Interprofessional Education: Development of an Interdisciplinary Health Care Team Project at a Midwestern U.S. University

INTRODUCTION

For at least 20 years, national and international organizations and task forces have called for reform in health professions education and have urged that health professions students no longer be taught in isolation from one another.¹ In 2000, the United States (U.S.) Institute of Medicine (IOM) released “To Err is Human: Building a Safer Health System”, which called for the development of interdisciplinary teams as a way to increase health care quality and safety.² In 2003, the IOM reiterated the link between interdisciplinary teamwork and health care quality and urged health professions educators to incorporate interprofessional education (IPE) routinely into the curriculum.³ After reviewing 89 studies, the Cochrane Collaboration concluded that IPE should begin early in the curriculum for health professions students as a way to promote role understanding, better communication, and ultimately improve the well being of patients.⁴

In the growing body of literature on the importance of IPE across health professions programs and the development and implementation of various types of IPE programs for health professions students, different pedagogy have been described in the literature. One example of different pedagogy implemented to support the development of IPE for health professions students is to have them working together in problem-based learning (PBL).⁵ Other authors identify clinical experiences as an ideal way to develop and implement IPE programs that utilize teams interacting with patients. Clinical learning is central to IPE in health profession programs.⁶ An additional variation in theme from the literature focuses on how programs use a combination of both clinical and didactic learning as pedagogy for interprofessional learning.⁷ Chan and coworkers.^1,5 describe the formation of interdisciplinary teams with nursing and social work students. The students participate in problem-based learning (PBL) case studies during four cross-disciplinary sessions. Data collected relate to the students’ awareness of each other’s values, recognition of disciplinary knowledge, an appreciation for each other and discussion between the disciplines about further collaboration. The researchers report that discussion between the nursing and social work student teams “enhanced their understanding of their decision making process in their assessment and management of a patient”.⁵ Swisher, and coworkers describe both centralized and decentralized organization models for interprofessional education of students from physical therapy and medicine.⁶ When first implementing the IPE experience with these two groups of students in 2005, a centralized model was used in which there was scheduling of shared core courses. In the second and third year of implementation, IPE was changed to a decentralized model in which the interprofessional curriculum contained IPE learning experiences but not actual courses. Although the program continues with the first year utilizing the centralized model and the second and third years utilizing the decentralized model, some issues have developed regarding interprofessional education such as organizational commitment and culture change for the long-term sustainability of IPE. The authors identify certain steps to take with the implementation of the centralized/decentralized model to increase interprofessional communication. These steps include the development of interprofessional competencies to facilitate constructive discussion among professions.

The delivery of a designated interprofessional curriculum in college and university programs in both the U.S. and abroad has been accomplished using a variety of modalities. Hoffman and Harnish8 report using self-directed independent research, problem-based learning, and collaborative group discussions to promote IPE among health profession students in Ontario, Canada. Pollard9 describes the use of case studies for IPE in the United Kingdom but concluded that in order to develop interprofessional competency, the students who utilized case studies for IPE needed additional face-to-face interprofessional engagement. In Stockholm, Sweden, Hylin and coworkers describe the use of a clinical practice course for interprofessional training.¹⁰ This course was a two week mandatory course in which medical, nursing, physiotherapy, and occupational therapy students gained an “enhanced understanding of the roles of other professions and the importance of good communication to teamwork and patient care”.⁹ Conway11 reports the development in Australia of a department designated Multidisciplinary Learning Unit (MLU) in order to facilitate interprofessional clinical experiences. Select students from medicine and nursing participate in the care of patients on the Multidisciplinary Learning Unit (MLU). Continued support of the Multidisciplinary Learning Unit (MLU) with involvement of all health professions students is recommended by the authors. In 2003, Morison and coworkers.⁷ compared IPE done in a classroom versus a clinical setting for medical and nursing students in Belfast, Northern Ireland. Classroom learning involved the use of team work and case studies. The results indicated that learning occurred equally well in both settings and that each possessed merit for IPE. The authors suggest that pedagogies that provide an opportunity for interaction and active learning are most effective. Jacobsen and coworkers.¹² conduct a longitudinal study on an Interprofessional Training Unit (ITU) in Denmark in which medicine, nursing, physiotherapy and occupational therapy students were partnered in the clinical setting to care for patients. The results of the three year study were that students who participated were able to achieve the faculty-determined goals of IPE. The students felt that they had learned from the other professions, gained a better understanding of their own role, and worked better together as professionals. Faculty felt that new methods of coordinating and integrating clinical and didactic learning were discovered with the development and implementation of the Interprofessional Training Unit (ITU). In order to develop and implement a novel approach to interprofessional health care education, researchers and students at the University of Minnesota devised a student-run organization called Clinician Administrator Relationship Improvement Organization (CLARION).¹¹ The mission statement of CLARION is to further interprofessional education for health professions students. CLARION was created under the “premise that interprofessional experiences will facilitate the development of future leaders who will make the changes needed to provide high-quality, safe and effective health care”.¹³ These experiences include simulations, small group discussions, large group presentations, seminars, tours of units with integrated interprofessional care models, and an interprofessional case competition. The organization credits its many accomplishments to the development of the interprofessional case completion, a capstone course in which students compete in conducting and presenting root cause analysis of a fictitious sentinel event. Johnson and coworkers report the completion of this capstone course promotes interprofessional equality among the health professions students.¹³

Although there is increasing interest in implementing Interprofessional Education (IPE), there can be daunting logistical problems to overcome. Differing curricula, time constraints, geographic distance, and faculty buy-in can all make authentic, interactive IPE experiences difficult to create and sustain.¹ The purpose of this demonstration project was to attempt IPE integration across curricula in a College of Health and Human Services (CHHS) at a Midwestern U.S. university.

There is no doubt that the application of IPE to health professions curricula is imperative, and the literature reflects many different approaches to the development of IPE. Successes have been reported using didactic methods of engagement, traditional clinical learning, or a combination of the pedagogies. In this article, we report on one college’s attempt to breakdown the traditional silos that occur in academia, particularly in the health professions programs, through the implementation of a longitudinal IPE curriculum. With the implementation of this curriculum, we became the only university in a large regional area of the Midwestern U.S. where future health care professionals can engage in patient care-focused service learning activities in collaboration with students from other health care disciplines. The students who participate in these IPE Health Care Teams (HCTs) work together in classroom, lab, and field activities to facilitate the development of medical knowledge, technical expertise, and valuable understanding about what it takes to deliver safe, high quality patient care. Here we report on both success and challenges encountered in implementing this unique experience.

METHODS

Our campus is a regional campus of a large Midwestern university system in the US, a university system with the only medical school in the state. As part of the statewide medical education system, the medical school offers program sites at eight locations around the state; our campus is the only regional campus of the university to have one of these sites located on campus. Previously, the school of medicine branch was housed in a separate building and was only peripherally involved in the regional campus, as it primarily reported to the Statewide System School of Medicine and not the campus. However, in 2004 a new Medical Professional Building was built on our campus, bringing together programs in medicine, nursing, social work, and other health professions programs. In 2007-2008, a College of Health and Human Services (CHHS) was formed bringing together all the health professions programs under one administration and with the School of Medicine branch as an informal partner. Subsequently, the Assistant Dean and Director of the School of Medicine branch became the dean of the CHHS, with dual reporting to the Dean of the System School of Medicine, and the Academic Vice Chancellor of the regional campus. This new physical proximity of the health programs and the involvement of the School of Medicine created a “perfect storm” of events that served as the impetus for the development of an IPE program.

The evolution of IPE built upon an existing School of Medicine program termed the “Chronic Patient Project” (CPP). This project traditionally included a medical student following the care of patient over a period of two years. The IPE Health Care Team (HCT) pilot was developed from the CPP in Spring 2007. Two HCTs were formed, each consisting of a community residing patient, a graduate student in social work (MSW), an undergraduate nursing student and an undergraduate medical student (second year). These teams interacted over one semester with only loosely defined goals and objectives. At the end of the semester the teams presented their patient to faculty from the three programs. The Health Insurance Portability and Accountability Act of 1996 (HIPPA) guidelines were followed by all HCT participants in the presentations in order to protect the identity of the patients.

Although feedback from students indicated this had been a valuable experience, it also alerted us to some of the many logistical barriers we would face in expanding the program. Feedback from students included expected issues such as conflicting schedules, but also indicated that students were having difficulty actually having access to the patient since patients were relatively well, mobile adults living in the community. After much deliberation with faculty from all of the programs, it was decided that the Chronic Patient Project (CPP) model would be used, but that patients would be assigned from local extended care facilities (ECFs). This allowed access to many more patients and also created a “captive audience” of patients who would be available to students. Institution Review Board (IRB) approval for the qualitative research design was obtained.

The first full Health Care Team (HCT) cohort began in the spring semester of 2008 and included 18 teams. A second, expanded cohort began in spring 2009 and the third in spring 2010. The specific objectives of the HCT included to: 1) develop the skills needed to understand the physical, emotional, and financial impact of illness on a patient’s life; 2) develop a deeper understanding of the impact of disease on the patient and their family, and how cultural values and socio-economic conditions impact adherence to medical treatment and advice; 3) practice and improve skills related to obtaining a detailed health history and performing a physical examination; 4) develop communication skills necessary for receiving and relaying information to other members of the healthcare team, and 5) develop a better understanding of how each member of the healthcare team contributes to the care, well-being, and quality of life of a chronically ill patient. Each HCT includes a first year medical student, junior nursing student, and graduate social work student and the HCT works together and follows an assigned patient for three consecutive semesters starting in the spring, then fall, and finally spring of the following year.

The HCT contracts with the patient and asks them to sign consent for inclusion in the program. Patients are informed in writing what to expect in terms of visits from students, that the regular care they receive from their primary physician will not be changed in any way, and that it is the patient’s regular physician or health care provider who should be contacted for health issues. In other words, it is made clear to patients that the students are not there to substitute for the care they receive from their regular providers.

Assignments for the HCT are discipline specific; however, near the end of the third semester team members prepare and present a team presentation to peers and faculty from all three disciplines. Assignments otherwise occur on a semester-by-semester basis. The medical students, in year one semester one, complete and present a patient history, and in semester two of year one complete and present a complete physical exam. The nursing students complete an Elder Reminiscence Paper in the first semester and a comprehensive nursing care plan in the second semester. The social work students complete a biopsychosocial assessment in the first semester and progress notes in the second semester. Although the students can meet with the patient individually, HCTs are required to meet together a minimum of two times during the semester and to document communication using a modified “Situation, Background, Assessment and Recommendation” (SBAR) format. Each discipline is responsible for submitting typical discipline related paperwork to their respective faculty, and each student receives individualized discipline specific credit or clinical time for their involvement in the project. Additionally, students share a course management site (Oncourse ®) that allows for e-discussions, communication with their professors, and electronic submission of assignments.

RESULTS

After the first cohort completed all three semesters, the students were asked to evaluate the experience. Feedback received from the first cohort primarily concerned communication issues. Students struggled with communicating with students from different disciplines, mostly because of varying and busy schedule. Students involved in the Health Care Team (HCT) stated their preferred forms of communication were email and texting, and when they did not receive rapid responses from their team members they were quite frustrated. Another issue was patient turnover. In an effort to create a captive audience of patients, faculty failed to take into consideration how frequently patients were lost from the Extended Care Facilities (ECFs) due to death, discharge, or hospitalization. Several teams dealt with patient loss in the middle of their three semester experience; however, most indicated that the loss of their patient, while difficult, was a professionally meaningful event. The ECFs were asked to identify patients who were communicative and medically stable; however, as can be expected, some patients deteriorated over the project term.

Many students stated that the roles of the professional disciplines represented within the HCTs were confusing for them, and that it created a sort of role confusion for them as they attempted to internalize their own professional role, while attempting to understand the roles of the other disciplines within the team. Some suggestions from the HCT members for future cohorts included requiring more frequent mandatory team meetings and providing permanent liaisons for the students to contact at the ECF.

Student group presentations of their three semester experience are very revealing. It is very common to hear comments indicating that while the worth of the project was not evident at the beginning (and that some students even resented having to participate), there is almost universal agreement that the project is worthwhile and should be continued. Inclusion in the project is required for the medical students, the social work students participate on a voluntary basis, and the nursing students are nominated by faculty to participate. Students present the patient case from their own disciplinary perspective, and comments such as “I really didn’t know what nurses (physicians, social workers) did for the patient” are very common.

DISCUSSION

Recommendations for future HCT cohorts based on student evaluation include, among other things, the necessity of having a formal explanation and presentation of the professional roles represented by each member of the HCT. This should be done at the beginning of the project when teams are being formed. Development of a new clinical setting with an assigned agency liaison will assist in meeting the needs of the HCT students, by giving them a point person for contact when issues arise. A minimum number of face-to-face mandatory meetings are expected of students, and an evolving HCT handbook has been developed based on ongoing feedback and refinement of the program. Additionally permanent faculty advisors for each discipline are now in place to allow for better coordination of the project and in order to model the interdisciplinary behaviors that are expected from students. Another way we will be promoting better communication and collaboration among HCT students is by implementing TeamSTEPPS ® (http://teamstepps.ahrq.gov/ accessed March 2009) training, a patient safety initiative from the Department of Defense (DoD) and the Agency for Healthcare and Research Quality (AHRQ). TeamSTEPPS ® training promotes communication between health care professions by creating a common language that all HCT members can use and understand.

CONCLUSIONS

It is hoped that this brief description of our first attempts at IPE will be informative to those who are just beginning on the journey. We continue to collect data as the cohort’s progress in order to track trends related communication and collaboration among disciplines. The current expansion of IPE programs allows health care professionals to enter the workforce having an education in interdisciplinary collaboration and communication. As the body of knowledge accumulates about IPE, implementing and assessing the effectiveness of IPE interventions is vital to the continued success of the program.

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