be supported by
to local needs, values, and resources. Across all professions, valued by students, and hold its
10 sites the work depended on partnerships appropriate place in curricula and assessment
between academic programmes and commu- processes. The barriers are considerable and
nity healthcare providers. the evidence to help us is slim. So, where do we
IPEC demonstrated that IPE could be go from here?
created in a way that benefits both learners and Firstly, we must agree on the goals. The key
communities.55 Knapp and colleagues identi- questions are:
fied the following strategies: + What kind of education?
(1) Understand community health issues: in + For what kind of student?
order to create a concrete, meaningful learning + Leads to what kind of impact?
experience for students priority setting activi- + On what kind of outcome?33
ties using community health data must be What exactly are the knowledge, skills, and
completed prior to student involvement. attitudes related to interprofessional work that
(2) Connect the institution and the commu- are required for best care? Along with indi-
nity: the faculty must have knowledge of the vidual expertise, knowledge of healthcare
community and the health issues being ad- systems, communication skills and respect for
dressed. They must facilitate the two way con- the work of other professions, it would appear
nection between the educational institution, that the ability to both share one’s own knowl-
students, and the community. edge and to listen and respond to that of others
(3) Define a target community: student im- is key to working well in teams.35 Our aim
provement projects must target smaller popula- should be to produce health professionals who
tions within the context of the larger whole. are prepared and positive about this aspect of
(4) Understand the people you wish to serve: to their work. We would suggest great caution
design and implement appropriate client sensi- about ideas that IPE should aim to have learn-
tive services it is imperative to gain knowledge ers and workers that can easily move between
from the people you wish to serve. diVerent professions.49 57 Such a goal seems to
(5) Identify appropriate short term projects: it risk what we have suggested to be valuable dif-
is diYcult for students in one semester or even ferences between the health professionals that
one year to develop and implement health are vital for best patient care.
improvement projects that will have an impact Secondly, we must agree on the most appro-
on a broad community health measure. Yet priate methods. While there is considerable
students can conduct projects that can be done agreement on the need to build interprofes-
in a short time frame and contribute to the sional competencies, there is little evidence to
knowledge base. support one approach over another. Can sepa-
(6) Practise interprofessional teamwork: com- rate health professional student populations,
munity health improvement work is intrinsi- working in collaboration with educators and
cally interprofessional and is therefore an clinicians from other disciplines, acquire the
excellent format to explore teamwork with stu- learning needed, or must students from diVer-
dents. ent disciplines learn together? The first, while
A three site collaborative in the UK (Health not easy, is clearly less complex and may be
Improvement through Interprofessional Edu- more sustainable than the second. If the second
cation Programme) began in 1999 with spon- results in better care, then we must work harder
sorship by the NHS Executive South West and on the obstacles.
their early experience included similar barriers Thirdly, what should be learned when? We
and lessons.50 56 In addition, some new initia- argued above that interprofessional working,
tives (such as the “New Generation Project” at like other complex professional skills, should
the University of Southampton in the UK) are be taught as a continuum, starting early and
putting such lessons into practice from the very continuing throughout professional and con-
inception of projects. Each of these initiatives tinuing education. But what exactly should be
highlight some key issues to be faced in oVered when? Koppel et al found that changes
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ii52 McPherson, Headrick, Moss
in individual behaviour and benefits for well functioning coherent teams, and contrib-
organisations and patients occurred primarily ute to better healthcare outcomes. This result
when IPE was designed for professionals in cannot be expected from some magical cascade
practice, yet demonstrable learning took place of benefit, nor can we expect that these goals
at the pre-qualifying level.37 In contrast, will be achieved without some change to our
eVective interprofessional teamwork in the care current system of education. To continue with
of complex patients requires individual profes- the status quo may in fact be damaging.30 58
sional competence and ongoing learning While there are understandable calls for
focused here may be more eVective. Since “proof” that IPL is eVective, we (and our
important attitudes about working with other patients) cannot aVord to stand still where we
professionals emerge long before the end of are.
training, attention to these should be part of To create successful IPL we must agree on
the early aspects of professional education and what we hope to achieve, and then create and
reinforced throughout. examine new hypotheses about how education
Fourthly, we must attend to the need of is designed, when it should occur, and how it is
health professional faculties to develop their evaluated. As professionals we must reflect on
own competence in interprofessional working. how we present our own knowledge to others,
IPEC suggested the following for education in and how we attend to other’s knowledge. It
the context of interprofessional teams45: would be helpful if leaders in the diVerent pro-
+ Encourage teams to invest time in develop- fessions show the way, and if funding bodies
ing a shared aim. support such initiatives. These steps will help
+ Develop team skills through practice and us to develop a knowledge base that sustains
reflection. and promotes collaborative work in addition to
+ Pay attention to internal team relationships. specialist knowledge and skill. Our patients
+ Identify changes in the educational infra- deserve both.
structure required to help sustain interpro-
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