A few weeks ago the ETSU Academic Health Sciences Department was holding its second full-day experience for students enrolled in the Interprofessional Education (IPE) Program. The day’s experiences centered on values and ethics in team based care, and the importance of considering social determinants of health. Student teams (nursing, medicine, pharmacy, psychology, public health and a range of allied health disciplines) worked with patient actors that presented with social problems that were intertwined with chronic medical conditions. These budding health professionals found themselves uncertain in determining their roles, how to work together, and in what they may have to offer.

 

The one thing that was clear to them, indeed it was the aim of the exercise, was that they needed each other to address the patient’s needs. The students saw the utility of the “pit crew” referenced by Atul Gawande¹, and, we hope they started to see the value of team based care, which has been recognized for some time and has been shown to have a positive impact on range of measures including access to care, prevention, and movement toward health goals.^2-4 While the Agency for Healthcare Research and Quality suggests that team training improves patient care and safety, ⁵providers continue to be largely trained in silos. IPE is trying to move the needle with training like this one, and move the new-in-training toward readiness for a team care environment.

IPE is a fast-growing area as academic health sciences training programs scramble to bring their students up to speed with the evolution of health care toward a team focus. It was in the 2000s that IPE represented a paradigm shift in health care with the Institute of Medicine’s report Crossing the Quality Chasm: A New Health Care System for the 21^st Century calling for fundamental changes in addressing quality and service. The Interprofessional Education Collaborative (IPEC) was established in 2009 when six national education associations representing health professions formed a collaborative to promote and advance interprofessional learning experiences that would prepare health professionals for a new health system. The first Collaborating Across Borders conference was held at the University of Minnesota in 2007. The World Health Organization (WHO) Study Group on IPE and collaborative practice was formed with the report Framework for Action on Interprofessional Education and Collaborative Practice being published in 2010.⁶

The WHO defines IPE as when “two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”.⁷ The WHO has identified a number of competencies that are widely accepted, but when examined more closely, are very broad and not operationalized. The members of our IPE initiative at ETSU reviewed a number of competencies addressed in the literature and pooled input from those doing team based care to formulate a list of competencies deemed important for the teaching rather than the practice of team based care (see Table 1). We have been working to identify specific, measureable behaviors for each of these competencies, and how they would be addressed in a curriculum. Most institutions who have been developing curriculum and IPE programs have moved from simply championing the benefits of team based practice to the identification of just how they may teach competencies and measure the impact of instruction through simulation and orchestrated exercises.

Table 1 Interprofessional Competencies

• Communication

• Teams and Teamwork

• Roles and Responsibilities

• Values and Ethics

• Knowledge of Healthcare Policy Relating to Team Care

• Learning Healthcare Systems

But where do we go from here? In reading the current literature on IPE and noting the aims of many presentations offered at national conferences addressing IPE, it seems that discussion is only beginning in how and in what way IPE is being translated to health care change and practice. A useful “tool” in examining this issue may be to consider three legs to IPE where instruction moves between being informational, formational, and transformational. The footers or building blocks to IPE are found at the informational level of instruction, instruction centers on concepts, ideas, and the identification of skills. It could be argued that most approaches to IPE are only at this informational level of instruction. A second leg, formational instruction, is where the focus centers on team member function, practice, and role-identity. Instruction moves beyond being about information and the learning of instruction, but to engagement and the practice of skills. To suggest that IPE instruction can and should be transformational, the third leg, is to capture the spirit of the WHO in championing team based care, where there is actual change in the “dance” of team members and a revolutionary change in health care. A true paradigm shift.

So, we are preparing future providers to change or influence the landscape of health care’s future. But we wonder if they will be ready for what they will find in the marketplace today. It is a difficult balance to be idealistic and innovative, while also training health care workers for actual positions. For this to work, the health care system needs to be willing for flexibility and open to change. We are beginning to see changes in payment incentives that encourage some movement toward team based care. Health care institutions are asking applicants about their experience and training in team based care. But once employed, how are current members of the healthcare workforce adequately prepared to operate in teams when their own educational experiences reflect historical educational silos? There is some talk of certifications and recognition for these experiences and there is a growing number of sites that offer training and tools for teaching and doing team based care, such as the Nexus Center for Interprofessional Education and Practice website (https://nexusipe.org/); however, utilization of these resources outside of educational institutions remains unclear.

In the same way that we have seen IPE evolve from a few championing the cause to the unifying of educators and providers behind a common goal (such as the formation of IPEC), we are now in need of organizations with similar passions to join forces in furthering research and a common set of principles in doing IPE. There are several organizations, such as the Collaborative Family Health Association, The Society of Teachers of Family Medicine, and certainly the Interprofessional Education Collaborative, as well as others, who have addressed aspects of IPE, though often indirectly under the auspices of “workforce development,” and not necessarily tied to articulated competencies. While many belong to a number of these organizations, there is a lack of shared vision and mission at the organizational level. This could be addressed by conferences occurring in tandem or perhaps having combined conferences from time to time where common efforts and collaboration could take place. The leadership of organizations could request that there be positions for representatives of other similar minded organizations so as to enhance common infrastructure for IPE. Perhaps there could be a national IPE commission that encompasses leadership representatives from the various organizations that are invested in IPE.

Just like that early day in February at our University, ETSU, as early health professionals were attempting to find their roles, work together, and determine what they may have to offer in regards to patient care, those with a passion for IPE could become more united in moving toward being transformative and in reaching a common ground. Perhaps then there would not only be pit crews for patients, but a common set of tools these mechanics can use. 

 

Resources 

1. Gawande, A. (2011). Cowboys and pit crews. Harvard Medical School Commencement Address. Retrieved from http://www.newyorker.com/news/news-desk/cowboys-and-pit-crews

2. Grumbach, K. & Bodenheimer, T. (2004). Can health care teams improve primary care practice? Journal of the American Medical Association, 291(10), 1246-1251.

3. Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21^st century. Washington, DC: National Academy Press.

4. Leape, L. Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., Lawrence, D., Morath, J., O’Leary, D., O’Neill, P., Pinakiewicz, D., & Isaac, T. (2009). Transforming healthcare: A safety imperative. Quality and Safety in Health Care, 18(6), 424-428.

5. Agency for Healthcare Research and Quality. (2009). TeamSTEPPS™: national implementation (online). Retrieved fromhttp://teamstepps.ahrq.gov/index.htm.

6. Thompson, B., Kelman, G., Romanoff, B., Pieper, B., & Dacher, J. (2012). Interprofessional education and collaborative practice. Retrieved from http://www.sage.edu/centers/asset/IPE_PPT_Final_Integrated.pdf

7. World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice (WHO/NRH/HPN/10.3). Retrieved from http://www.who.int/hrh/nursing_midwifery/en/

	Thomas W. Bishop, Psy.D.Assistant Professor of Family MedicineDirector of Behavioral MedicineEast Tennessee State University
	Jodi Polaha, Ph.D. is a licensed clinical psychologist and Associate Professor in the Division of Primary Care Research, Department of Family Medicine, East Tennessee State University.  She has worked exclusively in integrated practice since 1998, and describes herself as a “pracademic,” engaging in a balance of clinical training, program development and research.  She has directed the integration of behavioral health into over 25 primary care clinics, has developed and implemented interprofessional training curricula across disciplines and learner-levels, and conducted funded research on integrated behavioral health in pediatric primary care.
	Dr. Colleen Clemency Cordes is a licensed counseling psychologist, and the Director and Clinical Associate Professor in the Doctor of Behavioral Health Program at Arizona State University, the first graduate program dedicated to training the integrated behavioral health workforce. She has worked in primary care within multiple organizations, including Banner Good Samaritan Hospital in Phoenix, AZ, the VA Hospital in Long Beach, CA, the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, MA, and HonorHealth’s Neighborhood Outreach and Access to Health (NOAH) clinics. She received a certificate in Primary Care Behavioral Health from the University of Massachusetts Medical Center, and is currently on the board of directors for the Collaborative Family Healthcare Association (CFHA).